Food and good health
By Dr Maninder Kaur
The management of chronic non-communicable ailments like cancer, cardiovascular diseases, arthritis and cataract, has undergone vast changes during the past few decades. The vital role played by antioxidants in the prevention of these diseases has recently become the focus of attention. (Naturally occurring antioxidants include vitamin E, urate, vitamin C and beta carotene pro-vitamin A).

Relief beyond belief
By Dr J.D. Wig
There seems little doubt that humans in the pre-anaesthetic era had a different understanding and relation to the concept of pain, in particular surgical discomfort. They were more inured to everyday suffering than those of us in this industrialised century. How were human beings able to tolerate such suffering and endure overwhelming levels of pain?

Who is afraid of squint ?
By Dr Kanwar Mohan

Normally, both of our eyes are aligned parallel in all directions of movement with the help of six muscles attached to the outside of each eye. To focus the eyes on the same spot, all the muscles in each eye must be balanced and working together in a coordinated manner. Squint, commonly called "Teer", is a condition in which the eyes are misaligned and point in different directions because some muscles in one eye become weak and some become strong owing to various reasons.

The strong muscles pull the eye towards them and this causes the turning of that eye inward, outward, upward or downward.

It occurs in 3 to 5 per cent of all children.

Squint may be present at all times, called "constant squint" or may be present only occasionally, called "intermittent squint". An intermittent squint may become constant as the age of the patient increases.

Sometimes, there is only a tendency towards squint, called "latent squint" which is kept under control by efforts of the eye muscles. When the eye muscles are tired due to overwork, fatigue or illness, they are not able to control the latent squint and the squint becomes clearly visible.

Usually there is no clearly defined cause and a child is just born with squint or it develops during infancy or childhood. Sometimes, there may be a family history of squint and the child may inherit it. Any disease or injury leading to reduced vision or damage to the eye muscles and their nerves or damage to that part of the brain which controls eye movements can cause squint.

Squint is especially common among children who have disorders of the brain like mental retardation, delayed development, brain tumours etc. It can also occur if one eye is considerably more near-sighted or far-sighted than the other.

The main symptom of squint is that one eye is not straight and it looks bad cosmetically. In older children and adults, it gives rise to psychological problems. The affected person avoids mixing with others and hesitates to attend functions.

Sometimes the child will close one eye in bright sunlight or tilt the head to use the eyes together.

Normal vision develops during childhood when both eyes have normal alignment. The first six years of life are particularly important, since this is the period when vision is developing. If squint develops during this age, normal vision will not develop and the child will have reduced vision in the squinting eye, which is called amblyopia or lazy eye. Lazy eye occurs in about 50 per cent of the children with squint.

With normal alignment, both eyes focus at the same spot. The brain then fuses the images from each eye into a single three-dimensional image. This three-dimensional image gives us depth perception. When one eye squints, two different images are sent to the brain. In a young child, the brain recognises the image from the straight eye and ignores the image from the squinting eye. This causes loss of depth perception which is an important component of binocular vision. In adults, the brain is not able to ignore the image from the squinting eye and the person has double vision. Latent squint usually does not cause symptoms. But if it is large, the eye muscles may need a great effort to keep the eyes straight to avoid double vision. This may lead to eye strain and headache.

Squint can be diagnosed during an eye examination. Often parents note that the eyes of the child are pointing in different directions and bring the child for an eye check-up. Young children may have a wide, flat nose and a fold of skin at the eyelids near the nose which can make the eyes appear squinting. It is called "false squint". This appearance of squint improves as the child grows and does not need any treatment. An eye specialist can usually tell whether the child has true squint or false squint.

The child should be examined for possible squint as soon as a misalignment is detected by the parents, no matter how small the misalignment or how young the child. No child is too young to be examined. The infant's eyes are often slightly misaligned during the first month of life. However, large degrees of misalignment or misalignment persisting beyond one month of age should be investigated. It is recommended that all children should have their vision and eye alignment checked at or before their fourth birthday. If there is a family history of squint or lazy eye, the vision should be checked even earlier than three years of age. The aim is to prevent amblyopia (lazy eye) and to allow the development of binocular vision.

The treatment of squint does not mean only to straighten the eyes. It is also aimed at preserving vision and restoring binocular cooperation. As poor vision (lazy eye) occurs in about 50 per cent of the children with squint, it is extremely important to treat the lazy eye first and then concentrate on straightening the eye later. Remember that making the eyes straight by surgery or glasses does not cure the lazy eye. Lazy eye has to be treated separately by placing a "patch" on the normal (straight) eye and forcing the child to use the squinting eye. Patching is stopped when vision in the lazy eye has improved to the maximum and there is no further improvement in spite of a sincere use of patch for three or four months. If lazy eye (amblyopia) is not detected and treated early, permanent visual loss will occur.

Glasses can cure only a special type of squint called "accommodative squint". Here the child is far-sighted (using plus glasses) and can focus the eyes to compensate for the far-sightedness, but the focusing effort (accommodation) to see clearly causes the eyes to cross. Glasses reduce the focusing effort and straighten the eyes. Sometimes bifocals are needed to achieve straight eyes. Remember that in all other varieties of squint, glasses do not cure squint but may help to keep it under control.

Eye exercises are effective in curing only a latent squint where the person has only a tendency towards squint. They do not have any role in a patient with visible squint and squint surgery will be required in most of these patients. The intake of a high-protein diet and vitamins etc. can help in controlling a latent squint. Diet has no role in a patient with visible squint.

Generally, squint surgery should not be done unless poor vision (lazy eye) has been treated or declared untreatable, because vision has some effect on the plan and success of squint surgery. Also the treatment of lazy eye may cause some change in the amount of squint and this can alter the surgical plan.

For children with constant squint, early surgery offers the best chance for the eyes to work well together. Therefore, children should have squint surgery in early childhood (within one and two years).

Often, treatment of lazy eye continues for a long time because of the child's non-cooperation and by the time amblyopia is declared treated or untreatable, the child is already above this age. Surgery in older children and adults is usually for cosmetic purpose only.

In squint surgery, depending upon which direction the eye is turning, the weak eye muscles are strengthened by making them short and the strong muscles are weakened by positioning them backwards on the eye-ball by a pre-planned amount to balance the effective forces of these muscles on the eye-ball. This brings the eyes into normal alignment.

After squint surgery, recovery is usually rapid and patients are usually able to resume their normal activities within a few days. Early after surgery for a month or two, exercises may be prescribed in suitable patients to redevelop the ability to use both eyes together. In many cases further surgery may be needed at a later stage to achieve the best alignment of the eyes.

Squint surgery is usually a safe procedure as it involves only the external parts (mainly muscles) of the eyes and no knives penetrate deep into the internal structures of the eye.

The results of squint surgery are better in certain types of squint as compared to others. If squint has been constantly persisting for a long time, certain eye muscles remain stretched all the time and become tight. This affects the success of squint surgery.

Vision has a very important role in the success of squint surgery. If the squinting eye has untreatable poor vision, squint has a tendency to reappear after the initial successful alignment of the eyes by squint surgery. The success of squint surgery depends very significantly on the accurate assessment of squint, an accurate surgical plan and very meticulous surgery.

For successful squint surgery, the surgeon has to take care of many factors while doing the operation. Experience and expertise plays a very important role for the success of squint operation.

Most patients can obtain satisfactory cosmetic results and often good eyesight with some binocular vision if the treatment of squint is started early enough and in a consistent manner. So, do not ignore squint.

Food and good health
By Dr Maninder Kaur

The management of chronic non-communicable ailments like cancer, cardiovascular diseases, arthritis and cataract, has undergone vast changes during the past few decades. The vital role played by antioxidants in the prevention of these diseases has recently become the focus of attention. (Naturally occurring antioxidants include vitamin E, urate, vitamin C and beta carotene pro-vitamin A).

Epidemiological studies show statistical correlations between the incidence of disease and low levels of antioxidant nutrients in the blood or diet. This is the case in respect of cancer and selenium, vitamin A, beta carotene, vitamin C and vitamin E. There is also an inverse relationship between the incidence of cardiovascular disease and the status of vitamin E and vitamin C. There is some evidence that topical vitamin E can protect the skin against damaging effects of ultraviolet rays.

Vitamin E acts as a scavenger of harmful free radicals. It is the major lipid soluble antioxidant located in cell membranes which terminates the formation of free radicals. Vitamin E, vitamin C and pro-vitamin A also work synergistically in the body to boost the immune function which is the defence system of the body to fight infections.

Free radicals have been found to be associated with diseases such as cancer, rheumatoid arthritis and atherosclerosis. Today, it is believed that numerous diseases in both adults and neonates are associated with free radicals and their damaging effects.

In the last couple of years efforts have been directed towards altering the course of these diseases by modulating the processes that form free radicals.

What is a free radical? A free radical is an atom or a molecule that has one or more unpaired electrons. Its consequent tendency to acquire an electron from other substances renders it highly reactive and potentially toxic to tissues. Free radicals are generated in the human body by peroxidation (autoxidation) of polyunsaturated fatty acids (PUFAs) which are the normal constituents of cellular and subcellular membranes.

Endogenously, oxidative reactions during normal metabolic processes also produce free radicals as intermediates. These free radicals in the human body damage cell membranes, tissues and genes where they may be a cause of cancer, inflammatory diseases, atherosclerosis, ageing etc.

Free radicals also break DNA and may cause somatic mutations leading to cancer. They are produced by ionising radiations (X-rays, nuclear explosions etc). Cigarette-smoke contains high concentrations of various free radicals.

The breathing of 100 per cent oxygen in one atmosphere for more than 24 hours produces the destruction of the lung endothelium, lung oedema and even death. This is due to the release of free radicals by activated neutrophils (a type of white blood cells). Reperfusion injury after myocardial ischaemia (heart attack) and kidney transplant, too, is caused by free radicals.

To control and reduce lipid peroxidation both humans and nature invoke the use of antioxidants. Antioxidants act by decreasing the formation of new free radicals, trapping free radicals and scavenging them. This explains why our medical stores now have various commercial antioxidant plus multivitamin preparations in circulation. However, it is recommended that the consumption of cereals, nuts, fruits and vegetables — all good sources of antioxidants — should be increased.

Antioxidants used as food additives include propyl gallate, butylated hydroxyanisole (BHA) and butylated hydroxytoluene (BHT) because auto oxidation of lipids exposed to oxygen is also responsible for the deterioration of items of food (rancidity). Vitamin E being fat-soluble is a lipid phase anti-oxidant and vitamin C being water-soluble is an aqueous phase antioxidant. Vitamin C acts by regenerating vitamin E from the vitamin E free radical. Beta carotene acts as a free radical chain-breaking antioxidant. Selenium has been found to decrease the requirement of vitamin E and vice versa. They act synergistically with each other in minimising lipid peroxidation.

According to the most recent research conducted by Dr Neal Bernard, a Washington-based physician and President of the Physicians Committee for Responsible Medicine (PCRM),"Free radicals attack the melanin producing cells which results in greying, the consumption of antioxidants as citrus foods, oranges and green leafy vegetables can stabilise oxygen molecules (free radicals) in the blood stream. The intake of beta carotene found in sweet potato, carrots and spinach and diet rich in vitamins C and E can slow down the ageing process".

He says the Physicians Committee for Responsible Medicine has succeeded in including vegetarianism in dietary guidelines for the American Federal Food Policy. Dr Bernard adds that a plant-based diet can help in preventing and reversing heart diseases, reducing cancer risks and managing diabetes more powerfully than drugs.

To conclude, antioxidant supplementation not only has an important role to play in the prevention of diseases such as cardiovascular ailments, cancer, arthritis etc; it is also helpful in leading healthy life. Therefore, it is recommended that the consumption of vegetables and fruits should be encouraged right from childhood.

Vitamin E: Vegetable oils, butter, margarine, cereals, meat products.

Vitamin C: Amla, guava, citrus fruits, green and leafy vegetables, potatoes, sprouted pulses.

Vitamin A: Fish liver oils, milk, butter, cheese, egg yolk, liver.

Beta-carotene (Pro-vitamin A): Yellow and orange-coloured vegetables and fruits (carrots, tomatoes, pumpkin, mangoes, papaya, peaches, apricots); green leafy vegetables like spinach.

Relief beyond belief
By Dr J.D. Wig

There seems little doubt that humans in the pre-anaesthetic era had a different understanding and relation to the concept of pain, in particular surgical discomfort. They were more inured to everyday suffering than those of us in this industrialised century. How were human beings able to tolerate such suffering and endure overwhelming levels of pain?

The people of today would cringe at yesterday's thought of having to be so tortured.

Maybe, those in the 19th century did not feel it as we do. Education and cultural refinement have produced excessive sensibility. Bizarrely, some physicians viewed surgical pain as an essential element of healing and considered the advent of anaesthesia as a threat to the overall recovery process of post-operative patients.

Pain relief after surgery is of particular significance for several reasons. First, post-operative pain is a major concern for patients about to undergo surgery. Second, surgery can be associated with very intense post-operative pain, and successful therapy is one of the hallmarks of optimal post-operative management.

Post-operative pain may lead to increased concentration of stress hormones. In addition, pain can lead to poor respiratory effort which may contribute to post-operative lung dysfunction. The inability to cough leads to the retention of secretions with the collapse of the lung and infection. This may delay the discharge of patients from the hospital.

Adequate and effective pain relief, thus, is of utmost importance after surgery for the post-operative prevention of lung complication and for smoother recovery.

The goals of post-operative pain therapy are to relieve pain and to facilitate the resumption of normal activities, including ambulation and effective coughing and deep breathing.

A variety of modalities are currently in use for the management of post-operative pain. To optimise pain management and outcome, there is a continuous search for new analgesies and alternative routes of delivery. The various methods are:

The standard method: The drugs may be used through oral, rectal, intranasal, intramuscular or intravenous and subcutaneous routes. Subcutaneous administration of drugs, a new method, has the potential advantage of relatively even and slow absorption into the blood stream. This prevents high-peak blood-levels that occur after intravenous bolus administration.

Post-operative pain control may be enhanced by the combination of drugs. Pain can be moderate to severe in intensity and difficult to control with oral medication.

Doctor-controlled administration of pain-relieving agents: Continuous nerve block with local anaesthetic has been reported to produce good pain relief and is narcotic-sparing. Intraspinal techniques include caudal or lumbar epidural. The drugs are absorbed from the epidural space into the systemic circulation. A combination of an epidural pain relieving agent and an opioid improves dynamic pain relief compared with either drug alone. Patients report good pain relief with this method.

Aiming at peripheral targets: For the treatment of post-operative pain aimed at peripheral targets one may use local anaesthetics and a number of other drugs. The potential adverse effects on wound-healing and bleeding from the wound need to be evaluated.

Patient-controlled analgesia (PCA): Patient-controlled pain relief has become a common and widespread method for all kinds of pain. PCA is used not only for post-operative pain but also for the treatment of pain in patients with cancer, in patients with myocardial infarction, during labour, in trauma cases and in burn patients. PCA is a very pleasant and convenient method for the treatment of pain.

The primary advantage of PCA is the effective maintenance of therapeutic blood levels of pain-relieving drugs as compared to conventional on-demand, pain-relieving drugs. Patients report more satisfaction as the waiting time and dependence on a nurse are reduced. Portable infusion pumps with the flexibility to deliver drugs have become commercially available. Repeated boluses are delivered and this maximises clinical benefit and minimises the risk of drug toxicity.

The treatment of post-operative pain has improved in recent years because of an increased understanding of pain physiology, and the development of new analgesic drugs and techniques for analgesic delivery.

Clinical studies have supported the concept of balanced analgesia — combining different analgesics as well as the use of different sites of administration in order to improve pain-relief and to reduce the adverse effects, thereby allowing early rehabilitation. Studies on optimal drug compositions are still being carried out. Additional studies are necessary to document the cost-effectiveness of this concept.