Pediatric Ophthalmology, Strabismus & Health Informatics
Blogs about Pediatric Ophthalmology, Strabismus, Health Informatics and More
Every year, the Sentro Oftalmologico Jose Rizal conducts a Clinical Course for two weeks, reiterating eye problems seen in practice. This lecture is on Common Motility Problems seen both by those in general ophthalmology practice, and those dealing with the subspecialty. Some clinical guidelines and salient features are discussed.
This is the slideshare link to this lecture.
http://www.slideshare.net/AlvinaPaulineSantiag/2015-common-motility-problems-v2
Telemedicine and the Facebook platform seem to be tempting bed fellows, but there are many reasons why physicians, who swore to protect our patient’s privacy, need to step back and rethink, if not condemn this as an option for telemedicine.
http://efocalpoint.pao.org.ph/v6n2/index.php?route=pavblog/blog&id=31
#HI201 #MSHI: The Final Frontier (Documenting the semester that was)
Online Interaction and (New) Learning Competencies
I felt accomplishing quite a feat, really. Never mind that I am late again in posting this homework. (It seems I have often been so!). For a mid-centenarian(?) I was able to blog, tweet, use Facebook to connect and comment, even got introduced to Basecamp, which incidentally, I could no longer open. [As a paranoid, mistrusting internet and computer user, luckily, I have printed the comments of Dr. MM on my EHR assignment). As my professor in HI201 said, I too, am not sure what I am doing here. There is probably some divine hand in this undertaking…for while I was a student, a foreign-based consultant wanted the local eyeMDs to post patient data via Facebook!, or even suggested using Dropbox, duh. Certainly, I have enjoyed the ride, and the “cool” learning experience, I could even discuss with my 16-year old son.
ENQUIRY.
I knew nothing about health informatics when I started. The course design, the reading materials, the assignments (although soooo many) helped me see the field, ask the right questions, and find the right sources. I know I am at the tip of the iceberg. I know there is a whole field waiting to be discovered. I only saw glimpses. I liked what I saw. There is more to look into. There is a wealth of information still waiting to be discovered.
PRODUCTION.
What I found the hardest, up to this date, is the making of the INFOGRAPHIC. I made a cryptic info graphic, didn’t realise I needed numbers, numbers, numbers, and not just information. Took me a while… went through piktochart, easel.ly, visual.ly among the many sites that gave “free” templates. It was supposed to be easy (ask Burr!, who did his info graphic homework 10 minutes before classes started), but it took me forever to modify my info graphic, to make it look a little bit closer to what an info graphic should look like.
There were a lot of presentations. Each week, there was a written blog, and an oral presentation we prepared for. The power point presentation was a breeze, as I had been a user of powerpoint for my lectures. I did know how to cram a presentation while my classmates were presenting, haha! Just before I started the course, I also had been sharing my slides on SLIDESHARE, so the transition (was there one?) was easy.
I still don’t get the difference between a MINDMAP and a CONCEPT MAP. Not sure if I did right or wrong there, but managed to answer the driving questions, and the assignment (I hope).
PARTICIPATION.
Rank has its privileges, or maybe age? I had a mentor, a colleague in Alexander Reyes, MD, a self-made Health Informatics Specialist. Like myself, he was an ophthalmologist. He pushed me to participate, beyond the usual comments. He provoked my thoughts with questions, or even twists on a current assignment. He had his own take on health informatics, topics, and controversies. He even invited me to take courses with coursera. I probably will, once I finish my homework. Even “strangers” commented on my work!
I also had a chance to look into my classmates thought processes. The novice that I am at health informatics, I could freely comment and give input, hoping I didn’t sound incomprehensible. It helped that we were coerced to comment on at least 3 of our classmate’s post on mobile health application.
I didn’t get as much activity on the assignments on twitter, but did learn a lot from attending a few of the #healthXPH Saturday night activities.
DIGITAL LITERACY. I am not sure how to classify myself with what I was when I was just starting #HI201. I knew email, how to send, attach files. The first assignment, was to blog, get on Facebook, and twitter. I had a Facebook account my son had set up, now I check it everyday– for homework, social networking, school announcements, among many things that get posted. I didn’t understand why the # sign is called a hashtag, when I new it as “number” or even a “pound sign.” I needed my son to help me follow my teacher on twitter, or tag you on Facebook. He taught me twitter syntax, and told me there was a limit to the number of characters…anything that exceeded, could not be tweeted.
And, finally, the last requirement was documentation of the semester that was. Here is that link.
https://www.dropbox.com/s/ypcn0a6bqo4m9tx/HI201%20Final%20documentation.docx?dl=0
Had a good time! and I #learnedsomethingnew. 🙂
Can games improve health? #HI201 Last week! #MSMHI task: Evaluate a health-related mobile game app.
My knee jerk response is yes, there could be applications where games can improve health. But I am an ophthalmologist, can a mobile game app improve eye health? Hmmm… could be a problem. It is unconscionable not to mention the ills of computer games in this blog (lest my patients and parents read this).
Before I proceed then, let me disclose that I am not an avid fan of computer games. I did not take my son to the video arcades, believing it was a money trap that only served to strain the eyes and even induce seizures!
Furthermore, I am a paediatric ophthalmologist. I get questions (which I sometimes think are rhetorical) such as, “do computers and gadgets affect children’s vision?,” and “how much time should a child spend in front of their gadgets?” Moreover, I can actually gain financially from patients using games in a mobile app who develop symptoms of headache, blurring of vision, diplopia, sometimes even nausea and vomiting, when they consult the clinic.
The following eye problems from computers and gadgets have been observed and reported:
1. Reduced blink rate, which in turn leads to
2. Dry Eye Syndrome, (child can complain of blinking, drying, foreign body sensation, burning sensation)
3. Asthenopia or eye strain
4. Ciliary muscle fatigue or accommodative spasm
5. Induced refractive error, typically myopia and astigmatism, and
6. Induced strabismus in predisposed individuals.
7. Computer eye syndrome or video terminal display syndrome
8. Computer addiction affecting social skills and interaction
These being said, I have also found gadgets and computers useful in the clinic to get and sustain a child’s attention; for orthoptics especially for patients with intermittent exotropia; give the child something interesting to look at; provide a good diversion; aside of course from the obvious tools in the clinic such as the eye chart and auto refraction machine many are familiar with.
Proceeding with the game application that needs to be evaluated for this task, I migrated to food-based games just like Mr. Cardenas’ “Gobbles Eat and Run.” [3]
The first one I looked at was “Awesome eats.” Although it had music and started with teaching the player how to swipe, then sort, I didn’t last long and found the game boring. The skills required were too elementary, but the trivia provided was for a much older age group. For example, the snippet for trivia text read “if you can’t tell a hard boiled egg from fresh eggs, give them a spin. The egg resistant to spinning is uncooked, but if it spins, it is hard boiled.” I needed less than 5 minutes to judge this app, and forget about it.
I checked out “Eat this not that! Game by Men’s Health,” Classic Edition and was finally happy with what I saw. It didn’t require finger dexterity, or eye-hand coordination required in “temple run” type games.
The game simply presented two types of meals one is commonly confronted with, the player having only to choose which food to eat. The pictures looked like what one would see in a food magazine, or in an actual life setting. It teaches facts, with details about calories, and explains why one food choice is better than the other. It quells common misconceptions, and simulates one’s dilemma when choosing from a menu. There is a classical version, a kids version, and even a drinks version.
I actually plan to keep playing this game, learn from the choices and repeat the game to reiterate the right choices in my mind and my easily tempted appetite. Perhaps though, this game appealed more to the “older” age group, not the kids who grew up with moving frenzied targets, with speed of graphics that keep changing as the clock ticked. The game I would think is more cerebral, and appealed more to the problems that beset an older age group needing to make the right dietary choices. It is not the type of game that will induce a seizure.
In conclusion, yes, games can improve health, and is an excellent tool for fun learning and edutainment. Games can motivate, enhance, prevent, support, train and rehabilitate. [1, 2] That knowledge, however, is tempered by the fact that as an ophthalmologist, I know games can affect eye health. If not moderated and abused, can open a Pandora’s box of eye symptoms and findings, not to mention seizures (!) in predisposed population.
References:
1. McCallum S. Gamification and serious games for personalized health. Studies in health technology and informatics 2012;177:85-96. http://www.miro.ing.unitn.it/download/Didactics/Misure2/2012%20pHealth%20-%20Gamification.pdf
2. Gamberini, Luciano, et al. “A game a day keeps the doctor away: A short review of computer games in mental healthcare.” Journal of CyberTherapy and Rehabilitation 1.2 (2008): 127-145. http://htlab.psy.unipd.it/uploads/Pdf/Publications/Papers/Cyber_rehab08.pdf
3. Cardenas, Isidor. Game based learning: theory and applications. Webinar given 30 November 2014, 1-2 pm.
Week 16 assignment for #HI201 #MSMHI
This week’s task: How can mobile applications be useful in primary care? Propose an app idea for a primary health care scenario. (Your app idea must not duplicate any app already available in the market.)
Screening children for vision, identifying children needing glasses can be a daunting task. Refracting them and giving the correct prescription is both an art and science that requires not only skill in refraction, but application of principles that can interplay and even contradict each other. Even in this day and age, several communities are wanting in providing a simple service to our children. There are those who are never screened, those who are not screened correctly, or children who are unable to access the right eye care professional, or unable to helped by a lack of knowledgeable eye care professional who can assist in giving the correct eyeglass prescription.
The difficulty in prescribing eyeglasses in children is confounded by:
1. Different ages requiring different adjustments in prescription. A child less than five years of age, will tolerate the full hyperopic correction, as is recommended for patients with refractive accommodative esotropia. However, there will be children who will see poorly with a full correction, and can tolerate only a fraction of the hyperopic prescription. Age of 5 years, may also be violated, as some cooperative children less than age 5 do complain of blurring of vision and headache with a full correction. The key is finding the maximum tolerated plus prescription that will control the deviation. Sometimes, a compromise at 20/40 or 6/12 vision can be tolerated to avert the need for surgery.
2. Strabismus conditions that affect decision in prescribing. While patients with refractive accommodative esotropia are given as much plus correction as they can tolerate, in exotropia where eyes deviate outwards, over-minus lenses even in the absence of a refractive error may be prescribed to stimulate the accommodation-convergence synkinetic reflex to help control the outward drifting. In patients with esotropia and myopia, giving an over-minus lens by the same accommodation-convergence synkinesis mechanism can worsen the inward turning.
3. non-cycloplegic refraction and cycloplegic refraction can vary immensely. Refraction taken objectively, without cycloplegic agents is very useful especially for the older cooperative child, but is difficult to obtain in a young especially non-cooperative child. Cycloplegia can also vary in strength…it can be weak and short acting as tropic amide, moderate strength with intermediate duration like cyclopentolate, and strong with longest duration like atropine. Different degrees of cycloplegia may yield different refraction results and can confuse the novice eye care professional and can be at a loss as to what to prescribe.
4. Subjective refraction can be different from objective refraction. When does one give in to a higher subjective refraction? How much of the induced myopia and astigmatism will one prescribe? For children who can read, the typical minimum visual acuity that should be obtained during manifest refraction should be 20/40. Typically, the lowest minus, and lowest cylinder (of induced error) that will give a 20/40 vision is prescribed.
5. Different rules apply for myopia and hyperopia for very young children and the older child. Lowest minus prescription whereas the highest plus prescription is preferred when prescribing glasses in children who cannot cooperate for subjective refraction.
6. Tolerated prescription can be different from refraction that gives the best visual acuity. Sometimes in the older child, especially those with asthenopia, ciliary muscle fatigue, or accommodative spasm, a higher myopia or cylinder is chosen by the patient. However, when worn for a long time, this type of prescription may worsen the asthenopia, or soon make the child dependent on a wrong “higher” prescription.
7. Some children will benefit from subjective refraction. With the advent of video terminals, computer games, and gadgets, there is an increasing number of children requiring a higher subjective prescription compared to what is obtained objectively by the eye care professional.
8. Children with eye strain and fatigue can have induced myopia and astigmatism. Sometimes, varying degrees of strain, fatigue, and sleep can change the refraction.
9. In the amblyopic age group, a wrong refraction or prescription can mean confounding an existing amblyopia problem, or even cause amblyopia if a wrong prescription is worn.
10. Computer auto refraction is probably close to 90% inaccurate in children (but close to 90% accurate in adults). The problem is discerning when the computer gives a good estimate, and when the computer is way off the mark. A skilled refractionist, using the old reliable retinoscope is often better than a computer auto-refraction in the paediatric age group.
11. Diseases such as diabetes, water retention, allergic eye involvement, dry eye, can affect refraction, and should be recognised before a prescription can be made correctly.
12. Different paediatric ophthalmologists, eye care professionals can have varying biases andy prescribe different glasses even under the same conditions or clinical scenarios.
13. Some children, babies included of course, cannot read the traditional letter or number chart. Some may identify figures, but there are some who will not be able to give accurate vision assessments, but may still require glasses. The challenge is picking up those with problems and giving them the correct prescription.
My proposal is simple…at the community level, especially where there are no paediatric ophthalmologists around, wouldn’t it be good to have a virtual paediatric eyeMD that can help determine the correct prescription for patients in different clinical scenarios? Plug in age, associated strabismus, objective refraction, dry refraction, wet refraction, etc., and the application will come up with a recommended prescription. Better yet, prescription can be linked to an eye care provider that can assist in making glasses, as well as judge the soundness of the app’s recommendations.
References:
1. Freifeld CC, Chunara R, Mekaru SR, Chan EH, Kass-Hout T, et al. (2010) Participatory Epidemiology: Use of Mobile Phones for Community-Based Health Reporting. PLoS Med 7(12): e1000376. doi:10.1371/journal.pmed.1000376
www.plosmedicine.org/article/fetchObject.action?uri=info%3Adoi%2F10.1371%2Fjournal.pmed.1000376&representation=PDF, accessed November 26, 2014.
2. Kaplan WA. Can the ubiquitous power of mobile phones be used to improve health outcomes in developing countries? Globalization and Health 2006;2:9 http://www.biomedcentral.com/content/pdf/1744-8603-2-9.pdf, accessed November 26, 2014.
3. Qiang CZ et al. Mobile Applications for the Health Sector. April 2012. ICT Sector Unit, World Bank. http://www-wds.worldbank.org/external/default/WDSContentServer/WDSP/IB/2012/09/18/000333038_20120918020413/Rendered/PDF/726040WP0Box370th0report00Apr020120.pdf, Accessed November 26, 2014.