Lecture: Spectacle Compliance

[Phanindra] Good evening, everybody. I’m Phanindra, the CEO of Vision 2020 India. On behalf of Vision 2020 India and Divyajyoti Trust, let me welcome you to this webinar on compliance of spectacle wear among school children. We will run this session for an hour, including a Q&A. Vision 2020 India has been organizing the various webinars underneath the Knowledge Hub Initiative. This webinar is yet another very important, expected to bring in quality and setting good practices that our member hospitals can learn and implement at their hospitals.

Coming to the brief context of this session. Many of our member hospitals are engaged in school screening, the school eye has screening programs. It is considered one of the important activities to prevent childhood blindness. And it was observed that the compliance of spectacle wear among school children was very low. We are spending a good amount of resources on this activity and the result is not appearing as expected, then the activity needs a reconsideration definitely.

Let us see why are we saying this and what is the basis of it. We’ll hear more from our faculty today. And at the end of the day I think we should be able to understand the issues in the spectacle compliance among the school-going children. And the possible actions that we all can take to address such kinds of issues. I’m happy to introduce our today’s speaker, Dr. Uday Gajiwala. Dr. Gajiwala is currently the director of Divyajyoti Trust and is a medical superintendent of Tejas Eye Hospital run by the Trust. He’s also the co-founder of the Divyajyoti Trust and our Family Commission Trust. And he completed his MS in ophthalmology from University. He’s a member of Omni Ophthalmology Society, the Delhi Ophthalmology Society and their medical association. Various medical colleges association, Hospital Infection Society of India, and he’s also an international member of American Academy of Ophthalmology.

He’s considered an expert in the infection control practices and so he’s been providing a lot of guidance and mentorship in the infection control practice also to many of our hospitals. He and the other recorder, several manuals and guidelines. And also he has got several publications in the national journals as well as international journals and received several awards, individually and also from the administration side. Thank you Dr. Gajiwala, sir, for really taking your time and helping all of us to look at issues of spectacle wear compliance among the school children.

[Uday] Thank you, Dr. Phanindra. Thanks for the introduction. We’ll talk about this spectacle compliance study. This was an operational research study and it was sponsored by Vision 2020: Right to Sight India program only. This was done in 2009-10. And this was a multi centric study with six centers participating in the study.

Not going too much in details, but as you all know the burden of refractive error among children is very high.

[Phanindra] Sir, sorry, could you be a little louder please, maybe come closer to the mic.

[Uday] Yeah, sure.

[Phanindra] Thank you, sir.

[Uday] Yeah, sure. As we all know the global burden of refractive error is very high among school going children. And more than 90% of the visual impairment in 5-15 age group is due to myopia.

Government of India under the School Health Program is trying to address, not just eye care issues, but also the physical and mental needs of children. And it has been linked with nutrition and counseling also. Preventive and curative services have been provided. And that can give you long term results in terms of improving the maternal and child program and RCH program also.

In terms of implementation of this school screening, 6-18 years of age group has been covered. That is from first to 12th standard. Government and government-aided schools have been screened regularly. There’s a biannual screening being done, screening, health care and referral for disease, deficiency, and disability has been an integral part of this school health program. And there’s a partnership being expected with the school systems in terms of teachers getting involved in screening and communication with the parents.

Various models have been used, some states are using the exclusive teams, some states are doing it in campaign mode, some states nurses are posted as schools for regular healthcare of the children. A mixed approach has also been followed in some states. Involvement of public health infrastructure has also been tried out and RBSK we all know where a complete team is formed to take care of all the health issues among school children.

We all know the flow of examination of school eye screening activity. By and large in the program it is needed that the teacher will do the preliminary screening. But one important thing I want to highlight here that the visual acuity cut off which is used is 6/9. We’ll come to this later.

We’ve been performing better and better in terms of school screening and spectacle distribution through the program. But still, a lot needs to be done.

Coming to the issue of coverage of refractive error services, there are some issues involved here. Uptake of spectacles is one issue in terms of cost, the perception of need of spectacles, and access to good quality spectacles. The compliance to spectacle wear is also an issue because of the social acceptance being low in some parts. Comfort, cosmesis, and perception that spectacle would cause vision to deteriorate among the community has been hindrances.

Lack of awareness of the role of refraction and wearing the spectacle for all vision-related activities. The awareness is lacking. And lack of awareness of the need for refraction is also there.

Over years it was observed that if a child is prescribed spectacles, there’s peer pressure and the child is called names in the school which leads to the child not wearing spectacles. And there’s a lack of acceptance of spectacles in the community and even at home. Sometimes it was seen that the same color of the frame was given to all the children who required spectacles in the school because the vendor was the same probably. But that gave an impression of uniformity and that also created a hindrance. The need for spectacles was not felt. Many times some of the children, particularly when the small degree of refractive errors were prescribed, and that’s why the International Center for Eye Health London has suggested that we need not prescribe myopia less than 0.75 diopter, hypermetropia less than two diopters, and astigmatism less than 0.5 diopter.

In rural areas, especially for girls, it is believed that the child with spectacles will not find a match later in life very easily. And sometimes inappropriate refractive error services led to wrong correction and the child will develop a headache, watering, et cetera, and will not wear spectacles.

These were the observations which led us to conduct this study. And what we wanted to study through this was whether parent’s education, their occupation, or their economic status had any effect on the compliance. Whether there was any delay in provision of the spectacles to the child after the school screening activity was conducted. If the child is not using spectacles, the reasons thereof which can throw light on what can be done as a correcting measure to improve the compliance. Whether the child is aware about the spectacle power and the need for regular yearly examination or not. This was also another objective. This will tell us if our efforts at IEC activities are bearing enough fruits or not.

Then the next objective was whether we are prescribing nonsignificant refractive errors and if at all that was the case, if we can suggest to NPCB to issue directive to all the people involved in the activity not to prescribe non significant refractive errors. One more issue which was not listed previously but it was seen that children were using adult frame. We wanted to find out whether the type of the frame and the fitting job that was done properly or not. And if it was not proper, then we can focus on the providers to improve the quality of the work. And if the children are wearing adult frames that definitely needs improvement immediately.

These are the objectives when we set up the study. As I said it was an operational research study conducted in 2009-10. Six centers across the country participated in data collection.

SEWA Rural, Jhagadia was one. Shri Sadguru Netra Chikitsalaya, Chitrakoot was another. Vivekananda Mission Ashram Hospital, Chaitanyapur was third. Khairabad Eye Hospital, Kanpur, Alakh Nayan Mandir Eye Hospital, Udaipur, and Lions NAB Eye Hospital, Miraj, these were the six centers and these are the names of the people who were involved in the activity.

The Technical Advisory Group was also created which included myself, Anand Sudhan, Dr. Asim Sil, Dr. GVS Murthy, Dr. JS Thakur from WHO India Office, and Dr. BR Shamanna from Hyderabad.

We had thought that we’ll enroll a minimum of 200 students at each partner hospital, six centers were selected. The study questionnaire was developed and pre tested. Guideline for implementing the questionnaire was developed, tested, and then shared with the partners, who in turn translated the same into local language.

Before collecting the data, a complete list of all the schools with the distance from the hospital was sent to the coordinator, who randomly selected schools to be included in the study, and the selected schools list was sent back to each partner. Questionnaire was administered by an ophthalmic assistant or the vision technician to the school going children from 10-14 years, age group class 5-9. The ophthalmic assistant who was involved in doing refraction at the schools was not involved in the study intentionally. The supervisor and in charge of the study at each location made sure that the ophthalmic assistant collected data carefully. And this was done by a supervisor visiting another partner hospital while the data collection was in process.

Coming to the statistics. Totally 162 schools were visited and there was 982 school children who were enrolled in the survey. Unfortunately data from Khairabad Eye Hospital came late and could not be used and that data is showed that figure in blue. 982 was adding those numbers from Kanpur.

We had valid data for 970 students of which SNC Chitrakoot contributed the maximum 22.3%. However they have to visit more than 19,000 students for this small sample of 217 students.

Coming to the observations, 35% of the students had lost their spectacles and did not get a new pair of spectacles. Only 30% of students were wearing spectacles at the time of the study questionnaire being implemented. And this indicates very poor utilization of the services offered.

There’s no difference gender wise between the enrolled students for the study.

How long the spectacle was being used. About 60% of the students were using glasses for a year or longer. This means about 40% were not using it.

Distance from the distribution site is not very important but 62% of the students were residing within 10 kilometer distance from the place of distribution. As I said, age group was from 10-14 by and large, that’s because we had taken fifth to ninth grade students only.

Coming to the source of spectacles. 33% of students had received their spectacles from NGO hospitals, 12.9% students had received spectacles from outreach activities, and 22% students had received spectacles from District Blindness Control Society.

How long the spectacles were being used during the day, only 28% students were using their spectacles for the whole day. 35% students were using it for less than four hours of the day. That means only when they had to read or write they’ll wear the spectacles. The remaining time they’ll remove their spectacles and not use it. And the other students, almost 40%, were not using spectacles at all.

In terms of regularity of usage, 60% students denied the regular use of spectacles and this is a big number. More than 50% students not using spectacles regularly.

Upon asking whether they received a new pair of spectacles or not after a year or so, only 22% of students had received a new pair of spectacles which is really, really small number. Idealing all 100% should be going for repeat exam every year.

When we asked them whether they found any advantage of wearing the spectacles or not, 60% students say they felt some advantage of wearing the spectacles. The other 40% did not find any major advantage.

Whether they liked the frame or not, 60% students say they liked their frames, meaning 40% did not like their frames. Close to about half of these students wearing spectacles.

Where they were going for their eye examination. 25% students had gone to government hospital, 38.5% had gone to NGO hospital, and 13% of students had gone to private hospital. This indicates the need for free services at government and NGO hospitals.

To our major surprise, almost 25% students were wearing adult frames. Dr. Asim was instrumental in adding this aspect in the study. He insisted that many students were wearing adult frames per his observation and it really came out to almost one out of four students were wearing spectacles were wearing adult frames.

Almost 35% students were wearing spectacles with the optic power less than 0.75 diopter. This is a very important observation, we’ll come to this later when we talk about the recommendations. Gender had no impact on the amount of time the child will wear spectacles. Both genders were wearing for equally long or short, whatever you want to call it, duration.

Source of spectacle did affect the regularity somehow. 47.6% students had received spectacles from base hospital and they were using it regularly. When it was received from DBCS only 25% were using it regularly.

Coming back to the small degree of refractive error, when the power of the spectacle was 0.75%, 78.7% were using it regularly. Whereas if it was more than that, almost 85.6% students were using it regularly.

Power of spectacles. If it was less than 0.75 diopter, only 24% students were using it for the whole day. Whereas if it was more than 0.75 diopter, 31.7% students were using it for the whole day.

There’s no statistically significant difference in the power of spectacle against the gender. Both genders were using it equally.

Again, relating the length of use of spectacles with the power of spectacle, 50% of the students with the power greater than 0.75 diopter, they’re using it for longer than one year. Whereas only 16.7% students with less than 0.75 diopter power were using it for longer than one year. In routine day to day practice also what we see is that when it is a non significant refractive error, young adult patients do not want to wear spectacles. The same finding is being reiterated time and again over here.

When the spectacles were procured from base hospital, 74% students liked the frame. From outreach, 72%, from DBCS 43% students liked the frame that they received.

One more study was done recently. The one that we are talking about for Vision 2020 was done in 2009-10. Recently in 2019, we conducted a short study again in south Gujarat. And what we found is similar. Only 50% of the students were compliant to the use of spectacles regularly. And when the visual acuity was better than 6/12, that means non significant refractive error was being prescribed, only 34% students were using it regularly. And even when we looked at the monocular visual acuity better than 6/12, that also were a small number of students who were complying to the use of spectacle. That means when the non significant refractory is prescribed, children even after almost the difference of 10 years were not complying to the use of spectacles.

And then the major reasons for non compliance found in the recent study were also similar: broken glasses, broken frames, being teased by friends, called names, lost spectacles, dislike the spectacles, et cetera.

Then coming to the results. All children who were refracted under the school screening program had not received spectacles. We had to go to a large number of students to get the required sample size against the number of children who had undergone refraction. Coverage of school screening activity is not 100% in majority of the areas. Sensitivity of the school administration and teachers is not uniform. A lot of teachers did screening in the initial years and then later they denied and then we had to use alternative approaches for preliminary results activity spending in schools.

Overall percentage of children who were prescribed spectacles at some point of time in school screening activity was found to be only 2.17%. I’m afraid this could be because this needs to be cross checked and confirmed, maybe because we involve more students from the rural areas where the prevalence of refractive error, even today on the lower side. This I’m not sure, needs to be confirmed.

Only 30% of students were found wearing spectacles. 70% of our time, energy, and efforts spent in school screening activity is going to waste. There is no difference in prevalence of refractive errors gender wise. Only 25% students are examined in government set up and have received spectacles from DBCS. 40% students have received their spectacles from NGO hospitals.

DBCS is supposed to be providing spectacles free to the students in primary schools up to 8th standard now. Majority of the students in need of spectacles are found in secondary school. That’s a dichotomy. Only 28% students use the spectacles for the whole day and only 31% of the students using spectacles regularly. Also indicated that the resources spent behind the activity are not put to proper use.

Only 22% of students have gone for a repeat examination to get a new pair of spectacles. And of these, 68% students have gone to the base hospital for a new pair of glasses. This shows that those who are motivated enough to go for a regular eye check up and get a new pair of spectacles are going to the base hospitals rather than waiting for the school screening activity. Simply meaning that the advantage is already good among these students. But what about the remaining 78% of the students who are not gone for a repeat examination? And this calls for more efforts on IEC activity. Particularly making the parents aware about the need for yearly, regular examination.

Nearly 40% of students upon questioning told that they did not find any advantage in wearing their spectacle. And we believe largely these were wearing spectacles with far less than 0.75 diopter, non significant refractive errors.

39% students said that they did not like the frames they were wearing. Either the frames were uncomfortable, big, small, heavy, they did not like the color, et cetera, et cetera. About 25% students were wearing adult frames and this should not happen under any circumstances. How can a child wear an adult frame? It will not stay properly on the face and the optical center will not remain in front of the pupil. The power will be made difference and the child will not be able to see clearly. And naturally the peer pressure will create more issues for this child.

Of the total students wearing spectacles at the time of survey, 34% students were using spectacles with dioptric power less than 0.75 diopter. There was no statistically significant difference gender wise in the use of the spectacle over a long period of time.

When the spectacles were procured from the base hospital, the likelihood of being used regularly were high: 47%. Where if procured from DBCS the likelihood of regular use was only 25%. Need to go into details of the reasons why. When the power of spectacles is more than 0.75 diopters, the chances of the same being used regularly are higher by 10%. Which is quite significant and that is where I’m pointing to this fact repeatedly. Many times the supply of spectacles was delayed by as much as six months after the refraction. In these cases, students were losing their interest in getting the spectacles. The delay should be reduced to the minimum possible amount of time.

Based on these results and what are the recommendations that I’ll talk about just now, this manual was prepared for a school screening activity and recommendations have been incorporated in this manual. It is available at the office of Vision 2020: The Right to Sight India.

So then coming to the recommendations. We felt that the visual acuity cut off of 6/9 which is being used presently should be changed to 6/12 or even 6/18. I don’t know if Dr. Praveen Vashist is with us or not, he had agreed to this addition. And just for information but International Center for Eye of London also said that we can change the cut off to 6/18. And this will remove the non significant refractive errors from being prescribed which really are not used or not felt to be really important by the children. The school children should be done from 5th glass onwards. Primary school enrollment is 90% and those children that are not covered in higher classes due to lower enrollment can be covered later.

First four grades of children, first to fourth class students, they will not be able to cooperate in visual acuity screening. And very experienced screeners are required to check visual acuity in the young children. And the prevalence of refractive error below nine year age group is very low. That is why this recommendation.

There’s no need for primary screening in rural areas. I should not say no need for primary screening, but this should be undertaken over where we have enough resources. And that’s because we found the prevalence only to be 2.17%. We should do regular screening where we found the prevalence to be more than 5%. However this needs to be validated to studies which have larger sample size. We all know that the development of refractive error is directly related with the use of eyes for near work. This has been proved now. Before that there is no need to screen the school dropouts, however, this was not part of the study. This is our belief included here. We believe that we should screen students from fifth standard onwards up to 12th standard. And DBCS spectacle provision should be more available up to 12th standard students because the prevalence of refractive areas increased in increasing age. Myopia develops in the secondary school children more often.

Prescribing non significant refractive errors should come to a stop and for that the visual acuity cutoff should be changed. Children should be given a choice of different spectacle frames of different colors and different types so that they are interested in wearing them. Today children come and ask I want to wear the frame that Akshay Kumar was wearing in this particular film or Aamir Khan was wearing it in this particular film. So we give them a choice of different types of frame and colors of the frame. Maybe they’ll be tempted to use it regularly. And spectacles must be supplied within a short time after refraction, otherwise children lose their interest in wearing the spectacles.

Emphasizing that the IEC activity will be part of health. The children and parents should learn about the refractive errors, how to take care of the spectacles, and they should know the importance of wearing glasses as a corrective measure. We need to follow a whole family approach. This will ensure that parents are involved in the activity and they understand the importance of the spectacles and understand the importance of continuous yearly follow-up examination.

To make teachers find this activity interesting, we may think of we can consider provision of presbyopic correction for teachers. That may attract them towards this activity. This addition is based on the empathy of school teachers seen in our area in Gujarat. Promoting healthy school environment can be done at the school level. Identification and referral of common eye complaints of children by the school teacher can be encouraged. And identification of common eye complaints of children, for example squint or white pupil, or nystagmus, or abnormal head or face, and red eye, inability to copy from the blackboard, or any other gross eye abnormality can be taught to the school teachers and this may help in taking care of the visual impairment among school grade children in a better way.

Coming to some of the issues that we need to consider for the school screening activities. Will the impact of training of school teachers and ASHA workers get diluted over time? At what interval such training should be repeated to maintain the impact and the interest of the teachers and ASHA workers? Food for thought for everybody whether we need to screen the non-school aged children or not? Treatment in terms of correction of refractive errors, particularly for female children who are neglected or the family does not allow them to wear spectacles. This is prevalent even today in some parts of the country. How to motivate the children to go for correction of their refractive errors and wear spectacles constantly. How to ensure availability of base hospitals, in government sectors or NGO sector, which pediatric eye care unit and availability of trained pediatric ophthalmologists in all the districts. I’ll say taluka level here, but at least at the 6th level, how to ensure all that? And how to ensure more and more involvement of local NGOs even non eye care non health care NGO? We can train their workers in preliminary screening and referral. And what kind of financial incentive can be included in school screening for ASHA workers who would be there. These are some of the issues that we can consider for improving the performance of the school ICE activity.

That was it from the team who did this study. I take this opportunity to thank Vision 2020: Right to Sight India for entrusting us for the study and I thank all the partners who participated in data collection. I thank Mr. Anand Sudhan for doing the data analysis for this study. Thank you so much and now it is open for question and answer.

[Phanindra] Thank you, sir, thank you very much. It’s really wonderful, sir. This is very elaborate, a lot of data. And a lot of issues, very important issues to deliberate further. Sir, before we start the Q&A, I’m requesting participants please put their questions in Q&A and we’ll take it up very quickly. But before anybody asks, I’m taking the liberty to comment on a couple of things.

Of course you already mentioned that 2.17% children only prescribed, were given a prescription. That is, I think, a very lowest figure that we come across. I expected maybe 40% as I said, but it is only 2%, yes. There’s further request we look at it.

[Uday] Phanindra it cannot be 40-50%. Most studies have said maximum 7% prevalence of refractive error among school children.

[Phanindra] Okay, okay. And the age group of 6-18.

[Uday] Got it.

[Phanindra] Okay. One person wondering what point this study that Vision 2020 study in 2009 and 10 and the study that you talked of was in 2019, this gap of 10 years. In 10 years period, I was really shocked to see the scenario the same. With not much of any significant improvements between all the 10 years spread. That was really I think a point that everybody, I think all of us need to take a note of. And need to get into the kind of reasons why there are no improvements noted in the same area after a decade of any kind of positive improvement. But with all interventions I think generally it should pick up something at least, maybe by 10% is going to increase by the socioeconomic development patterns. But I was really surprised to see no improvements in the 10 years period. All the eye care providers and the manufacturers, et cetera, I think is a good point to take a note of it.

[Uday] One possible reason was that even this time we conducted the study only in rural area. We did not go to any large, not even large cities, not even a small city. All these children were from the rural area only. Truly that is the reason why the compliance has still remained the same.

[Phanindra] And said another point is a six month delay in receiving the spectacles. That is also another shocking finding. Six month delay I think it’s very difficult for any child to wait for it and then expect any compliance to the spectacle wearing. But I think six months, I was actually traveling to one of the states very recently last week and I found six months, nine months, from CSC, and they said that nine months is waiting time are really short. The prescription could be the reason they identified was from a CSC, the prescription goes to the terminal from, what is the state I’m talking about, what is to? Terminal the prescription goes and then comes back to what it say, takes nine months time. God knows whether actually the patient by then actually there are not and one can expect the complaints coming back and take the spectacles take nine months and the power changes et cetera. That’s also an issue that I think the whole supply chain issue under the free spectacle program is what I think one has to look at it.

One thing, one very basic particular point, you said the visual acuity cut off should be changed to 6/18 and somebody else also recommending 6/18. And then the prescription for glasses of a small degrees of refractory is unnecessary. Wondering is it because of people not wearing that we’re recommending this change or technically that small degree of refractive error for spectacles is not needed to wear?

[Uday] When the visual acuity is 6/12 we do not even call it a visual impairment.

[Phanindra] Okay, technically. Okay.

[Uday] Technically. And so what happens is that these smaller degrees of refractive error, the correction, the child also does not find so much advantage in wearing that spectacle. That is why I said even adults when they come for an examination, if you prescribe them a small degree of refractive error, many times they don’t even use it.

[Phanindra] Yeah, probably that’s the reason 40% mentioned they didn’t find an advantage. Probably is the reason. Because they were given these small degrees of refractive error.

[Uday] That’s right.

[Phanindra] Hmm. We expect them to wear continuously, regularly also another point to be noted.

[Uday] Does not happen.

[Phanindra] Still one important point that you also brought out these people not wearing for a number of reasons because it’s not comfortable, and they didn’t like the color, aspect of frame, didn’t like it. And the weight of the whole spectacle is also an issue. But I think that was 10 years back, but also in 2019 that you found the same thing. But hopefully now that the technology is changing, a lot of Indian-made glasses are coming up in the country. Hopefully the eye care manufacturers, particularly in the optical industry, they’ll take care of this issue. I remember some of the companies coming forward with spectacles with very less weight and more designs, more frames, et cetera with designs. Hopefully people take advantage of it.

And then those kind of manufacturing level initiatives will address the sudden issues of the common issue that you pointed out like weight issue and the frame issue, color issue, et cetera. But now different colors are coming up, different weights, different models are coming up, able to choose a range of eyeglasses particularly manufactured in India, even coming from outside us that now look very attractive. Hopefully I think the eye care manufacturing industry is the lesson from this presentation, sir.

Let me just look at any Q&A. Somebody’s asking questions. Anindita, would you like to take up this question. And facilitate it, please?

[Anindita] Yes, sir, there is a question. I’ll read that out for you. After the post-COVID period the education was accepted to online mode and children are mostly depended on their online gadgets for their education. Is the percentage of refraction error cases increasing in the present day?

[Uday] Well, definitely yes. Prevalence of myopia has increased and there are a couple of papers published also recently on this point. As we all know today we have proof that use of eyes for nearwork is directly related with development of refractive errors. In Western world, large number of teenage students develop myopia of 2-3 diopters by the time they reach 15-16 years of age. And the same thing is now happening in India. Myopia prevalence is increasing. Yes. Percentage of refractive error because the use of gadgets for online education definitely is increasing.

[Phanindra] Meanwhile the other points at 22% only went for repeat examination.

[Uday] Yes.

[Phanindra] I think that also for the counseling effort, to be done at the school level, I think there’s some reflection coming on this. Because large percentage, 78%, did not go on their own for repeat examination after a year, which is actually much, that’s what we promote every year at least you go for an eye check up and see. But it’s only 22%. What matters for this? Last one here 2019, not much improvement, that’s what’s really shocking. What could be the major aspect that you think, sir, the major reason behind it? What major reason?

[Uday] I think because when we conduct school screening activity, parents are not around. Even when we hand over the spectacles I don’t think we are inviting parents to come at the time of distribution of the spectacles. So probably the method is not reaching the parents and that is why I’m sharing the need for a whole family approach. At least at some point of time we should be interacting with the parents and we should be able to convey the message to the parents that a yearly, repeat exam is mandatory. Probably this is not happening right now.

[Phanindra] Yeah, I think that the school screening is done, probably children are not carrying forward the message to their parents at home. And the parents also did not know that their children had been screened for eye examination they went through. And I think there’s a gap between the children and to the parents as you pointed out. But daily, in particular, or even the daily goalment they’ll introduce their parents meeting once in six months or so. But probably that can affect is first problem needed in other government schools in other states also. That where parents come to know these kind of initiatives taken at the school level. Otherwise the gap will remain the same, will remain forever. I think the loop has to close somehow.

[Uday] You see, as you also said that the gap between a examination and passed spectacles is huge. And that is what happens in the refractive error has changed by nine months when the spectacle arrive. The child will not be able to see clearly with that spectacle which he received and then he’ll not find it interesting to use it. In fact he may develop even a headache using that spectacle. We need to look into all the aspects very closely and because it’s a lot of energy, effort, and resources going into this activity, if it is not bearing the desired fruits we must be looking at it very critically to make whatever change is required to make this more effective.

[Phanindra] Anindita, there is one question if you want to.

[Anindita] Yes, sir. The next question is how does one make a child continue to wear spectacles against the background of social issues?

[Uday] Wearing spectacles was a real taboo about 10-20 years back. Today that is changing rapidly. More and more students in the same class may be wearing spectacles so that may indirectly help the student. But we must be able to emphasize that if you use spectacles you will be able to see clearly at a distance. And you’ll be able to read whatever is being written by teacher on the blackboard will be seen clearly by you. And that we should show to the child. We should emphasize this point that your reason will be better with spectacles. And that will make the child wear the spectacles.

Again, education of parents in the use of spectacles. Because previously for a female child, when the girl grows up marriage will become an issue if she is using spectacles. And that is why when the LASIK procedure, the laser came into market, a lot of girls of marriageable age ran for getting the spectacle bar removed. But now with more female students also wearing spectacles, that is becoming less important. We need to highlight these things to the child, through the teacher, and to the parents. As I said, we have to go for the whole family approach and whole society should be made aware of the need of spectacle. And that adds to the reason why non significant refractive error should not be prescribed. Because when we prescribe small refractive error we are again creating issue with really non-existent for that particular child.

[Phanindra] Thank you, sir. I think there is one comment that I’d like to read about it. Somebody says that the education about eye to be included in the school curriculum and the effort by any of us and may not be binding by it. But the important point, I think education yes, about the eye to be included in the school curriculum. Actually to prime some primary aspects of it as well I think it’s a good idea. Both for the children and the parents and the school, everybody will be notified about it, is a good point.

And so I’m taking two points back home from this session. One is their accommodation very clear about visual acuity cut off change from 6/9 to 6/12 or 6/18, preferably 6/18. And also the other point is the family based approach involving the parents. I think these are the two my take points back to home today from this session. Although there is a lot of data, a lot of big issues it is throwing out. One requests more time to deep look at it and understand some more issues from the data that is throwing to us.

Anindita, any questions please? We have now realized the time up, it’s five o’clock now. Any other key questions?

We will be sharing the PPT and complete video link of the discussion from 4-5 PM, the one hour session, including having the link of the audio/video link completely embedded in the webinar session of this webinar, we will be saving it in a couple of days time. You can actually right now keep it for a future purpose or maybe you can share it with colleagues who could not attend it, that would be a good one. We will be sharing the link to all of you soon.

If there are no questions, then I’d like to conclude the session here. Thank you, sir, Dr. Gajiwala, once again, for really a wonderful presentation and your time, sir. A very informative video, important issues. We discussed some of the important aspects of it but I think it requests a lot many of these kinds of questions. And we’ll understand the data and more reasons behind why people are behaving like this. And why this situation did not change the last 10 years in the same geographical area.

And thank you all, audience, thank you dear member hospitals, thank you so much.

[Uday] Bye, thank you.