EDITORIAL
Eye Care for the Developing World: The Next Frontier Marc F. Lieberman, MD* and Robert Ritch, MDÞ he article by Lawlor and Thomas1 in this issue brings to the fore a stage in the evolution of eye care delivery in the developing world: an approach to the detection and management of glaucoma, the leading cause of irreversible blindness. Whereas blindness due to cataract can be treated surgically, and great headway has been made in this area, the focus now needs to evolve into the detection and management of noncataractous causes of preventable blindness, the major entities being glaucoma and diabetic retinopathy. The predicted prevalence of 80 million cases of glaucoma worldwide several years from now will disproportionally impact the populations in the Asia-Pacific region, an area that will contain half of the world’s glaucoma patientsVthe bulk of whom suffer from angle closure, which is a disproportional cause of glaucoma blindness. In looking back over the past 30 years, although cataract remains the world’s leading remediable cause of blindness, strategies for efficiently and effectively addressing it have rapidly developed. Both large-volume mobile cataract camps and, in areas of high-density population, efficient ‘‘hub’’ centersV which coordinate the screening and transport of patients in need of quick, sight-restoring extracapsular cataract extraction/intraocular lens surgeryVhave become the norm for large-scale cataract care in parts of the developing world. Fortunately, cataractous visual impairment is amenable both to simple diagnosis by screening without the necessity for expensive instrumentation and to correction by a standardized and affordable 1-time procedure, which can be mastered by dexterous surgeons with varying levels of ophthalmic knowledge. Moreover, such large-volume approaches use standardized and portable equipment and require only short-term follow-up. A favorable side development of this model has been the facilitation of many beneficial interactions among volunteer surgeons from the developed world who visit host venues, participate in training, and impart invaluable diagnostic and surgical skills. Cataracts may be envisioned as relatively ‘‘low-hanging fruit’’ in terms of the simplicity of conceptualizing and mobilizing discrete resources to eliminate blindness for so many. The authors state that most government agencies and many nongovernmental organizations concentrate mainly on cataract because the numbers dealt with, both in screening and treatment, attract publicity, appeal to donors, and generate awareness of ocular health. Lawlor and Thomas1 are now sounding the call to gird for the next stage in attacking preventable blindness from an altogether more insidious affliction: the glaucomas, in their various manifestations. This will require an entirely new paradigm and developmental level of commitment. The key point is the need to intensify training efforts at the local level. And for skilled ophthalmologists to be available locally, they must be adequately trained in large numbers. Hence, intensive, long-term support and proctored education at the residency level of training must focus on the mastery of comprehensive eye examinations capable of detecting and managing a variety of sight-threatening ocular conditions. In other words, to address the unmet challenges of glaucomatous pathology, efforts need now to focus on managing multiple ophthalmic conditions by better trained ophthalmic generalists, rather than focus on transferring cataract surgical skills. This article highlights basic issues that differentiate the recognition and care of glaucoma from cataract detection, which is usually accomplished by screening large numbers of patients and arranging prompt treatment. With respect to glaucoma strategies, there are 3 major weaknesses in population screening: (i) faulty detection and discrimination of different types of glaucoma when assessed by technicians, (ii) the ophthalmologist’s need to master distinctive management protocols for different glaucomas, and (iii) difficulties providing follow-up for patients after interventionVeither iridotomy or trabeculectomy. Especially after filtration surgery, the demands are greater: for systematically monitoring for the possible surgical sequelae of infection or of late-onset cataractVeither of which ‘‘resets’’ the need for new interventions and more careful follow-up.
T
From the *University California San Francisco; Director of Glaucoma Services, California Pacific Medical Center; and Tibet Vision Project, San Francisco, CA; and †New York Eye and Ear Infirmary and Mount Sinai School of Medicine, New York, and New York Medical College, Valhalla, NY. Received for publication December 30, 2011; accepted December 31, 2011. The authors have no funding or conflicts of interest to declare. Reprints: Robert Ritch, MD, New York Eye and Ear Infirmary, 310 East 14 St, New York, NY 10003. E-mail: [email protected]. Copyright * 2014 by Asia Pacific Academy of Ophthalmology ISSN: 2162-0989 DOI: 10.1097/APO.0000000000000038
Asia-Pacific Journal of Ophthalmology
&
Volume 3, Number 1, January/February 2014
www.apjo.org
Copyright © 2014 Asia Pacific Academy of Ophthalmology. Unauthorized reproduction of this article is prohibited.
1
Asia-Pacific Journal of Ophthalmology
Editorial
Population screenings for glaucoma, so popular 2 decades ago, consisted primarily of measuring intraocular pressure. This unfortunately produced large numbers of false positives, overloaded the medical system, and missed many cases of normaltension glaucoma and angle closure; in addition, glaucoma patients whose intraocular pressure may have been normal at the time of screening but elevated at other times (eg, diurnal fluctuation) were not detected. Successful negotiation of these hurdles will require a significantly higher level of skill sets than the training of nonphysicians for large-scale cataract management. Thus glaucoma’s distinctive needs are clearVbut perspectives on how to effectively and efficiently meet them are just now being elaborated, as Lawlor and Thomas1 outline here. Regrettably, even skilled population-based screening has proven deficient in both cost-effectiveness and efficacy of detection of either primary open-angle glaucoma (POAG)2 or primary angle-closure glaucoma (PACG).3 The sobering conclusion is the inescapable need to ‘‘ratchet up the game’’: by committing intensive and prolonged resources for residency-level mastery of comprehensive eye examinations and familiarity with clinical signs requiring skilled intervention and providing long-term follow-up. The shift from the solitary focus on screening and cataract surgery to investing in the infrastructures needed for quality residency training in general ophthalmic skills is formidable. In an evaluation of ophthalmology residency programs in India a decade ago, despite specific guidelines and investment in equipment and training, reassessment after a multiyear follow-up was disappointing in virtually all categories.4 Moreover, both glaucoma and cataract care face the twin ‘‘head winds’’ of persistent worldwide povertyVwhereby disease severity and poor access to care are directly related both to low socioeconomic status5 and to continued population growth, which increases the number of the elderly. Despite massive worldwide efforts for cataract care, these trends have frustrated the reduction of either the prevalence of blindness or of significant visual impairment.6 The sobering perspective of Lawlor and Thomas’1 article is nevertheless embedded with hopeful glimmers on how to proceed. First is their calling explicit attention to the need for a major change of focus for public health and ophthalmic thought leaders to recognize that this next stage of care, side-by-side with ongoing and successful cataract strategies, is whole-hearted investment in educational infrastructures, which will reap benefits in many ways. This challenge is reminiscent of the Flexner Report of 1910, issued in the United States for American medical schools to explicitly achieve 3 goals: (1) to enact higher admission and graduation standards, (2) to adhere strictly to the protocols of mainstream science in their teaching and research, and (3) to develop and apply criteria for experiential and hands-on teaching. Many American medical schools fell short of the standards advocated; subsequent to its publication, nearly half of such schools merged or were closed outright. Nevertheless, the high standards and requirements for modern medical training this revolution engendered, a century later, remain the de facto universal, transnational foundations for health care excellence throughout the developed world. Although new technologies hold promise, such as telemedical evaluation of visual field results and optic nerve images for remote glaucoma screening,7 a comprehensive historical assessment of the value of tests in diagnosing and managing glaucoma cautions against the persistent fallacy of ‘‘techno-lust,’’ whereby inflated expectations fall far short of evidential performance. Training informed and competent clinicians, rather than excessively relying on new instrumentation, is the most indispensible investment of human, time, and financial resources.8 Residency training in glaucoma must focus on detection, proper diagnosis, and knowledge of approaches to treatment and the methods of
2
www.apjo.org
&
Volume 3, Number 1, January/February 2014
treatment, including appropriate management of surgical complications and long-term follow-up. Even in the United States, gonioscopy was not routinely performed a generation ago, and it was the advent of laser trabeculoplasty that forced many ophthalmologists to learn the procedure. Indentation gonioscopy is essential to the management of angle closure. Examination of the optic disc and its variations and appearance in glaucoma, with photographic documentation, has become another essential feature in proper diagnosis and management. Unfortunately, these procedures are not taught in residency programs in many programs in developing countries, and if the instructors are not familiar with them, then they cannot teach them. The very inclusion of the word ‘‘opportunity’’ in the title of Lawlor and Thomas’1 piece reflects an optimistic nod that such a shift toward comprehensive ophthalmic education is slowly preceding. For example, they illustrate that under conditions of high population density, models such as that of LV Prasad Institute in Hyderabad, whose innovative pyramidal levels of screening in remote centers by technicians are integrated with staged, referred care to higher levels of generalists and specialists as needed.9 Or that the skill set a surgeon masters for small-incision cataract/lens implant surgery can be translated, with training, into mastery of trabeculectomy surgery for glaucoma.10 The authors’ focus on the glaucomas is crucial: as the second leading cause of visual impairment, many of whose forms can be successfully surgically addressed if detected early enough, enormous benefits accrue: to the treated patient whose vision is saved, to the ophthalmologist’s sense of involvement and mastery, and to rising community expectations of the availability of quality comprehensive eye care.11 And by integrating the more demanding skills of clinical detectionVgonioscopy, optic nerve and retinal assessment, perimetric interpretation, and so onVinto systematic and comprehensive eye care, the wider public health spectrum of vision loss and ocular disease are engaged. Implicit in the development of more comprehensive eye care is its integration into larger health systems, as envisioned by the most current World Health Organization Global Action Plan for the prevention of Avoidable Blindness 2014Y2019.12 This tightly reasoned article is well worth re-reading and pondering. It is nothing less than a manifesto that specifically highlights crucial elements of the next steps on the map for addressing preventable blindness among our fellow human beings. When the ideas and approaches conveyed in this article are widely adopted, the major proportion of blindness from glaucoma, now the leading cause of irreversible, but potentially preventable blindness, can and will be overcome, saving millions from a lifetime of suffering, economic disadvantage, and lack of fulfillment of their potential, in addition to the savings to society itself.
REFERENCES 1. Lawlor MT, Thomas R. Addressing glaucoma in developing countries of the Asia-Pacific region: an opportunity to transition from disease specific responses to integration of eye care [published online ahead of print]. Asia Pac J Ophthalmol. 2014;3:4Y8. 2. Moyer VA. Screening for glaucoma: U.S. Preventive Services Task Force recommendation statement. Ann Intern Med. 2013;159:484Y489. 3. Thomas R, Sekhar GC, Parikh R. Primary angle closure glaucoma: a developing world perspective. Clin Exp Ophthalmol. 2007;35:374Y378. 4. Thomas R, Dogra M. An evaluation of medical college departments in India and change following provision of modern instrumentation and training. Indian J Ophtalmol. 2008;59:9Y16.
* 2014 Asia Pacific Academy of Ophthalmology
Copyright © 2014 Asia Pacific Academy of Ophthalmology. Unauthorized reproduction of this article is prohibited.
Asia-Pacific Journal of Ophthalmology
&
Volume 3, Number 1, January/February 2014
5. Wesolosky JD, Rudnisky CJ. Relationship between cataract severity and socioeconomic status. Canadian journal of ophthalmology. J Can Ophtalmol. 2013;48:471Y477. 6. Stevens GA, White RA, Flaxman SR, et al. Global prevalence of vision impairment and blindness: magnitude and temporal trends, 1990Y2010. Ophthalmology. 2013;120:2377Y2384. 7. Kumar S, Giubilato A, Morgan W, et al. Glaucoma screening: analysis of conventional and telemedicine-friendly devices. Clin Exp Ophthalmol. 2007;35:237Y243. 8. Lieberman MF, Congdon NG, He M. The value of tests in the diagnosis and management of glaucoma. Am J Ophthalmol. 2011;152:889Y899.
Editorial
9. Rao GN. An infrastructure model for the implementation of Vision 2020. Community Eye Health J. 2005;18:61Y62. 10. Thomas R, Parikh R, Muliyil J. Comparison between phacoemulsification and the Blumenthal technique of manual small-incision cataract surgery combined with trabeculectomy. J Glaucoma. 2003;12:333Y339. 11. Thomas R. Glaucoma in developing countries. Indian J Ophthalmol. 2012;60:446Y450. 12. WHO Sixty-Sixth World Health Assembly. Draft action plan for the prevention of avoidable blindness and visual impairment for 2014Y2019. Provisional Agenda Item 13.4. A66/11.2013. Available at: http://www.who.int/blindness/actionplan/en/. Accessed: January 14, 2014.
"History is a vision of God’s creation on the move." V Arnold J. Toynbee
* 2014 Asia Pacific Academy of Ophthalmology
www.apjo.org
Copyright © 2014 Asia Pacific Academy of Ophthalmology. Unauthorized reproduction of this article is prohibited.
3
Eye Care for the Developing World: The Next Frontier Marc F. Lieberman, MD* and Robert Ritch, MDÞ he article by Lawlor and Thomas1 in this issue brings to the fore a stage in the evolution of eye care delivery in the developing world: an approach to the detection and management of glaucoma, the leading cause of irreversible blindness. Whereas blindness due to cataract can be treated surgically, and great headway has been made in this area, the focus now needs to evolve into the detection and management of noncataractous causes of preventable blindness, the major entities being glaucoma and diabetic retinopathy. The predicted prevalence of 80 million cases of glaucoma worldwide several years from now will disproportionally impact the populations in the Asia-Pacific region, an area that will contain half of the world’s glaucoma patientsVthe bulk of whom suffer from angle closure, which is a disproportional cause of glaucoma blindness. In looking back over the past 30 years, although cataract remains the world’s leading remediable cause of blindness, strategies for efficiently and effectively addressing it have rapidly developed. Both large-volume mobile cataract camps and, in areas of high-density population, efficient ‘‘hub’’ centersV which coordinate the screening and transport of patients in need of quick, sight-restoring extracapsular cataract extraction/intraocular lens surgeryVhave become the norm for large-scale cataract care in parts of the developing world. Fortunately, cataractous visual impairment is amenable both to simple diagnosis by screening without the necessity for expensive instrumentation and to correction by a standardized and affordable 1-time procedure, which can be mastered by dexterous surgeons with varying levels of ophthalmic knowledge. Moreover, such large-volume approaches use standardized and portable equipment and require only short-term follow-up. A favorable side development of this model has been the facilitation of many beneficial interactions among volunteer surgeons from the developed world who visit host venues, participate in training, and impart invaluable diagnostic and surgical skills. Cataracts may be envisioned as relatively ‘‘low-hanging fruit’’ in terms of the simplicity of conceptualizing and mobilizing discrete resources to eliminate blindness for so many. The authors state that most government agencies and many nongovernmental organizations concentrate mainly on cataract because the numbers dealt with, both in screening and treatment, attract publicity, appeal to donors, and generate awareness of ocular health. Lawlor and Thomas1 are now sounding the call to gird for the next stage in attacking preventable blindness from an altogether more insidious affliction: the glaucomas, in their various manifestations. This will require an entirely new paradigm and developmental level of commitment. The key point is the need to intensify training efforts at the local level. And for skilled ophthalmologists to be available locally, they must be adequately trained in large numbers. Hence, intensive, long-term support and proctored education at the residency level of training must focus on the mastery of comprehensive eye examinations capable of detecting and managing a variety of sight-threatening ocular conditions. In other words, to address the unmet challenges of glaucomatous pathology, efforts need now to focus on managing multiple ophthalmic conditions by better trained ophthalmic generalists, rather than focus on transferring cataract surgical skills. This article highlights basic issues that differentiate the recognition and care of glaucoma from cataract detection, which is usually accomplished by screening large numbers of patients and arranging prompt treatment. With respect to glaucoma strategies, there are 3 major weaknesses in population screening: (i) faulty detection and discrimination of different types of glaucoma when assessed by technicians, (ii) the ophthalmologist’s need to master distinctive management protocols for different glaucomas, and (iii) difficulties providing follow-up for patients after interventionVeither iridotomy or trabeculectomy. Especially after filtration surgery, the demands are greater: for systematically monitoring for the possible surgical sequelae of infection or of late-onset cataractVeither of which ‘‘resets’’ the need for new interventions and more careful follow-up.
T
From the *University California San Francisco; Director of Glaucoma Services, California Pacific Medical Center; and Tibet Vision Project, San Francisco, CA; and †New York Eye and Ear Infirmary and Mount Sinai School of Medicine, New York, and New York Medical College, Valhalla, NY. Received for publication December 30, 2011; accepted December 31, 2011. The authors have no funding or conflicts of interest to declare. Reprints: Robert Ritch, MD, New York Eye and Ear Infirmary, 310 East 14 St, New York, NY 10003. E-mail: [email protected]. Copyright * 2014 by Asia Pacific Academy of Ophthalmology ISSN: 2162-0989 DOI: 10.1097/APO.0000000000000038
Asia-Pacific Journal of Ophthalmology
&
Volume 3, Number 1, January/February 2014
www.apjo.org
Copyright © 2014 Asia Pacific Academy of Ophthalmology. Unauthorized reproduction of this article is prohibited.
1
Asia-Pacific Journal of Ophthalmology
Editorial
Population screenings for glaucoma, so popular 2 decades ago, consisted primarily of measuring intraocular pressure. This unfortunately produced large numbers of false positives, overloaded the medical system, and missed many cases of normaltension glaucoma and angle closure; in addition, glaucoma patients whose intraocular pressure may have been normal at the time of screening but elevated at other times (eg, diurnal fluctuation) were not detected. Successful negotiation of these hurdles will require a significantly higher level of skill sets than the training of nonphysicians for large-scale cataract management. Thus glaucoma’s distinctive needs are clearVbut perspectives on how to effectively and efficiently meet them are just now being elaborated, as Lawlor and Thomas1 outline here. Regrettably, even skilled population-based screening has proven deficient in both cost-effectiveness and efficacy of detection of either primary open-angle glaucoma (POAG)2 or primary angle-closure glaucoma (PACG).3 The sobering conclusion is the inescapable need to ‘‘ratchet up the game’’: by committing intensive and prolonged resources for residency-level mastery of comprehensive eye examinations and familiarity with clinical signs requiring skilled intervention and providing long-term follow-up. The shift from the solitary focus on screening and cataract surgery to investing in the infrastructures needed for quality residency training in general ophthalmic skills is formidable. In an evaluation of ophthalmology residency programs in India a decade ago, despite specific guidelines and investment in equipment and training, reassessment after a multiyear follow-up was disappointing in virtually all categories.4 Moreover, both glaucoma and cataract care face the twin ‘‘head winds’’ of persistent worldwide povertyVwhereby disease severity and poor access to care are directly related both to low socioeconomic status5 and to continued population growth, which increases the number of the elderly. Despite massive worldwide efforts for cataract care, these trends have frustrated the reduction of either the prevalence of blindness or of significant visual impairment.6 The sobering perspective of Lawlor and Thomas’1 article is nevertheless embedded with hopeful glimmers on how to proceed. First is their calling explicit attention to the need for a major change of focus for public health and ophthalmic thought leaders to recognize that this next stage of care, side-by-side with ongoing and successful cataract strategies, is whole-hearted investment in educational infrastructures, which will reap benefits in many ways. This challenge is reminiscent of the Flexner Report of 1910, issued in the United States for American medical schools to explicitly achieve 3 goals: (1) to enact higher admission and graduation standards, (2) to adhere strictly to the protocols of mainstream science in their teaching and research, and (3) to develop and apply criteria for experiential and hands-on teaching. Many American medical schools fell short of the standards advocated; subsequent to its publication, nearly half of such schools merged or were closed outright. Nevertheless, the high standards and requirements for modern medical training this revolution engendered, a century later, remain the de facto universal, transnational foundations for health care excellence throughout the developed world. Although new technologies hold promise, such as telemedical evaluation of visual field results and optic nerve images for remote glaucoma screening,7 a comprehensive historical assessment of the value of tests in diagnosing and managing glaucoma cautions against the persistent fallacy of ‘‘techno-lust,’’ whereby inflated expectations fall far short of evidential performance. Training informed and competent clinicians, rather than excessively relying on new instrumentation, is the most indispensible investment of human, time, and financial resources.8 Residency training in glaucoma must focus on detection, proper diagnosis, and knowledge of approaches to treatment and the methods of
2
www.apjo.org
&
Volume 3, Number 1, January/February 2014
treatment, including appropriate management of surgical complications and long-term follow-up. Even in the United States, gonioscopy was not routinely performed a generation ago, and it was the advent of laser trabeculoplasty that forced many ophthalmologists to learn the procedure. Indentation gonioscopy is essential to the management of angle closure. Examination of the optic disc and its variations and appearance in glaucoma, with photographic documentation, has become another essential feature in proper diagnosis and management. Unfortunately, these procedures are not taught in residency programs in many programs in developing countries, and if the instructors are not familiar with them, then they cannot teach them. The very inclusion of the word ‘‘opportunity’’ in the title of Lawlor and Thomas’1 piece reflects an optimistic nod that such a shift toward comprehensive ophthalmic education is slowly preceding. For example, they illustrate that under conditions of high population density, models such as that of LV Prasad Institute in Hyderabad, whose innovative pyramidal levels of screening in remote centers by technicians are integrated with staged, referred care to higher levels of generalists and specialists as needed.9 Or that the skill set a surgeon masters for small-incision cataract/lens implant surgery can be translated, with training, into mastery of trabeculectomy surgery for glaucoma.10 The authors’ focus on the glaucomas is crucial: as the second leading cause of visual impairment, many of whose forms can be successfully surgically addressed if detected early enough, enormous benefits accrue: to the treated patient whose vision is saved, to the ophthalmologist’s sense of involvement and mastery, and to rising community expectations of the availability of quality comprehensive eye care.11 And by integrating the more demanding skills of clinical detectionVgonioscopy, optic nerve and retinal assessment, perimetric interpretation, and so onVinto systematic and comprehensive eye care, the wider public health spectrum of vision loss and ocular disease are engaged. Implicit in the development of more comprehensive eye care is its integration into larger health systems, as envisioned by the most current World Health Organization Global Action Plan for the prevention of Avoidable Blindness 2014Y2019.12 This tightly reasoned article is well worth re-reading and pondering. It is nothing less than a manifesto that specifically highlights crucial elements of the next steps on the map for addressing preventable blindness among our fellow human beings. When the ideas and approaches conveyed in this article are widely adopted, the major proportion of blindness from glaucoma, now the leading cause of irreversible, but potentially preventable blindness, can and will be overcome, saving millions from a lifetime of suffering, economic disadvantage, and lack of fulfillment of their potential, in addition to the savings to society itself.
REFERENCES 1. Lawlor MT, Thomas R. Addressing glaucoma in developing countries of the Asia-Pacific region: an opportunity to transition from disease specific responses to integration of eye care [published online ahead of print]. Asia Pac J Ophthalmol. 2014;3:4Y8. 2. Moyer VA. Screening for glaucoma: U.S. Preventive Services Task Force recommendation statement. Ann Intern Med. 2013;159:484Y489. 3. Thomas R, Sekhar GC, Parikh R. Primary angle closure glaucoma: a developing world perspective. Clin Exp Ophthalmol. 2007;35:374Y378. 4. Thomas R, Dogra M. An evaluation of medical college departments in India and change following provision of modern instrumentation and training. Indian J Ophtalmol. 2008;59:9Y16.
* 2014 Asia Pacific Academy of Ophthalmology
Copyright © 2014 Asia Pacific Academy of Ophthalmology. Unauthorized reproduction of this article is prohibited.
Asia-Pacific Journal of Ophthalmology
&
Volume 3, Number 1, January/February 2014
5. Wesolosky JD, Rudnisky CJ. Relationship between cataract severity and socioeconomic status. Canadian journal of ophthalmology. J Can Ophtalmol. 2013;48:471Y477. 6. Stevens GA, White RA, Flaxman SR, et al. Global prevalence of vision impairment and blindness: magnitude and temporal trends, 1990Y2010. Ophthalmology. 2013;120:2377Y2384. 7. Kumar S, Giubilato A, Morgan W, et al. Glaucoma screening: analysis of conventional and telemedicine-friendly devices. Clin Exp Ophthalmol. 2007;35:237Y243. 8. Lieberman MF, Congdon NG, He M. The value of tests in the diagnosis and management of glaucoma. Am J Ophthalmol. 2011;152:889Y899.
Editorial
9. Rao GN. An infrastructure model for the implementation of Vision 2020. Community Eye Health J. 2005;18:61Y62. 10. Thomas R, Parikh R, Muliyil J. Comparison between phacoemulsification and the Blumenthal technique of manual small-incision cataract surgery combined with trabeculectomy. J Glaucoma. 2003;12:333Y339. 11. Thomas R. Glaucoma in developing countries. Indian J Ophthalmol. 2012;60:446Y450. 12. WHO Sixty-Sixth World Health Assembly. Draft action plan for the prevention of avoidable blindness and visual impairment for 2014Y2019. Provisional Agenda Item 13.4. A66/11.2013. Available at: http://www.who.int/blindness/actionplan/en/. Accessed: January 14, 2014.
"History is a vision of God’s creation on the move." V Arnold J. Toynbee
* 2014 Asia Pacific Academy of Ophthalmology
www.apjo.org
Copyright © 2014 Asia Pacific Academy of Ophthalmology. Unauthorized reproduction of this article is prohibited.
3
