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Mohammed Abrar Hassan1*, K Kavita2, Suwaibah Fatima Samer3
1Department of Physiology, Bhaskar Medical College, Yenkapally, Moinabad, RR (Dist.), AP, India.
2Dept of Obstetrics and gynecology, Bhaskar Medical College, Yenkapally, Moinabad, RR (Dist.), AP, India.
3Department of Ophthalmology, Bhaskar Medical College, Yenkapally, Moinabad, RR (Dist.), AP, India.

ORIGINAL RESEARCH ARTICLE
ARTICLE INFORMATION

Article history
Received: 16 December 2013
Revised: 26 December 2013
Accepted: 29 December 2013
Early view: 30 December 2013

*Author for correspondence
E-mail: drmhabrar@rediffmail.com
Mobile/ Tel.:0000000000

Keywords:
Presbyopia
Accommodation
Convergence
Pregnancy.

ABSTRACT

Objective::The main aim of this study is to Project the early onset of presbyopic changes in multi gravida females, Association of socio economic parameters as contributing factor ,Nutritional deficiency during the stages of pregnancy ,Role of pregnancy induced hypertension in establishing recession of near point of convergence.
Subject and Methods:: This study is prospective study being carried out on 100 female subjects attending the Department of Obstetrics and Gynecology of Bhaskar Medical College. The subjects were divided into two groups between the age of 20 to 30 years. A detailed obstetric history of every patient was recorded along with routine investigation to access the nutritional status and the vital data to access the cardiovascular changes. The ocular examination was done to access the visual acuity for distance and nearby using Snellen’s chart and Jager’s near vision chart. While the near point and accommodation point was recorded by using RAF rule (Royal air Force) finally the AC/A ration assessment is derived from the available data.
Result:There was significant increase in accommodation and convergence values in group 1 subjects in the range of 16-20 cm amounting to 26%, followed by 24% in the range of 21-25 cm but there is significant increase in the subjects ranging between 26-40 cms amounting to 48% i.e. about ¼th of total subjects. The group 2 subjects form the control group in the same age group in non-pregnant category shows a significant number of subjects in the 10-20 cmsf range amounting to 92% and this range is considered as normal values for accommodation and convergence state of eyes.
Conclusion: : This study shows that convergence insufficiency is encountered in post partum period and this is attributed to general health, and the stress induced during the period of pregnancy and as well during parturition.

INTRODUCTION

Pregnancy is a physiological process occurring in a woman’s life to achieve the motherhood. The term pregnancy looks simple but the woman’s body undergoes series of adaptation and adjustment to cope with the increased demands and requirement of body. Though the body has a lot of reserve but still there is a scope of Physiology becoming altered physiology and the woman may develop some unwanted temporary pathology which gets reversed by the termination of pregnancy (Samra, 2013). Some time these changes may become permanent. In this regard the most common change experience by a pregnant woman is the recession of near point of convergence leading to early establishment of presbyopic changes. Presbyopia is a vision disorder that is typically associated with aging adults. For women who are pregnant, the complications of presbyopia, while rare, can occur at any time during the pregnancy and progressively worsen throughout. This disorder is associated with inability to appreciate the near object or fixing the gaze at near point will be difficult. This change is attributed to weakness of intraocular muscle. These muscles are susceptible to general weakness, could be due to anemia or any B complex vitamin deficiency (Samra, 2013).
It is commonly noted in almost every pregnancy, the pregnant women suffer with either iron deficiency, B12 or folic acid deficiency leading to Anemia, there are lot of studies carried out to define the cause of fatigue or weakness in pregnancy, some author have even attributed thyroid hormones deficiency or myasthenia gravis as a cause of weakness but it is sure that there is certain electrolyte deficiency as reported by (Furara et al., 2008). Even there is correlation between toxemias of pregnancy with recession in near point; the recession is greater in cases of pregnancy induced hypertension rather than normal pregnancy (Caesar et al., 1958). Presbyopia is a vision disorder that is typically associated with aging adults. For women who are pregnant, the complications of Presbyopia, while rare, can occur at any time during the pregnancy and progressively worsen throughout. As a vision disorder that leads to an inability to see items and things up close, women who develop Presbyopia during pregnancy (Pickwell et al., 2002).

SUBJECTS AND METHODOLOGY
Ethical consideration
After obtaining the approval of the Institutional Ethics Committee, the study was carried out in the Department of Obstetrics and Gynecology at Bhaskar Medical College, Moinabad, AP, India. The implications of the study were elucidated to each of the subjects in English and Telugu (local language). A written formal informed consent has also been obtained on a prescribed pro forma fulfilling all the norms of ethics from every individual participant. Necessary precautions were taken to protect the identity of subject and fulfill ethical committee’s requirements.
Study
The prospective study was carried out on 100 subjects attending the Department of Obstetrics and Gynecology of Bhaskar Medical College, Moinabad, AP, India. The subjects were divided into two groups between the ages of 20 to 30 years. Group-1: 50 subjects in post partum period; group-2: 50 control age matched, non pregnant.
A detailed obstetric history of every patient was recorded along with routine investigation to access the nutritional status and the vital data to access the cardiovascular changes. The ocular examination was done to access the visual acuity for distance and nearby using Snellen’s chart and Jager’s near vision chart. While the near point and accommodation point was recorded by using RAF rule (Royal Air Force). Finally the AC/A ration assessment were derived from the available data. The data was analyzed for statistical significance by using paired‘t’-test.
Inclusion and exclusion criteria
 Inclusion criterion –Non complicated pregnancies ending up in normal delivery.
 Exclusion criterion–All the caesarian sections deliveries.

RESULT
There is significant increase in accommodation and convergence values in group 1 subjects in the range of 16-20cm amounting to26%, followed by24% in the range of 21-25cm but there is significant increase in the subjects ranging between 26-40cms amounting to 48% i.e. about ¼ of total subjects.

Table 1-2 Group-1 and Group-2.

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DISCUSSION
To support the assumption that there is an early onset of Presbyopia in women due to loss of convergence due to early pregnancies and repeated pregnancies there is a study carried out in Ghana which compared Presbyopia in males and females, and those of mothers and childless female adults for particular age groups. Correlations were found between ages and reading additions for both sexes, and Presbyopia occurs at a younger age than published (Morny 1995).It was found that the degree of Presbyopia was associated with increasing difficulty with daily tasks (P < 0.0001) according to a study conducted in Tanzania (Patel et al., 2006). Presbyopia plateaus after age 50, and it is more common in females. In addition, the 3-fold increased odds in town versus village dwellers was unexpected and suggests that research of other factors, including environmental factors, is warranted based on a Population-based study of Presbyopia in rural Tanzania (Burke et al., 2006). The cause of the increased Accommodation and Convergence values in the group 1 in the higher range could be due to Convergence spasm, Convergence paralysis. Causes include 3rd N anomalies, head trauma, Parinaud’s syndrome., and lastly due to Convergence insufficiency. Convergence insufficiency (CI) is a condition in which the patient has an inability to sustain sufficient convergence for comfortable near vision. Although CI is frequently associated with convergence weakness exophoria, which presents as a decompensated exophoria for near with any distance exophoria being both well compensated and of less amplitude than for near .CI is one of the most common causes of ocular discomfort and muscular asthenopia and that it frequently has an aetiological connection with accommodative difficulties.

Table 3Accomodation and convergence.

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Figure 1Accommodation and convergence.

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Figure 1Comparison of accommodation and convergence in both groups.

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CONCLUSION
This study shows that convergence insufficiency is encountered in post partum period and this is attributed to general health, and the stress induced during the period of pregnancy and as well during parturition.

REFERENCES

Burke AG, Patel I, Munoz B, Kayongoya A, McHiwa W, Schwarzwalder AW, West SK. Prevalence of presbyopia in rural Tanzania: a population-based study. Ophthalmology. 113, 723–727, 2006.
Caesar B. Piper Jr., James W. Nofles, Recession of near point of convergence in toxic hypertensive syndrome of pregnancy. J National Med Assoc. 50, 103–106, 1958.
Furara S, Maw M, Khan F, Powell K. Weakness in pregnancy – except the unexpected. Obster Med. 1, 99–101, 2008.
Morny FK. Correlation between presbyopia, age and number of births of mothers in the Kumasi area of Ghana. Ophthalmic Physiol Opt. 15, 463–466, 1995.
Patel I, Munoz B, Burke AG, Kayongoya A, McHiwa W, Schwarzwalder AW, West SK. Impact of presbyopia on quality of life in a rural African setting. Ophthalmology. 113, 728–34, 2006.
Pickwell, David; Evans, Bruce JW. Binocular vision anomalies. Investigation & Treatment. 3rd Edition, Oxford. Butterworth Heinemann, 2002.
Samra KA. The eye and visual system in pregnancy, what to expect? An in-depth review. Oman J Ophthalmol. 6, 87-91, 2013.