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Leonard Kaban, DMD, MD, FACS

• Walter C Guralnick Professor and Chairman
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• Harvard School of Dental Medicine
• Chief, Department of Oral and Maxillofacial Surgery
• Massachusetts General Hospital
• Boston, Massachusetts

In majority of the cases impotence urinary purchase avanafil once a day, there is a spontaneous and more or less complete Retrobulbar Neuritis recovery impotence erectile dysfunction buy avanafil 100 mg online. But the disease has a tendency for Retrobulbar neuritis is an inflammation of the remissions erectile dysfunction doctors in south jersey cheap avanafil on line. Differential Diagnosis the acute form manifests when there is primary involvement of the nerve fibers erectile dysfunction what age buy avanafil master card, while in Retrobulbar neuritis should be differentiated from chronic form, degeneration of nerve fibers occurs hysterical and cortical blindness. The Treatment condition is transmitted in a sex-linked manner generally through unaffected females to males. Systemic administration of Clinical Features corticosteroids helps in the speedy recovery of vision. Oral corticosteroid therapy alone may the disease is characterized by unilateral or increase the risk of recurrence of optic neuritis. In some cases followed by oral prednisolone 1 mg/kg body the disk margins may be found blurred. The oral prednisolone is Pseudoedema of the disk, peripapillary quickly tapered and stopped in next 3 days. Most of the cases on visual field recording Neuroretinitis develop a central or centrocecal scotoma and a Papillitis associated with retinitis is called few present with concentric contraction of the field neuroretinitis. Neuroretinits often develops following viral Treatment infection, cat-scratch fever and Lyme disease. It is Earlier visual improvement had been claimed after not a manifestation of demyelinating disease. However, no treat Neuroretinitis presents with features of papillitis ment has been shown to be effective. The treatment of neuroretinitis Toxic Amblyopia is same as that of optic neuritis. However, in most Toxic amblyopia or chronic retrobulbar neuritis cases it is a self-limiting disease which resolves includes a number of entities in which the optic in 6-12 months after appropriate treatment of the nerve fibers are damaged by exogenous toxins. Gastric lavage and administration of intravenuos sodabicarbonate, folic acid and ethyl alcohol may Tobacco Amblyopia help the patient. Etiology Quinine Amblyopia An abuse of tobacco either by smoking or chewing can cause toxic amblyopia. Its toxicity increases if Etiology the patient also has an over indulgence in alcohol Quinine amblyopia may occur following the use or suffers from nutritional deficiency, particularly of quinine even in small doses in susceptible of vitamin B-complex. The recommended dose of the drug is nicotine and its volatile decomposed products, 150 mg per day. Cyanide present in tobacco smoke is extremely toxic and Clinical Features injurious. The patient develops a near total blindness Clinical Features associated with tinnitus and deafness. Marked pallor of the optic the patient usually complains of diminution of disk, extreme attenuation of retinal vessels and vision and difficulty in near work. A history of retinal edema are characteristic ophthalmoscopic consumption of tobacco, temporal pallor of the signs. Treatment Treatment Elimination of the drug, administration of Complete abstinence from tobacco, large doses of multivitamins (B1, B6, B12) and nutritional vitamin B1, B6 and B12 and systemic vasodilators supplementation may restore some useful vision. Methyl Alcohol Amblyopia Ethambutol Amblyopia Etiology Etiology Methyl alcohol amblyopia occurs from drinking Ethambutol is commonly used in the treatment of methylated spirit which is oxidized into formic tuberculosis. It is administered in the doses of 15 acid and formaldehyde causing swelling and mg/kg/day. Toxicity of ethambutol is likely to degeneration of the ganglion cells of the retina. The drug may induce edema of the optic nerve head, splinter hemorrhages and optic neuritis. Central or centrocecal scotoma is a typical visual field defect but when the optic chiasma is involved, bitemporal hemianopia develops. Treatment Withdrawal of the drug and administration of vitamin B-complex, vitamin C and zinc may improve the vision. Classification of Optic Atrophy Optic atrophy can be classified on the basis of ophthalmoscopic appearance as primary and secondary. Primary Optic Atrophy In primary optic atrophy the disk is white with a bluish-tint, lamina cribrosa is seen, margin is sharply defined and retinal blood vessels and. This type of optic atrophy reflects a chronic process and is not usually preceded by congestion or the edges are blurred, retinal vessels are attenuated edema of the optic disk. Secondary Optic Atrophy Ascending Optic Atrophy In secondary optic atrophy the optic disk is waxy In ascending type of optic atrophy, the primary gray, lamina cribrosa is not seen and cup is filled, lesion is in the retina or the optic disk. It occurs Diseases of the Optic Nerve 323 due to glaucoma, retinochoroiditis, retinitis pigmentosa and central retinal artery occlusion. Descending Optic Atrophy In descending type of optic atrophy, the primary lesion usually lies in the brain or in the optic nerve. Intracranial space occupying lesions, meningitis and demyelinating diseases are common causes of descending optic atrophy. Toxic optic atrophy is a common feature of Etiological Classification of Optic Atrophy toxic amblyopia. Consecutive optic atrophy occurs secondary terized by marked excavation of the optic to the retinal diseases such as retinitis cup. Vascular optic atrophy occurs due to occlusion of central retinal artery or vein, arterio Damage to the retinal ganglion cells is the hallmark sclerosis, anemia and sudden massive loss of optic atrophy. Postneuritic optic atrophy ensues after optic but in secondary optic atrophy gliosis and neuritis. Pressure optic atrophy occurs due to pressure disk impart it a dirty gray appearance. Nerve can also be strangu lated at the optic foramen in osteitis the optic nerve functions are usually deranged in deformans. The nerve functions can be assessed 324 Textbook of Ophthalmology by visual acuity and color vision, pupillary Treatment reactions, optic disk appearance and visual fields. The treatment of optic atrophy is largely preven Vision: Mild or severe loss of vision is the main tive. The impairment of be treated in early stages to prevent the nerve vision may be sudden or gradual depending on damage. However, in the tumors of the optic nerve are classified as unilateral optic atrophy, there is a loss of ipsilateral primary and secondary. Glioma, meningioma, melanocytoma and Severe form of optic atrophy is identified by a chalky hemangioma are described in the chapter on Diseases white appearance of the optic disk with well-defined of the Orbit. Disk looks waxy in consecutive optic the optic nerve is secondarily involved in atrophy. The optic disk appears dirty pale with retinoblastoma, malignant melanoma of the blurred margins and filled cup in postneuritic optic choroid and intracranial meningioma. The localization of lesions of the visual pathway has a great importance in neuro-ophthalmology. The imaginary line dividing nasal and temporal fibers passes through the center of fovea. All temporal fibers lying lateral to the line do not cross, while the nasal fibers cross to the opposite optic tract in the chiasma. Because of this orderly arrangement, the superior visual field is projected onto inferior retina, the nasal field onto temporal. If only one optic nerve is damaged, it results in ipsilateral blindness with loss of ipsilateral direct and contralateral consensual pupillary reactions. The lesion of the proximal part of optic nerve results in ipsilateral blindness and contralateral superotemporal field defect (Traquair junctional scotoma) due to looping of crossed fibers in the optic nerve of opposite side. Lesions of the Optic Chiasma the nasal fibers, which constitute about 60% of the total fibers, cross in the chiasma to the opposite optic tract.

Larger replacement transfusions thrombotic thrombocytopenic purpura and haemo would require blood to be collected over a longer lytic uraemic syndrome (see p erectile dysfunction emedicine cheap avanafil online master card. Frozen plasma is usually them ideal for children erectile dysfunction treatment delhi order avanafil with a visa, surgical cases impotence natural treatment buy discount avanafil line, patients at prepared from single donor units although pooled risk from circulatory overload and for those on products are also available impotence support group discount generic avanafil uk. It is also used for fuid replacement in patients undergoing plasmapheresis and sometimes for fuid replacement in selected patients with Protein C concentrate hypoalbuminaemia. Principal indications for its use Pooled immunoglobulin is a valuable source of are patients with nephrotic syndrome or liver antibodies against common viruses. It may also be used in immune thrombocytopenia Cryoprecipitate and other acquired immune disorders. The haemoglobin begins to rise this may be obtained from donors with high titres by about the seventh day but, if iron stores have of antibody. This is usually unnecessary in adults at Acute blood loss losses less than 500mL unless haemorrhage is con After a single episode of blood loss, there is initial tinuing and may not be needed with losses of up to vasoconstriction with a reduction in total blood 1. The problems of the haemoglobin and packed cell volume fall and massive blood loss and massive transfusion are con there is a rise in neutrophils and platelets. Cross-matching of donor red and the red cells must be matched cells with recipient plasma is therefore between recipient and donor. These antibodies in a and protein products including fresh frozen recipient may haemolyse or opsonize plasma, albumin solutions, coagulation donor red cells if these contain the antigen. Early iron defciency is likely if the serum logical system and an understanding of the physi ferritin is below 15 g/L together with serum iron ological changes that result is obligatory in order to <10 mol/L and should be treated with oral iron interpret any need for therapeutic intervention. Blood plasma volume increases by approxi mately 1250mL, or 45%, above normal by the end Folate requirements are increased approximately of gestation and although the red cell mass itself twofold in pregnancy and serum folate levels fall to increases by some 25% this still leads to a fall in Hb approximately half the normal range with a less concentration. In approxi Idiopathic (autoimmune) thrombocytopenic mately 7% of women this fall is more severe and purpura (see p. In over 75% of cases this is mild to the fetus, as the antibody crosses the placenta and and of unknown cause, a condition referred the fetus may become severely thrombocytopenic. The platelet noglobulin G (IgG), rituximab and splenectomy as 9 count is always > 70 1 0 /L and recovers within 6 appropriate. No treatment is required and the infant is At delivery, umbilical vein blood sampling or not afected. It is more severe indicated when the maternal platelet count is when associated with pre-eclampsia and if severe the > 50 1 0 9/L unless the fetal platelet count is known 9 primary treatment is as rapid delivery as possible. Platelet transfusion may be 80 % 60 40 20 0 Incidental Hypertensive Immune Others thrombocytopenia disorders disorders Figure 30. In the blood flm, nucleated red bophilic conditions in the mother and with recur cells will be seen for the frst 4 days and for up to rent fetal loss. It crosses the rises throughout childhood again to reach adult placenta and in addition is associated with embry levels at puberty. Heparin does not cross the placenta but a more prone to iron and folate defciency in the frst signifcant side efect of prolonged use is maternal few months of life. Neonatal haematology Anaemia in the neonate this should be considered for Hb <14 g/dL at birth. It physiologically low levels of inhibitors of coagula can be minimized by ensuring adequate iron and tion and the use of indwelling vascular catheters. Antithrombin and protein C levels are approxi Erythropoietin is used in some centres. Homozygous protein C defciency is associated with fulminant purpura fulminans in early life. Neonatal polycythaemia Terapeutic protein C concentrates are now avail this is defned as a venous haematocrit over 0. If symptoms are present it should be treated with partial exchange transfusion using a crystalloid solution. This uses diferential staining to esti Rh haemolytic disease of the newborn mate the number of fetal cells in the maternal cir When an Rh D-negative woman has a pregnancy culation. The mother chance of developing antibodies is related to the could also be sensitized by a previous miscarriage, number of fetal cells found. The dose of anti-D is amniocentesis or other trauma to the placenta or by increased if there is > 4 mL transplacental haemor blood transfusion. D-positive fetus, coats the fetal red cells and results in reticuloendothelial destruction of these cells, Sensitizing episodes during pregnancy causing anaemia and jaundice. If the father is het Anti-D IgG should be given to Rh D-negative erozygous for D antigen, there is a 50% probability women who have potentially sensitizing episodes that the fetus will be D-positive. All non-sensitized Rh D-negative lytic disease in the fetus can be assessed by women should be given at least 500 units (100 g) velocimetry of the fetal middle cerebral artery by of anti-D at 28 and 34 weeks gestation to reduce Doppler ultrasonography as increased velocities cor the risk of sensitization from fetomaternal haemor relate with fetal anaemia. If the fetus is transfusion of irradiated Rh D-negative packed red Rh D-negative, no further anti-D prophylaxis is cells may be indicated. Haemoglobin has been eluted from the other red cells by an incubation at acid pH and these appear as colourless ghosts. The cursor is placed over the middle cerebral artery and an increased blood velocity corre lates with anaemia. Phototherapy (exposure of the 2 Moderate disease The baby is born with anaemia infant to bright light of appropriate wavelength) and jaundice and may show pallor, tachycardia, degrades bilirubin and reduces the likelihood of oedema and hepatosplenomegaly. Although 15% bilirubin by the neonatal liver has not yet reached of pregnancies in white people involve a group O full activity. Exchange transfusions high reticulocyte count; the baby is Rh D-positive, are needed in only 1 in 3000 infants. In moderate and severe cases, many and B antigens not being fully developed at birth erythroblasts are seen in the blood flm. More than one exchange transfusion may shows autoagglutination and spherocytosis, poly be required and 500mL is usually sufcient for each chromasia and erythroblastosis. Platelets counts also There is a fall in haemoglobin because of fall on average by 10%, but in some an increased plasma volume that is women this physiological fall may be proportionally greater than a 25% increase severe or may be caused by immune in red cell mass. Chapter 30 Pregnancy and neonatal haematology / 423 Neonates have higher haemoglobin levels Rh anti-D to RhD-negative mothers at the than adults. Anaemia at birth is usually time of exposure to RhD-positive fetal cells caused by haemorrhage or immune or blood products. It is usually mild and brought about by RhD antibodies made by may occur in the rst pregnancy. It is most a RhD-negative mother crossing the frequently caused by group O mothers placenta. It may cause death of the fetus making immune IgG antibodies (which (hydrops fetalis) or haemolytic anaemia. It cross the placenta) against a group A or B is now rare because of administration of fetus. They are provisional because there are insuf Acute megakaryoblastic leukaemia cient data to support their being a defnite entity, signifcant Acute basophilic leukaemia controversies about their defning features and/or uncertainty about whether they are unique or closely related to other defnite Acute panmyelosis with myelofbrosis entities.

The standard criteria of hemodynamic the condition needs to be considered in any patient in whom stability erectile dysfunction causes treatment purchase avanafil 100mg visa, appropriate monitoring erectile dysfunction zoloft order avanafil online from canada, and full knowledge and under purpura erectile dysfunction doctors in orlando order avanafil 200 mg line, a bleeding tendency statistics of erectile dysfunction in us cost of avanafil, and signs of organ injury, particu standing on the part of the family and accepting physician should larly of the central nervous system and kidney, develop. Because of the delayed bleeding pattern in description is further confused clinically by the variable acuteness hemophiliacs, it may be especially hazardous to transfer them long and intensity of intravascular clotting, the effectiveness of fbrino distances. Therefore, the importance of advance knowledge and lysis, and other systemic manifestations of the initiating disease. Liver disease of this severity is usually manifested by clinical jaundice and splenomegaly. Early treatment with replacement factor while attempts to control the primary process. Selective replacement therapy can be based on antiplatelet therapy and renal disease can alter platelet the laboratory and clinical response. Normalization the references for this chapter can be found online by of clotting times occurs too late to be of value in monitoring. Franchini M, Zaffanello M, Lippi G: the use of desmopressin in mild based practice guideline for immune thrombocytopenia. Petrus I, Chuah M, VandenDriessche T: Gene therapy strategies for management of primary immune thrombocytopenia. Cheng G, et al: Eltrombopag for management of chronic immune Haemophilia 2010; 16(Suppl 5):67. Ann Intern Differences between plasma-derived and recombinant products and the Med 1985; 103:542. Antithrombotic and thrombolytic therapy: American College of Chest J Thromb Haemost 2006; 4:1853. Hirsh J, et al: Parenteral anticoagulants: American College of Chest Br J Haematol 2003; 120:556. British Committee for Standards practice guidelines of the American Society of Clinical Oncology. The members of the committee responsible for the report were chosen for their special competences and with regard for appropriate balance. Printed in the United States of America the serpent has been a symbol of long life, healing, and knowledge among almost all cultures and religions since the beginning of recorded history. The serpent adopted as a logotype by the Institute of Medicine is a relief carving from ancient Greece, now held by the Staatliche Museen in Berlin. Photo courtesy of National Institute of Arthritis and Musculoskeletal and Skin Diseases. Image of chromosomal abnormalities in mouse cells from a study of leukemia-promoting effects of tumor necrosis factor-alpha in Fanconi anemia group C stem cells. Upon the authority of the charter granted to it by the Congress in 1863, the Academy has a mandate that requires it to advise the federal government on scientific and technical matters. It is autonomous in its administration and in the selection of its members, sharing with the National Academy of Sciences the responsibility for advising the federal government. The Council is administered jointly by both Academies and the Institute of Medicine. The committee appreciates the contributions of Aaron Kesselheim, author of Appendix B, and Laura Brooks Faden, coauthor of Appendix C. Lewis, University of California, Los Angeles John Linehan, Stanford University Dawn S. Pyeritz, University of Pennsylvania Joan Sokolovsky, Medicare Payment Advisory Committee Jess G. Appointed by the National Research Council and the Institute of Medicine, these individuals were responsible for making certain that an independent examination of this report was carried out in accordance with the institutional procedures and that all review comments were carefully considered. Physicians, nurses, and others who care for this group of patients recognize the huge burden on patients, families, communities, the health care system, and the health care financing system. All too frequently, providers are reminded of the gap between patient needs and our inability individually and collectively to meet those needs. In addition, research progress has suffered from segmented, disorder-specific approaches to projects and their funding. Each rare disease has its particular unmet needs, and these may not even have been documented for hundreds if not thousands of extremely rare conditions. Relatively few efforts have successfully addressed scientific or technical questions across a spectrum of rare diseases. As documented in this report, opportunities now exist to accelerate progress toward understanding the basis for many more rare diseases and for developing innovative medical approaches. For example, the genomic era some 20 years ago promised when it was launched to unravel the mysteries of genetic contributions to disease. Estimates that 80 percent or more of rare diseases have a genetic cause provided hope for many that solutions to their health problems might be around the corner. However, much of the initial effort to understand the genetic basis of disease was understandably focused on more common problems. Thus, we are poised to make rapid advances in the understanding and, in an increasing number of cases, the treatment of rare diseases. As past research has demonstrated, some of these advances will undoubtedly illuminate disease mechanisms and treatment avenues for more common conditions. Funding for research for many rare diseases has lagged and lacked coordination, and investigators interested in pursuing research on rare diseases face many obstacles related not just to the availability of funding but to the mechanisms under which research grants are awarded. Furthermore, the cost of drug development under current models and the high costs of new drugs for rare conditions raise questions about whether it is time to create alternative pathways for drug development, including public-private partnerships. Leadership of this planning and implementation effort, as well as mechanisms to sustain the effort over time, present formidable challenges but are not insurmountable with the commitment of patients and families, advocacy groups, policy makers, companies, investigators, and others. The committee is hopeful that its efforts will catalyze thought and action that will benefit millions of our citizens with rare diseases and thereby contribute to the overall health of the nation. Because the number of people affected with any particular rare disease is relatively small and the number of rare diseases is so large, a host of challenges complicates the development of safe and effective drugs, biologics, and medical devices to prevent, diagnose, treat, or cure these conditions. In recent decades, scientists, advocates, policy makers, medical product companies, and others have done much to respond to these challenges. Innovative approaches to basic research are making the identification of genetic causes of rare diseases easier, faster, and less expensive. Some of the same research approaches and technologies are also altering the processes and efficiency of therapeutic discovery and product development for rare conditions. Political and social developments also have altered the environment of rare diseases research and product development. Nearly 30 years ago, Congress passed the Orphan Drug Act, which provided incentives for companies to develop drugs for rare diseases. The law defines a rare disease or condition as one affecting fewer than 200,000 people in the United States. Notwithstanding the successes, many rare conditions still lack even a basic understanding of their cause or the mechanisms that underlie them. Consistent with its charge, the study committee that prepared this report did not examine medical foods or dietary supplements. The committee was not asked to examine strategies for moving scientific advances into clinical care, public health practice, and health-related personal behavior and ensuring that they actually benefit individual and public health. Given the scarce resources available for rare diseases research and orphan product development, it is particularly unfortunate for these resources to be used ineffectively. One broad goal should be to achieve reasonable consistency in the review of similarly situated products. The committee concluded that funding for the orphan products grants program has lagged far behind inflation and seriously undermined an important resource. An increase would allow more qualified researchers to benefit from this focused product development program. It identifies the causes and delineates the molecular mechanisms of these diseases as a basis for discovering therapeutic targets. Although many barriers will have to be overcome, the benefits should be significant from what a rare diseases research commons with several unlinked or loosely linked elements.

Ophthalmia neonatorum erectile dysfunction doctors in arizona buy avanafil 200mg on-line, interstitial keratitis and tabes optic atrophy are no longer prevalent impotence only with wife effective 200 mg avanafil. However how to treat erectile dysfunction australian doctor cheap avanafil 200mg without prescription, the blindness from cataract has increased due to the increased longevity of the population erectile dysfunction age graph purchase cheap avanafil on-line. As the diabetics are living longer, the blindness due to diabetic retinopathy is also increasing. Factory accidents and injury by foreign body can be prevented by appropriated guards, screens and goggles. There are frequent episodes of blindness seen nowadays due to liquor (methanol) poisoning. The iatrogenic blindness is also increasing due to the indiscriminate use of the sulphonamides, ethambutol, chloroquine, oral contraceptives, etc. Vision 6/60 or less with the best possible spectacle correction in the better eye. One eye has vision of 6/60 or less with best possible spectacle correction and the other eye has a visual field of 20o or less. The government of India has launched the National Programme for Control of Blindness in the year 1976. To provide comprehensive eye care through primary, secondary and tertiary level health care. The primary health centre, district hospital (secondary) and medical colleges (tertiary) are upgraded to render better and advanced eye health care and manpower development. The mobile eye units are extremely useful in arranging eye camps for cataract operations in remote areas with the cooperation of local voluntary organisation. We have to ensure that no citizen goes blind needlessly or being blind does not remain so, if, by reasonable deployment of skill and resources, his sight can be prevented from deteriorating or if already lost, can be restored. The second thursday in the month of October is celebrated as the with World Sight Day. Provision of comprehensive eye care facilities for primary, secondary and tertiary levels of eye health care. Substantial reduction in the prevalence of eye diseases in general, and reduction in the prevalence of blindness from 1. District hospitals Services: Secondary eye health care includes (in addition to primary eye care): 1. Services: Tertiary eye health care provides (in addition to secondary eye care): 1. It functions as a centre of excellence to provide overall leadership, supervision and guidance in technical matters, in planning and implementation of the programme. Occupational eye health services: this is to prevent and treat eye hazards in industries. Education on the prevention of occupational eye hazards and use of protective devices in some occupations are important. Manpower development: Technical manpower development is an important priority for effective implementation of national programme. Fellowship training to ophthalmologists and teachers of medical college under the prevention of blindness programme. They are active in the field of educative, preventive, rehabilitative and surgical services to control blindness. Therefore the global initiative vision 2020; The Right to Sight was officially launched on 18th Feb. Aim the aim of Vision 2020 is to eliminate the main causes of avoidable blindness in order to give all the people of the world, particularly the millions of preventable blind, the right of sight by the year 2020. Together this blindness is termed as with nutritional blindness, though the main factor is vitamin A deficiency. Vitamin A deficiency is a systemic disease that affects cells and organs throughout the body. The resultant changes in epithelial architecture are termed as keratinizing metaplasia. The characteristic ocular manifestations of vitamin A deficiency ranging from night blindness to corneal softening are termed as with xerophthalmia or with dry eye. Night blindness: It is usually the earliest manifestation of vitamin A deficiency. Conjunctival xerosis first appears at the temporal side as an isolated oval or triangular patch near the limbus in the inter palpebral fissure. In some cases keratin and saprophytic bacilli accumulate on the xerotic surface, giving it a foamy or cheesy appearance. Corneal xerosis: A hazy, lustreless dry appearance of the cornea is first seen near the inferior limbus. Thick keratinized plaques may form on the corneal surface and are often more dense in the interpalbebral zone. Xerophthalmic scar: They are usually bilateral and indicate healed sequelae of prior corneal involvement related to vitamin A deficiency. They include nebula, macula, leucoma, adherent leucoma, anterior staphyloma or phthisis bulbi. Treatment Xerophthalmia is a medical emergency as it carries a high-risk of corneal blindness. Oral administration is preferred, as it is safe, cheap and highly effective even in presence of mild diarrhoea (as it is also helpful for intestinal epithelium). Diet and medical care: Proper treatment includes rehydration, frequent feeding with easily digestible and protein-rich food and general supportive care. Administration of fortified commonly consumed food items (vitamin A fortification). The schedule for children is as follows: Doses Age 1st dose 9th month with measles vaccine 2nd dose 1. Increased Intake of Dietary Sources of Vitamin A Dark-green leafy vegetables are usually the least expensive and most widely available source of vitamin A. The dark-geen leafy vegetables should be boiled, shredded (mashed or sieved for infants) and should be combined with a small amount of edible oil to improve vitamin A absorption. Vegetables sources: Dark green leafy vegetables, spinach, carrot, drumsticks, tomato, pumpkin, papaya, mango, etc. Children with diarrhoea, lower respiratory tract infection or other acute infections. Braille system of education: this system was invented by Louis Braille a 16-year-old blind French. There are several blind schools where facilities for Braille system of education is available. Low vision aids: the term with low-vision denotes visual acuity between 3/60 and 6/24. The visually handicapped people can achieve improved useful vision by several special aids specially designed for near vision. Binocular magnifier (Head-band loupe): It requires the incorporation of base in prisms. Stepped lens (Fresnel lens): It consists of a plastic sheet with concentric ridges (series of prisms). Telescopic (Galilean) system: It provides binocular correction with large field and greater depth. Mobility: Blind people can be trained to move about with the help of a stick, perform household work and look after themselves independently, i. Vocational rehabilitation: Blind persons can be trained in making handicrafts, cane binding, book binding, candle and chalk making, cottage industries and as telephone operators. The blind workers are in no ways inferior to the sighted persons, as far as skill is concerned. Reservation of jobs: the job opportunities should be made available to blind persons in various institutions.

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