Are current guidelines for categorization of visual impairment in India appropriate.

Context: Visual disability in India is categorized based on severity. Sometimes the disabled person does not fit unambiguously into any of the categories. Aims: To identify and quantify disability that does not fit in the current classification, and propose a new classification that includes all levels of vision. Settings and Design: Retrospective chart review of visual disability awarded in a teaching hospital. Materials and Methods: The last hundred records of patients who had been classified as visually disabled were screened for vision in both eyes and percentage disability awarded. Data were handled in accordance with the Helsinki Declaration. Results: Twenty-one patients had been classified as having 30% disability, seven each had 40% and 75%, and 65 had 100% disability. Eleven of them did not fall into any of the current categories, forcing the disability board to use its own judgment. There was a tendency to over-grade the disability (seven of 11; 63.6%). The classification proposed by us is based on the national program for control of blindness' definition of normal vision (20/20 to 20/60), low vision (<20/60 to 20/200), economic blindness (<20/200 to 20/400) and social blindness (<20/400). It ranges from the mildest disability (normal vision in one eye, low vision in the other) up to the most severe grade (social blindness in both eyes). Conclusions: The current classification of visual disabilities does not include all combinations of vision; some disabled patients cannot be categorized. The classification proposed by us is comprehensive, progresses logically, and follows the definitions of the national program.

Paradoxical reaction in tubercular meningitis resulting in involvement of optic radiation.

A 25-year-old woman was diagnosed to have tubercular meningitis (TBM) with a right parietal infarct. She responded well to four-drug anti-tubercular treatment (ATT), systemic steroids and pyridoxine. Steroids were tapered off in one and a half months; she was put on two-drug ATT after two months. Six months after initial diagnosis she presented with sudden, bilateral visual loss. Vision was 3/200 with afferent pupillary defect and un-recordable field in the right eye; vision was 20/60 in the left eye, pupillary reaction was sluggish and the field showed a temporal hemianopia. On reintroduction of systemic corticosteroids vision improved (20/120 in right eye and 20/30 in left eye) within three days; the field defects improved sequentially to a left homonymous hemianopia, then a left homonymous inferior quadrantonopia. A diagnosis of TBM, on treatment, with bilateral optic neuritis, and right optic radiation involvement was made. Since the patient had been off ethambutol for four months, the optic neuritis and optic radiation lesion were attributed to a paradoxical reaction to tubercular allergen, corroborated by prompt recovery in response to corticosteroids. This is the first report of optic radiation involvement in a paradoxical reaction in neuro-tuberculosis in a young adult.