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“How Do I Know My Child Needs Glasses”

Young children usually cannot understand or complain that they cannot see clearly. If this problem is not diagnosed early and correcting glasses are not given timely, a child starts neglecting his work at school, his writing becomes bad and his performance in class drops. Gross near-sightedness reduces a child’s horizon as he can see clearly only up till a meter or a two meter distance hence he starts losing interest in outdoor activities which demand a good distant vision; he becomes more inclined towards indoor activities and becomes a loner.
As a parent, we can diagnose that the child needs glasses by keeping a look out for the following symptoms:
1) Frequent blinking or rubbing the eyes.
2) Squeezing both eyes to see at a distance object.
3) Closing one eye while a photograph is being taken or outdoors.
4) Watching T.V standing close to it.
5) Worsening of hand writing and performance at school.
6) Squinting of one eye while reading or looking at a distance.
7) Watering of eyes while watching T.V or outdoors.
If you notice any of these symptoms, please see a pediatric ophthalmologist who is especially trained to recognize this problem and rectify it. Longstanding neglect of a child’s poor vision results in a “lazy eye” which is difficult to treat.





Eid holidays finally ended but taught me an important lesson:

God has created a huge universe with our world just a tiny spec in it, occupied by a diverse population. Each person in it is different and is given a very important role by our Creator, which no one else can replace.

In every society, sweepers that clean our toilets, houses, gardens , roads, parks, streets, shopping malls, work places, schools are simply taken for granted, even looked down upon and treated with disgust.
My cleaning lady took a week’s vacation to celebrate Eid without even informing me. It was her right too to celebrate, but I was extremely angry at her that firstly, she left without informing me for how lone she’s going and when will she be back, and secondly, I had to do all her chores.
Whole one week I had to clean the house as guests were expected.

I was exhausted by all the hard manual labour for whole one week and realised :

Imagine one day I wake up and all cleaners / sweepers have vanished from this world. What will be the result ? Piles of trash everywhere, which will rot eventually as no one will be there to remove it; the whole environment will be full of stench, mice will be seen running around feasting on the trash and so will be stray animals.

Who will clean up all this mess.????

So next time you think of being harsh with your maid, your sweeper, car cleaner, gardener. Or any person providing you with any kind of service, just stop for a moment, and think, ” What if he quits, what if they all quit, go on strike, or VANISH???????

So my friends, for a clean peaceful environment and to save all your precious time and energy, look after all your workers, all service providers. Treat them with kindness, respect and reward them for their hard work !!!!!!

Remember, the role of each person in society, this world, UNIVERSE, is very important. Every person is like a minute piece in a clock (made up of million pieces fit together) and they make the clock work……..RESPECT THE WHOLE CREATION!


Gold Medal Award for Dr. Sameera.

Gold Medal Award for Dr. Sameera.

In a recent Ophthalmological Society of Pakistan,s annual meeting at Bhurban, May, 2014, Dr. Sameera Irfan has been given a Gold Medal award for academic and professional excellence in the field of Pediatric Ophthalmology in Pakistan for the year 2014.

This is in lieu of her major research on successful Amblyopia (lazy eye) therapy for children and adults as well as for writing 3 books on ophthalmic sub-specialties: Amblyopia, Strabismus, Oculoplastic surgery and numerous publications in national & international peer reviewed journals.

This is her third Gold Medal award; the first one was for distinction in Ophthalmology in MBBS final exam,  the second one was for best paper presentation as a junior ophthalmologist at the annual meeting of Ophthalmological Society of Pakistan’s meeting, 2000.

She has established the department of Pediatric Ophthalmology & Oculoplastics at the Mughal Eye Trust Hospital, Lahore which has been offering free clinical services to patients being referred from all over Pakistan and abroad. This is the first free, charity centre of its kind providing quality service to its patients.

Because of her successful work on Amblyopia (lazy eye)  management for patients of all ages, she has made an amazing contribution and difference in the field of pediatric ophthalmology. Patients presenting with squint usually have a poor vision in the squinting eye (lazy eye).  Her latest research on amblyopia management not only restores good vision in the squinting eye but also corrects the squint with glasses only;  such patients do not have to undergo squint surgery.

Dr. Sameera promises to keep up the good work and her efforts to make a difference in the field of pediatric ophthalmology and oculoplastic surgery.


“Understanding Strabismus”

The management of a patient with strabismus / squint is one of the most challenging asks for trainee as well as general ophthalmologists. This book is clinically oriented and describes the management of all kinds of strabismus in a most comprehensive and a concise manner which is easy to grasp.

You can order it from the publishers: Jaypee Brothers or send me a mail and I shall post it to you.

My e. mail:


“My Child is Squinting his Eyes”



Fever is a sign that there is an infection somewhere in the body. Similarly, squinting of eyes also indicates that something is wrong with the child’s eyes and it is mandatory to find the cause of the squint rather than having it corrected surgically.
Human eye is like a camera. It gathers light impulses from the objects and transmits that information to the brain which then analyzes the details of that image. Remember there are two cameras (eyes) operating side by side. If the information transmitted by one eye is hazy or blurred, the brain gets confused. It blocks the faulty information from the problematic eye and that eye starts to squint i.e. turns inwards or outwards. The eye conditions that lead to a squint are:
1) Droopy upper eyelids.
2) Clouding or haziness of the cornea or lens of the eye.
3) Gross short-sightedness or far-sightedness.
4) Retinal or optic nerve malformation.
The most common cause of a squinting eye in children is far-sightedness. The child needs glasses to see clearly. Failure to recognize and rectify this problem with correcting glasses makes the child squeeze his eye muscles which then turn the eye inwards.
Whenever this problem is noticed, the help of a pediatric ophthalmologist should be sought urgently before that eye loses its sight permanently.
Surgery for such an eye is not the answer as it can only straighten the eye for a short while but cannot restore the sight. An eye with poor vision will soon deviate again.


Amblyopia can be treated successfully at all ages

According to my recent clinical research at a tertiary referral center in Lahore, Pakistan, dense amblyopia was successfully treated in 195 children and adults between age 13 – 45 years (median 15 years). Their visual acuity improved from 6/60 to 6/6 Snellen’s after 2 months of full-time occlusion therapy and near visual activities for 3-4 hours per day.
It is important to realize that an amblyopic eye is not a dead eye but a lazy, sleepy eye; the brain connections lie dormant because of an inhibitory influence of the good eye. Once this inhibition is removed, the sleepy eye wakes up.
This therapy only works if the patient compliance is excellent.
Only highly motivated and inspired patients will comply to the therapy and will regain good vision,



“Life & its Choices”

“Life & its Choices”

                                                                “We never get what we want,

                                                                   We never want what we get,

                                                                   We never have what we like,

                                                                   We never like what we have.

                                                                   And still we live & love.

                                                                   That’s life…”


My mom used to tell me a story regarding life and its choices; she always would tell me to choose wisely: one wrong move and you will ruin your whole life.

                                                       “The story of a Shoe”

“A girl was planning a long journey, a long time ago. So she bought a pair of shoes which she THOUGHT looked nice as well as comfortable.  She had bought them without even trying them out for a while or asking anyone’s advice. When she started on her journey, the new shoes started pinching her feet. She ignored the hurt for a while, thinking that they are new and are bound to become comfortable after wearing them for some time. So she continued her journey

After a while, they did get comfortable a bit, particularly when she wore a pair of socks as well.

The journey was long. The socks got torn and the shoes started hurting her again

Soon there were blisters on the feet and then they burst and started bleeding because she continued her journey with the shoes on and had no choice, as that was the only pair she had. She met people on the way but she couldn’t tell them that the shoes hurt. After all, they were her own choice and she had to stick with the choice she made for herself.

Even if she told someone, the pain and the suffering she was going through, only she knew, no-one else could understand or feel its gravity.

She would take the shoes off at night, but the pain was too much and either gave her nightmares or a sleepless night because of constant aching in her wounds.

So she waited every day and prayed when the journey would end. Whenever she looked down the road, all she could see was a distant, empty horizon; and a very long way to go alone with that constant pain.

 May be, Allah was testing her courage, tolerance and the constant hurt”.

 Who do you think won in the end, I often wondered???



Cyclosporin Eye Drops: A magical steroid-sparing drug

Cyclosporin Eye Drops: A magical steroid-sparing drug

Cyclosporin Eyedrops are an effective therapeutic agent in the management of a variety of autoimmune diseases especially ocular surface disorders like vernal keratoconjunctivitis, dry eye syndrome, mild to moderate anterior scleritis, VKC, Mooren’s Ulcer, Neurotrophic Corneal Ulcer, Corneal Melting.

Mechanism of action: Cyclosporin is a new class of drug that appears to work by inhibiting cytokine production by immune cells (T lymphocytes) and interfering with the action of interleukin-2 (as in scleritis, Mooren’s ulcer, Dry eye syndrome). IgE mediated immediate hypersensitivity response as in VKC. Studies support the efficacy of topical cyclosporine treatment through its immunomodulatory action, reversing inflammation of the ocular surface and lacrimal glands.

Animal studies have shown that Cyclosporin has no intraocular penetration; it concentrates on the ocular surface which enhances its anti-inflammatory effect after long term use. Even after a year of regular topical therapy, none to minimal blood concentration is found in rabbits.

Rationale of using varying concentration of eyedrops: Cyclosporin eyedrops can be prepared in varying concentrations depending upon the severity of the ocular surface disease; if the inflammation is marked, then 1-2% concentration should be used, 3-4 times /day; gradually the strength and frequency is reduced according to the clinical improvement.

Preparation of eyedrops: Cyclosporin capsules are available in 25mg and 100 mg strength (Sandimum neural: Novartis) which contain a water miscible gel.

  • To make 1% concentration, take gel out of two 25 mg capsules by a disposable syringe, put it in a sterile eye drops bottle and add 5 ml distilled water. Shake it well and dispense.
  • For 2% concentration, take either one 100 mg capsule or four 25 mg capsules and mix their gel in 5 ml
  • For 0.5% concentration, take one 25 mg capsule + 5 ml distilled water.
  • For 0.05% concentration, take one 25 mg capsule + 10 ml distilled water.


  • Mooren’s ulcer, Severe VKC, severe scleritis, corneal melt: 2%
  • Moderate Scleritis, moderate VKC, Stevens Johnson’s syndrome: 1%
  • Dry eyes: 0.5 – 0.05%









It comprises of the lacrimal gland, Ocular Surface and a Neural Network to provide a feedback from ocular surface to the lacrimal gland. Only that amount of tears are produced as are required by the ocular surface, depending upon the information sent to the lacrimal gland through the neural network.

Pathogenesis of dry eye: A multifactorial disease. Either it results from reduced tear production with increased tear osmolarity & an inflamed ocular surface. Or increased tear evaporation due to deficiency of lipid layer. Or poor wetting of ocular surface causing dry, damaged corneal epithelium. Even in presence of adequate tear production.

Lipid layer deficiency: due to meibomian gland dysfunction  →  Tear evaporation.

Aqueous layer deficiency: in KCS which is divided into: SS (Sjogren’s Syndrome) as in RA, SLE, Multiple sclerosis and Non-SS KCS: in pregnancy, postmenopausal women, HRT

Mucin deficiency: Stevens Johnson syndrome, chemical burn, Trachoma, Ocular cicatricialPemphigoid  →     Poor Wetting of Ocular Surface.

 Predisposing Factors for Dry eye:

Old age: usually seen in post-menopausal women.

Connective tissue disorders

LASIK : lifting of corneal flap damages corneal nerves.

Drugs: beta blockers. antihistamines, AGT.

Diabetes: Type 2, impaired autonomic innervation to lacrimal gland, reduced corneal sensitivity, poor lac. Gland microvasculature, advanced glycation products activated cytokines.

Vitamin A deficiency

 Effects of Ageing:

Ageing causes androgen deficiency. Estrogen & androgen receptors are present in the lacrimal & meibomian glands. Androgens are trophic for lacrimal & meibomian glands. They are potent anti-inflammatoryagents  ( TGF beta) & suppress lymphocytic infiltration of lacimal glands. Androgen def. causes inflamed lacrimal and meibomian glands, with tear def. & hyperosmolar tears. These cause a pro-inflammatory environment on ocular surface. Also cytokine production and T-cell activation further inflame ocular surface, disrupt the neural arc.

Cytokines inhibit neuronal function. They convert androgens to estrogens and increase the level of tissue degrading enzymes


It is a STEP-WISE APPROACH. It is important to listen to patient’s symptoms, find and eliminate the predisposing factors and find and treat the cause. Simply prescribing artificial tears does not work. This is an ocular surface disease; unless a wetting surface is restored, loading the eye with tear drops is useless.

Smptoms: Burning, Blurring of vision,Photophobia,paradoxical tearing.All symptoms are worsened by smoking, reading, computer work. Find the predisposing factors by a careful history.

Examination: aim is to find the cause resulting in a dry eye and to grade its severity. Grading  decides the step-wise management and helps in assessing improvment on follow-up.

Grading of Dry Eye: according to symptoms & signs


LEVEL 1:                                                                                                                LEVEL 2:

1: Environmental & dietary modification               Pt. symptoms don’t improve, T BUT &Schirmer =/< 10

2: Eliminate the cause.                                                   Add: Anti-inflammatory therapy:

3: Artificial tears.                                                                steroids, CsA, omega 3 fatty acids, Tetracyclines

4: Eyelid therapy.                                                             Punctal plugs

 Tetracyclines: antibacterial, anti-inflammatory, antiangiogenic, reduce lipase production→ FFA→stabilize tear film.

CyclosporinA : increases aqueous &meibomian sec., increases goblet cell count, decreases cytokines & inflammatory cells in conj.

 LEVEL 3:                                                                                                                                LEVEL 4:

If symptoms are severe, conj. & central corneal staining;              Severe symptoms, SPK+++, conj

TBUT & Schirmer< 5mm                                                                              Scarring/symblepharon, TBUT

 Permanent punctal occlusion                                                                 immediate, schirmer<2mm :

 Autologous serum                                                                                  Systemic immunosuppressant drugs.

 Soft contact lens                                                                                     Surgery: amniotic or mucus membrane graft, lid surgery, tarsorrhaphy

Autologous Serum: Contains trophic factors which promotes growth & migration of epi. cells. immunoglobulins, vitamins & are non-antigenic. Containdications; HIV, Hepatitis B, anaemia. Complications: bacterial keratitis, conjunctivitis, scleral vasculitis & melting.


1)      Note subjective improvement.

2)      Check the status of lid margins, cornea, tear meniscus.

3)      Perform Schirmer’s test & TFBUT every visit to gauge efficacy of therapy.

4)      NOTE: 3 layers of tear film; 3 tests to diagnose the abnormality of tear film.


Merits of a Good Doctor

Merits of a Good Doctor

I teach under-graduates as well as post-graduates. My favorite question to them is “WHY ARE YOU BECOMING A DOCTOR”. I am always surprised at the variety of answers I get:

“I want to make a lot of money”, not bad; these days, criterion of a successful person is the one who makes a lot of money at the end of the day.

“My parents wanted it”, an answer I get quite often.

“So I could find a good spouse”, another popular answer. Female doctors are considered to make good house-wives and better mothers (can help in their children’s education).

“To serve humanity” is a very unpopular reason to become a doctor. That makes me wonder how our values have changed with time. Now we are living just for ourselves. We teach our children that money is what makes a person powerful and successful; it can buy anything but we often forget that it cannot buy HAPPINESS, HEALTH, SERENITY, CONTENTMENT AND AN INNER PEACE.

I see my peers working in teaching hospitals in the morning, then after a couple hours afternoon nap, they get busy in their private practice and come home middle of the night; by the end of each day, their bank balance  multiplies and they go home happy, feeling rich. I ask them sometimes, “How much time are you giving to your families”. They always talk about “quality time“; according to them a few hours over the weekend, taking the kids out to cinema, park or a club is enough; it suffices to make them a good parent. Wives have a surplus amount of money for shopping so everyone is happy spending it while our Hard -Working Doctor is just a money making machine. Once that machine gets old and retired from work, then he realizes that the kids, who have grown up now, have no time for him as they have nothing in common; no common topics to talk about, no hobbies or interests to indulge in together, the wife doesn’t know what to do with him as she has led all her life developing her own interests while our good Doctor was busy making money.

Now our good doctor sits alone in a park on a bench under a tree and reminisces about his life, what he achieved and what has he lost. He still has a healthy savings account but could it buy him company of his children or his wife NOW?……… …….