Age-related distance esotropia: main symptoms.
\r\n\tThe book equally expects submissions based on stand-alone research cases and review style summaries or more personal overviews of the outlined topics.
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Although these symptoms are not infrequent, they are badly neglected. A typical case example may explain the matter concerned:
Case 1: A 70-year-old woman was suffering from double vision but could not remember the time of onset. Her family doctor sent her to a neurologist, supposing some kind of palsy, but the neurologic state was normal. After this she consulted an ophthalmologist who prescribed new glasses, which did not correct the double pictures. Several other ophthalmologists stated correspondingly, her troubles were due to her age and there was no help. Finally, she was seen at the orthoptic department of the First University Eye Clinic of Vienna; the opinion of our colleagues proved to be correct, our diagnosis was “Convergent squint of presbyopic age” [1], which was the first denomination we allocated to this condition in 1976 and, of course, treatment was possible and not difficult.
In the following years I paid more attention to other age-related diseases of the eyes, such as cataract, glaucoma and maculopathy, in order to find out their influence on binocularity and reading ability. Out of 15,000 index cards from my private office for general ophthalmology, 901 were selected. All the patients older than 40 and were suffering from severe binocular problems; 526 patients of this cohort had double pictures as a consequence of an acquired squint position but not every eye deviation was connected with the emergence of subjective diplopia; because of visual field defects, the patient is not aware of the second picture. We have called this condition “masked diplopia” [2].
In the following sections the reader mainly finds pathologic alterations of the eyes and their symptoms to be the cause of double vision. In addition to these ophthalmologic findings, we have recognized many interactions with nervous functions and even systemic diseases of the body; the eyes are not an isolated functional system. Unfortunately, many physicians treat the symptom of diplopia with mental reservation because of their lack of knowledge. Therefore, this chapter should help to survey this difficult matter and enable colleagues to discern important details to differentiate between eye-related and/or neurologic disorders. The targeted groups of readers may be: ophthalmologists without training in the subspecialty of orthoptics, neurologists, general practitioners and orthoptists.
By covering each eye alternately, it is easy to decide which eye perhaps sees two objects in the proximity, or a shadow-like double contour or even three objects (triplopia). These symptoms may be caused by opacities in the optic system of the eyes, such as cataract, corneal scars and so on. But most commonly, we found the cause to be a high degree of astigmatism, uncorrected or with faulty correction.
Even elderly people do not like to wear glasses. As we know, uncorrected ametropia may lead to a latent misalignment of the eyes, for example, myopia to exophoria and hyperopia to esophoria. Thus, the development of a convergent squint in childhood is caused by an overactive accommodation to overcome the hyperopia. Although the accommodative power is highly diminished with age, the first step to evaluating the degree of an eye deviation is, independent of the patient’s age, the exact correction of their refractive error.
Usually double vision arises from a squint deviation of the eyes and is checked with a torch and a red glass before one eye to separate the pictures. Some patients report double pictures, but when checked with the torch, only one light is seen. Yet, the patients’ complaint is credible. An accurate description could typically be “When watching TV I see only one speaker, but the screen seems to be double, shifted to one side”. Such statements may occur in cases of age-related maculopathy or atrophy of the optic nerve, caused by an extended central scotoma. But both peripheral retinas are still in function and indicate the malposition of the eyes, provided that the fixed object exceeds the size of the scotoma.
Despite an acquired squint deviation of the eyes the patient is not aware of a second picture because the visual field of one or both eyes has become defective and causes a lack of perception in the central and peripheral parts. Even while wearing corrective glasses, the subjective symptoms are described as blurred vision, seeing of “clouds” and, most noticeable, the irresistible impulse to close one eye. These complaints by a patient cause suspicion of the unknown presence of binocular difficulties. After correction of the squint angle by prisms, the binocularity will be restored again and the patient will have clear vision from one moment to the other, an impressive effect for the patient and the treating physician. The symptoms mentioned are most common in cases of age-related maculopathy.
Without mentioning double vision or squint the patients let the observer assume some kind of anomaly of binocular vision, saying sentences like these: “One eye feels to be stuck”, “I am not able to estimate distances” and “The picture seem to tremble when I look with both eyes”.
The aging of the eye muscles, starting from the age of 30, is connected with an increase of their ring bands, which leads to a disruption of the myofibrils, and hence the weakening of muscle power (Mühlendyk) [3]. Sachsenweger [4] describes a thickening of the elastic fibers and an augmentation of the collagen tissues in the eye muscles. The result is an increased rigidity, combined with a reduction of their exact and fine functions. A step-wise decline of the ocular ductions between 20 and 80–95 years of age was measured: Supraduction was diminished by 35%, abduction by 21% and adduction and infraduction by 25% [5]. A reduction of the fusion amplitude and a weakening of the accommodative convergence were found to be signs of senile involution. Additionally, the impairment of neurological functions with age was noted: The reduction of visual field sensitivity, slower but sometimes hyperkinetic motor reactions, changes in alertness and attention as well as early fatigue [6].
This
A total of 125 relevant patients were registered in my office, 74 female and 51 male, aged between 45 and 93 years with a maximum between 71 and 85, the peak being at 71–75. The distribution of the refraction errors of 250 eyes was emmetropia 33 (mostly pseudophakic eyes), 114 hyperopia and 103 slight-to-medium myopia. Many patients showed organic lesions corresponding to their age: Pseudophakia (26), incipient cataract (26), age-related macular degenerations (24), glaucoma (7), lesion of the optic nerve (4), synchisis scintillans (2), heavy eye syndrome (7) and enophthalmus after loss of weight (1). Of course frequent internal diseases must be considered to influence the patients’ general condition as well as their eyes.
For an example, see patient 1.
Some typical statements given by the patients may be mentioned:
Once two distant cars were observed coming down the street, and when it passed nearby it proved to be only one car.
The patient sees the actor on stage in a theatre as two actors.
When driving a car the median line of the street seems to divide at a certain distance.
Almost all patients have no difficulties and good reading ability in near distances. But they cannot date the onset of their symptoms, which will set in gradually and therefore cannot be realized immediately. As a consequence, an ophthalmologist is consulted with a delay of months or even years.
Both visual axes of a test person without a squint are in a parallel position when looking at far distances, but the visual lines intersect at a near object to match the degree of convergence necessary for binocular fixation. In our aged patients, the visual axes are crossed at some distance nearer than about 20 m, according to the degree of convergent squint, the result being uncrossed double vision of distant objects. Fixing a near object the patient needs less convergence power to gain binocular perception; in relaxing the convergence the patient gains a normal eye position for near distances. Other patients cannot correct their eye deviation in this way; they maintain a convergent position even in near spaces; on the contrary, a convergence insufficiency may lead to a latent divergence at reading distance, that is, exophoria.
The first point is, of course, the complete inspection of the eyes and measuring the refractive error.
Visual acuity (VA): Almost all patients had 0.5 or better in both eyes. Only 11 had one eye worse between 0.4 and 0.01, and three of them did not complain about double pictures but habitually would close one eye. The corrected VA for reading was sufficient in all cases, in some only monocular.
The binocular state at a
Far distance: Uncrossed double pictures, comitant in all directions of gaze | Near distance: Eso - ortho - exophoria |
Onset gradually and unnoticed | No reading problems |
Peak age: 70–75 years | Independent of refraction error |
Age-related distance esotropia: main symptoms.
36 patients were observed over 2–19 (average 7.2) years. The squint angle did not change in 23 cases, increased in 9 (+4°) and decreased (−3.5°) in 4 patients.
The fitting of prismatic glasses is not quite easy and must be done by a highly qualified and experienced ophthalmologist or optician. Here only some principles are discussed. One main factor in assessing the strength of the prism is the patients’ fusion power, that is, the ability to overcome the eye deviation, either totally or partly. A total interruption of the fusion ability while measuring the angle of deviation is to be avoided, as done, for example, with Maddox-Rods or by covering with an additional prism bar. The examination should take place under visual conditions as natural as possible, and only slight dissociation of fusion should be used, such as that possible with the Bagolini striated glasses or a light-coloured red glass. Thus, the habitually compensated part of squint will remain and only the manifest part, which causes diplopia, would be corrected; the patient probably will tolerate well the prismatic glasses.
Another problem is the prismatic difference far/near. The glasses for distant vision should correct the diplopia, and for this purpose ground-in prismatic glasses are recommended; press-on prisms are blurring, tend to promote suppression and will not be well tolerated. But these distant-glasses are not suitable for reading. Depending on the near position of the eyes, the patient may need no prism at all or a different prismatic strength. The possibilities are two separate spectacles or only one frame with progressive glasses and ground-in prismatic correction, suited for distance viewing. As the progressive glasses have the same prismatic power in both distances, an exophoria for near fixation will be produced, but most patients are able to correct this deviation by forced convergence. If the difference far/near does not exceed eight prism diopters, progressive glasses are well tolerated and sufficient for daily life; reading of books for a longer time will require separate reading glasses.
Motility exercises at home, especially to the lateral side, in my experience, can prevent or slow down the progression of muscular degeneration.
This topic is frequently discussed; operations are always of higher interest than conservative therapy; every operator is convinced of his method as the best. In general, aged patients will refuse operations and prefer prismatic glasses, but there is a technical limit for prismatic glasses. If the eye deviation exceeds 25 prism diopters (Δ), the only possibility is an operation. Difficulties after surgery arise from the age-related loss of elasticity in the eye muscles and the reduced fusion strength; both are needed to accomplish the fine adaptation of the eye position which takes more time with increasing age.
In my last active years I operated 14 relevant cases, on average 71 years old and squint angle on average as 25Δ. I performed recession-resection of the non-dominant eye in 10 cases and bilateral resection of the external rectus in 4 cases in order to avoid a weakening of internal rectus muscles. The results after 1–16 (average 6.7) years were the following: 11 cases had orthotropia and 3 cases showed a small residual angle without diplopia. The results are much more stable than in childhood—a short-term repeated increase of the squint angle, very common in children, never occurs in elderly patients.
As usual, there are multiple determinant factors to be considered.
Divergence insufficiency or palsy:
Neurologists point out correspondingly that divergence palsy exists only within the scope of neurological diseases. Indeed, I checked 17 of my age-related convergent patients at the synoptophore and all patients showed a fusion range into divergence of 4–5 degrees.
Abducens nerve palsy—bilateral or unilateral:
The onset of palsy is always a shocking event which arises suddenly. One patient, I remember, was wearing prismatic correction for distance esotropia; some months later, a unilateral abducens palsy had occurred additionally; the neurologic findings in MRI were vascular encephalopathy with multiple lesions, especially in the pons region. Curran [11] was of the opinion that simulated divergence palsy could be a phase in the evolution of real abducens palsy.
Decompensated esophoria:
Two of my patients showed the transition from distance orthophoria to convergent squint because of forced accommodative convergence to overcome near exophoria, a spasm of convergence which cannot be relaxed in a short time. One of the patients was a dentist aged 55; 10 years later after retiring from his profession, the distant deviation regressed to orthophoria. A similar mechanism can be supposed for hyperopic patients refusing to wear glasses. We do not observe such binocular reactions exclusively in the elderly but also in younger patients.
Connective tissue degeneration in elderly patients [10]:
A degeneration of the connective band between the lateral and superior rectus muscle causes the lateral muscle to slip downwards, followed by esotropia and hypotropia of the bulb. This clinical entity was called “sagging eye syndrome” and resembles the “heavy eye syndrome” of high myopia, the first additionally being connected to ptosis and loss of orbital fat.
Age-related myopathy of the eye muscles:
In my opinion, the high-grade loss of elasticity is an essential factor explaining the disparity between the positions far/near. Performing surgery on patients in their 80s, I could notice the extreme density of their external rectus muscle, described [12] as senile fibrosis.
Everyone has to expect the acquisition of cataract, if the life is long enough; commonly, the cataract will develop bilaterally but not to the same degree. These days, we can operate every stage of cataract, be it binocular or monocular, by intraocular lens implantation. Yet, problems occur and disappointed patients will complain of diplopia.
Cortical opacities of the lens, such as a central spindle, generally cause monocular double contours or even triplopia. Cloudiness of the lens nucleus causes myopia and, if decentered, may additionally have a prismatic effect, evoking binocular diplopia.
The most difficult cases were those we saw 20–30 years ago, after the new technique of intraocular lens implantation (IOL) had entered into practice everywhere. A lot of patients with long-standing unilateral cataract or aphakia hoped to gain binocularity again, but instead of binocular depth perception they acquired intractable diplopia. Medical science had to learn some new facts [13]: Interruption of fusion over some years caused by a unilateral visual defect, effectively approaching blindness, represents visual deprivation in adults, which results in a total loss of fusion ability, reversible only in few exceptional cases. Unlike the visual deprivation of newborn children, which almost always causes irreversible amblyopia, the visual acuity of adults is hardly impaired. Through own binocular infrared oculography (IROG) studies [14] we were able to find out that the excursions of the interfixation movements (normally less than 30′ = arc minutes) of the deprived eyes were enlarged by up to 4°30′; that is an absolute obstacle for fusion.
Finally, a recommendation for the daily work of ophthalmologists: A patient having unilateral cataract and VA less than 0.3 should not hesitate longer than 1 year to be operated to avoid the postoperative risk of double vision.
Even patients who have never had binocular troubles may acquire double vision after cataract surgery. Studying such cases we found that most of them had a pre-existing compensated imbalance of their eye muscles, for example, a slight horizontal or vertical deviation.
During the period of progressive lens opacity not only will the VA be slowly reduced but so will the fusion power and thereby misalignments of the eyes are manifest, and even a distance esophoria may develop.
A group of 25 patients wearing prismatic glasses because of asthenopic complaints or diplopia returned to my office after receiving cataract surgery and wanted the prescription of new glasses. The results are shown in Table 2. An improvement (by up to 12Δ) was remarkable, especially in cases having convergent deviations based on high astigmatic anisometropia which could be eliminated by the operation. Vertical deviations are severe obstacles for fusion and mostly remain unchanged after cataract surgery.
6 patients | Prisms unchanged |
11 patients | Improvement 2–12Δ included: 8 distance esotropia, 2 exotropia and 1 hypertropia |
8 patients | Deterioration 1–4Δ included: 6 hypertropia, 2 esotropia |
Change of prisms after cataract surgery.
In early stages, glaucoma does not impair binocular functions. Difficulties arise with the slowly progressive defects of the visual field, mainly in the nasal areas, causing loss of fusion power and stereo vision. Subjective complaints of glaucoma patients are rare; the event of seeing double pictures only occurs exceptionally because there is no perception in damaged areas of the visual field. Yet, there are some consequences to be mentioned.
Bilateral total defects of the nasal visual field as far as the fixation point are equivalent to the total loss of fusion and of convergence. The consequences are a divergent eye position for near distances, inability of reading, lack of stereo vision and crossed diplopia or unilateral suppression, although the VA of both eyes may be 1.0. Imagine the difficulties such a patient has with reading: The left eye is able to perceive the beginning of a line but the following words have vanished and can only be seen by the right eye, which cannot join them to the word seen by the left eye because of the squint position. The prismatic correction of the squint angle could enable both eyes to read the continuous chain of words alternatingly.
Case 2: A woman aged 75, whose glaucoma I had treated years ago, called me in despair because the newly consulted ophthalmologist did not believe her complaints: Her left blind eye caused her to perceive double pictures. Indeed, she had a total atrophy of the optic nerve with only peripheral remnants of the visual field and the left bulb had drifted into a divergent position. The trial to correct the squint angle by a press-on prism 15 Δ base attached to the left glass was successful, and the patient was content.
Case 3: A chemist, aged 76, treated for glaucoma elsewhere, called me, saying “My vision is very bad, can you help me?” His eye tension was well adapted, the visual field showed intermediate defects and his corrected VA was RE: 0.8–1.0 and LE: 0.7–0.8. While testing his vision we noticed that the binocular vision was worse than the monocular, and the test objects seemed to be blurred; a state like this is a clue to binocular problems. In fact there was a manifest distant deviation of +6° and a latent near angle of +2°. Prisms of 6 Δ added to the distance glasses immediately produced “clear” binocular distant vision.
Although modern treatments are able to prevent wet maculopathies with neovascularization from developing into tumor-like fibrotic scars, enough problems remain to be discussed such as the influence of binocularity on reading ability and hence the quality of life; such considerations seem to be neglected in ophthalmology.
Subjective vision testing of visually disabled old patients is fraught with difficulties: The patient cannot decide which glass is the better one, wants magnification and prefers plus glasses too much; the duochrome test is not predicative due to the color vision defect of a damaged retina. And last, the refractometer measuring is not exact for eyes which cannot fix centrally. To get exact data of the refractive error we have to perform retinoscopy in mydriasis and some days later do a subjective test once more.
In our experience the refraction error changes with aging: Myopia increases just as astigmatism against the rule.
Case 4: An intelligent woman, aged 79, maculopathy LE > RE, could read only using a magnifying lens; the left eye had no reading ability at all, no squint position. The patient complained that her ophthalmologist had not given her a new glass for the left eye, but this eye supported the right eye and she needed it. The left glass was strengthened with +2,25sph +1,0x180°; with the new glasses the patient could read 0.4 text without magnification.
There exist some more examples to teach us that the refractive correction of an almost blind eye is highly beneficial for the master eye provided that the eyes are in a parallel position.
In spite of fitting glasses, the next complaint of a patient may be: “I can only read the newspaper when closing the worse eye”. This is a typical statement indicating the presence of a divergent squint when looking at near objects. These patients never complain of diplopia but show the symptoms of masked diplopia. For cases with one highly impaired eye we use Fresnel prisms, added to the glass of the worse eye; this procedure will be well tolerated and the prism can be changed easily as soon as the squint angle varies. With restored binocularity, the patient has a sudden experience of regained clear vision and no longer feels compelled to close the worse eye. Unfortunately, maculopathy is progressive and the initial success may be lost quickly.
The onset of a squint position depends on the size and the distance to the foveola of the central scotoma and whether it is sieve like or dense. No squint will develop if both eyes are deteriorating to the same degree.
Binocularity supports the reading ability most effectively if the damage is bilateral but with a large difference in vision, for example, 0.5 and 0.05. The peripheral fusion of the damaged eye is conductive to the macular orientation of the better eye and causes an increase of reading speed, provided an existing squint position is corrected by prisms.
The use of optical coherence tomography (OCT) allows seeing the pathology of the retina, swellings, cysts, distortions of the retinal layers and many more. The visual acuity of such eyes often may be almost normal but the optical pictures of both eyes don’t fit one to the other; the central fusion will be disrupted, the reading speed will be slower binocularly than monocularly and the patient will close one eye. If the affected eye is the non-dominant one, central suppression will develop. The confusing quality of the vision of a dominant eye can be reduced temporarily by hazy foils (Figure 1).
This is to imagine how a patient, having macular pathology, sees.
Although patients in general have been accustomed to their visual defects since their youth, situations evoking diplopia may occur even in later life.
Amblyopic eyes have fewer zones of suppression than alternating eyes. With aging, strabismic eyes have the tendency to drift into divergence, causing double pictures. The treatment consists of bringing back the deviating eye into the original position, either by prisms or by an operation.
Case 4: A middle-aged woman once noticed double pictures when looking to the right side; a neurologist diagnosed a palsy of the right abducens nerve. This diagnosis would have been correct in the presence of a convergent eye position while looking to the right, but, in fact, the eyes were divergent. The patient told us that a recession of the internal rectus of the left eye had been performed many years ago. With aging, the power of a weakened muscle will decrease even more; thus, an incomitant squint is produced without being caused by the palsy of a nerve.
Squint surgery in childhood previous to the age of 3–4 years is a precondition for the establishment of certain imperfect cooperation between both eyes, a sort of anomalous fusion. Such patients commonly do not develop diplopia in later life. But this danger is high for patients squinting since early childhood and operated with a delay of 10–20 years. In my office I have seen a lot of patients having had diplopia all their lives. When asked if they were suffering from their immanent double pictures the patients stated in agreement that these unreal shadows were only a problem when they paid attention to them.
This name is derived from the anatomical position of an eye, more myopic than the fellow eye, and hence larger and weightier, which causes a slight, unnoticeable displacement downwards. Our fusion ability to overcome vertical deviations is only 2°, and deviations more than this result in diplopia.
Case 5: A lawyer, aged 60, consulted me in despair. Since a few months, reading had become extremely difficult; the letters appeared double in the vertical direction, and he was hardly able to practice his profession. Some ophthalmologists he had consulted could not help. His glasses were RE −4.5 s + 1.0x15°, LE −6.0 s +0.5x90° and +2.5 s addition for near distances. VA was 1.0 for both eyes. The vertical deviation for near fixation in primary position was +VD 4° (=8Δ); for measuring we used the Lees-Screen, producing full dissociation of fusion.
Prescription of glasses: For his myopic correction ground-in prisms were added—RE 2.5 Δ base down, LE 2.5 Δ base up. With these glasses the patient was highly content and could work again without difficulties. As explained in Section 5.6.1, we gave prisms with just the strength necessary to overcome the deviation.
Patients having such problems are often middle aged and always myopic. In my experience, myopia may increase gradually from youth until the age of 60–65 and afterwards decrease again, due to the influence of presbyopia. These changes in refraction are not always developing symmetrically in both eyes, with the consequence of anisometropia and heavy eye syndrome.
When dealing with this disease, neurologic symptoms will, of course, have priority. Patients consulting an ophthalmologist will usually not declare themselves spontaneously to suffer from “Parkinson”. An experienced medical practitioner, however, can easily recognize those patients, observing their stiff movements and the blank, expressionless stare. The diagnose makes us consider a number of ocular symptoms connected with this disease (Table 3).
Convergence insufficiency |
Loss of stable fixation |
Dry eyes due to a decreased blink rate |
Hypometric saccades |
Decreased excursions of up-gaze |
Ophthalmologic symptoms of Parkinson’s disease.
The complaints of 17 patients at my office were diplopia at all distances (4), only at reading distance (12) and unilateral blindness due to glaucoma (1).
The most important problem is the convergence insufficiency with a consequent divergent eye position for near distances, causing reading inability. The first step to helping these patients is to measure the most comfortable reading distance between the eyes and the book, which should be seen binocularly. Many patients use a reading stand because of their hands’ tremors. For this specific distance we determine not only the strength of the reading glasses but also the prisms necessary to compensate the divergent position. Press-on prisms are not advisable to be put on the patients’ own reading glasses for trial; they would be rejected for blurring.
Additionally, a squint position for distance may be present. Two of our patients had a convergent and three a slightly vertical deviation. Those patients needed separate prismatic glasses for each distance.
Another problem is the instability of fixation, resembling a tremor of the eyes. Using IROG we found an anomalously high number of square-wave jerks in both eyes when fixing an object [2]. This fact, combined with inexact movements, may evoke an impression of double vision, perceptible only by the patient and only for a split second.
Finally, a prescription for wetting eye drops must not be forgotten.
This disease commonly affects middle-aged patients; the onset may be acute with swelling of the eyes and exophthalmos or insidious with asthenopic complaints and slowly developing diplopia. The first sign may be a restriction of elevation and convergence, unilateral or bilaterally asymmetric, caused by the swelling of the eye muscles. The treatment of the acute stage requires the cooperation of several medical disciplines.
The treatment of late stages is the task of the ophthalmologists. Owing to the inflammation, the muscle fibers are replaced by fibrotic tissues and lose their elasticity; consequently, the excursion of the bulb to the opposite side of the affected muscle is restricted, a condition proved by
This disease is based on a defective neuromuscular junction, a lack of acetylcholine and it is interesting for ophthalmologists because the first symptoms often are a uni- or bilateral ptosis and diplopia. In the course of a day the symptoms will deteriorate. The double pictures cannot be related to a certain eye muscle, like in a neurogenic palsy, and they are highly changeable; therefore, they cannot be corrected by prisms. Blood tests and stress tests will confirm the diagnosis. In general, neurologists will take charge of the treatment.
Yet, we recommend the colleagues of ophthalmology to consider the possible presence of myasthenia in cases of unsettled asthenopic complaints or unstable heterophoria.
This chapter is aimed at ophthalmologists without orthoptic equipment and at colleagues of other disciplines, such as neurology and geriatrics. With simple methods and a minimum of instruments, it is possible to find out whether double vision is due to an ophthalmologic or a neurologic disorder.
What we need:
A non-blinding penlight for the inspection of the eyes, for fixation in a near distance and to check the motility of the eyes.
A Maddox-Cross, mounted at a 5-m distance, serving as a fixation light for measuring the angle of squint in various directions of gaze.
Two red glasses, one bright and the other dark, for different degrees of fusion dissociation, while measuring the eye deviation.
Bagolini glasses for examinations under near physiological conditions.
A Maddox-Wing test for measuring deviations in near distances.
Occluder.
Partially, diagnostic instructions have already been given on the previous pages. A few most important items are to be further explained: The cover test, the motility of the eyes and their muscles and the Bagolini glasses.
The patient fixes an object | a. in the distance |
b. in the proximity | |
Alternate covering of both eyes, every second, without interruption | |
No movement = Orthophoria, | |
but exceptionally strabismus + amblyopia + eccentric fixation | |
(corneal reflexes to be noticed!) | |
Movement from nasal side = Esotropia or esophoria | |
Movement from temporal side = Exotropia or exophoria | |
-tropia = manifest squint | |
-phoria = latent squint, decompensation by fusion interruption | |
both can be differentiated by the unilateral cover-uncover test |
The alternate cover test.
Both eyes must be checked for distance and near fixation, and an interval to regain the original position is necessary. |
Observation of the |
1. While a. No fixation movement = Heterophoria |
b. Fixation movement = Heterotropia |
2. While a. Fixation maintained = alternating squint |
b. Fixation lost = unilateral squint |
The unilateral cover-uncover test.
To check the eye motility, a torch is moved in the main directions of gaze, monocular and, what is more important, binocular, while the head is fixed. For the main action of each muscle, see Figure 2. In the presence of double pictures the examiner has to ask in which direction the lights have the largest space between them; a red glass before the right eye enables to differentiate the eye which each light belongs to; the light in the most outward position indicates the palsied muscle.
The action of the eye muscles. The face is a photo of an antique statue.
The Bagolini glasses, always used binocularly, give information about the eye position, fusion ability or suppression. They should only be used in addition to the best correcting glasses of the refraction error. The possible results are shown in Figure 3.
Some results using Bagolini glasses: (A) orthophoria (or microtropia), (B) suppression of RE, (C) suppression of LE, (D) uncrossed diplopia (esotropia), (E) crossed diplopia (exotropia), and (F) central scotoma without squint.
Ocular diplopia:
anamnesis most important
onset slowly, unnoticed
concomitant motility pattern
loss of binocularity without diplopia = “masked diplopia”
intractable diplopia in the adulthood of infantile squinters or after the operation of a long-standing cataract
Neurogenic diplopia
onset sudden, flash-like
incomitant motility pattern
intractable diplopia after severe craniocerebral trauma
I would like to thank Reinhard Müller for technical support and Irene Manutscheri for copyediting the manuscript.
There are no conflicts of interests.
At the beginning of this century, the topic of global climate change became of particular relevance for the regions of the Arctic and the North. This problem is actual in modern conditions. The Arctic climate changes faster than any other part of the world; this is the only highly integrated system in this belt; changes in the Arctic will have a big impact on other parts of the world. The Arctic will become an increasing center of world attention. Over the past few decades, the average annual temperature due to an increase in the average winter temperature in the Arctic has grown two times faster than elsewhere, causing the melting of sea ice and permafrost and a reduction in the snow period. The consequences of global warming in the Arctic are already obvious and numerous. Modern climate changes significantly affect coastal communities, species diversity of animals and plants, human health and welfare, as well as the economy and infrastructure of the Arctic regions. Global warming is the process of gradual growth of the average annual temperature of the surface layer of the Earth’s atmosphere and the World Ocean, due to all sorts of reasons (increase in the concentration of greenhouse gases in the Earth’s atmosphere, changes in solar or volcanic activity, etc.). Global warming will change the habitats of many species of terrestrial and marine flora and fauna. The most large-scale changes will be felt by the indigenous peoples of the North, whose life is inseparably linked with the natural environment. As the permafrost is thawing, the threat of destruction of buildings, roads, pipelines, airports, and other infrastructure increases, which in a number of cases will lead to significant economic losses, deterioration in the quality of drinking water supply, social tension, forced migration, and, as a result, an increase in the number of infectious and noninfectious diseases, including mental disorders and psychosomatic and addiction diseases. Indigenous peoples of the North are the most vulnerable category of the population to the climate negative impact in the Arctic. Limiting the possibility of using bioresources as a result of hunting and reindeer herding, fishing, and gathering, as well as reducing the safety of movement when the parameters of ice and weather conditions change significantly, increases the risks to health and life and, possibly, in the future, threatens the very existence of some nationalities and cultures.
\nGradually, in countries the understanding comes that the nature is the original environment of human life, but not capital, which should be used in economic circulation. Preservation of this environment is becoming one of the main tasks of state policy based on the principles of energy efficiency and resource saving. For example, in the Russian Federation, such basic documents as the Strategy of Ecological Safety of Russia [1], the state program on energy efficiency and development of energy [2], etc. were adopted. However, despite the billions of dollars invested by developed countries in greening the economy, the development of innovative technologies, and the reduction of greenhouse gases, there are still no visible effects on a global scale, and in fact the world is facing a degradation of the natural environment. As Nobel laureate academician Vladimir Kotlyakov notes, our planet is experiencing an era of global warming. The increase in global air temperature in the last century was slightly more than 0.7°C. However, over the past 30 years, this growth has increased, which is especially reflected over the continental regions of Eurasia and North America and most of all in the Arctic [3]. The current model of the functioning of the world economy allows us to make disappointing forecasts: the growing population of the Earth will be able to supply the products of consumption only with the increase of production, the improvement of technologies, and, unfortunately, the destruction of the biosphere.
\nFigure 1 demonstrates the anomalies of temperature values in the Northern Hemisphere, including the Arctic. This gives grounds to predict the increasing influence of negative factors on the ecosystem of this region, as well as on the life of the indigenous population. Certainly, climate change is a particularly important issue in the context of the development of the Arctic and the indigenous communities that inhabit it. Indigenous peoples also have their own observations related to climate change, since no one can see better what is happening now in the North, and there are significant shifts in their strategies for adapting to these changes. Traditional knowledge is a valuable resource that can and should be used in various fields of exploration and development of the Arctic. Unfortunately the representation of indigenous peoples in international governance structures does not guarantee that traditional knowledge is entirely engaged in evidence-based policy making and that traditional knowledge is not always valued as an equal source of knowledge by some relevant scientific bodies [4]. Hundreds of years of tribal communities’ observations over the changes in the Arctic, the formation of ideas about the laws of nature, beliefs in the “living land of ancestors” give today the opportunity to transform traditional knowledge into the daily practice of government, business, and scientists in the extreme North and integrate it with modern technologies. According to the Paris Climate Change Agreement, indigenous peoples and local communities are recognized as the important actors in building a world that is resilient in the face of climate impacts [5].
\nMap of monthly values and anomalies of meteorological values in the northern hemisphere for June 2018 (source:
We can rightly call the Arctic zone a “locomotive” of the modernization of the Russian economy [6]. In this vein, state policy is being drawn up, investments are attracted, and projects are being implemented to extract natural resources (gas, oil, gold, rare earth metals, etc.). Almost every one of these projects implemented in the northern regions of the country, one way or another, affects the territories of traditional nature use—the habitat of indigenous peoples of the North. Therefore, the issue of research and assessment of changes in these territories under the impact of climate change and industrial development is very relevant, since it has a multifactorial specificity, centered on the unique culture of the northern people, its traditions, and its customs. In Russia, indigenous peoples of the North, as a rule, live in the rural areas of the Arctic zone, which population, according to the Federal State Statistics Service, declines annually. Therefore, it is important to study the changes in these territories and develop policies aimed at preserving not only local communities as a carrier of culture and traditions of northern peoples but also traditional economic activities (reindeer herding, fishing, hunting, etc.), since the reindeer herding is the basis of the traditional culture of the North (Figure 2).
\nThe numbers of the permanent population of the land territories of the Arctic zone of the Russian Federation as of January 1, 2018 (number of people) [
The future of the Arctic territories is connected, on the one hand, with the expansion of the zone of industrial development and the extraction in deposits and on the other hand the increasing pressure on the unique ecosystem of the Arctic, the changes in the territories of traditional nature use, the transformation of indigenous population’s way of life, and tribal communities under the influence, including climate change. In Table 1 the main indicators describing the territories of traditional residence and traditional economic activity of the indigenous peoples of Russia are presented. This type of territory is located in 21 regions of the Russian Federation with reindeer pastures, hunting grounds and rich fishing opportunities, and gathering of wild plants on a total area of 994.2 million hectares, including lands used directly as reindeer pastures—407.0 million hectares [8].
\nClimate change leads to the transformation of the traditional way of life and also forces regional and local governments to seek new approaches to managing these changes, allowing them to adapt and adequately respond to emerging challenges. Prospects for the revitalization of the industrial development of the North in the future involve the withdrawal of an increasing number of lands of traditional nature use for inclusion in economic circulation. Undoubtedly, industrial development of indigenous peoples’ habitats at the present time determines the prospects for their further socioeconomic and ethno-cultural development. Considering the strategic nature of the state interests in the Arctic region and the attention paid to the development of deposits in Siberia and the Far East, it is necessary to devote harmonization of interests of industrial development of these territories and preservation of the habitat of indigenous communities, creation of mechanisms for interaction of task forces on optimization of economic, and social and environmental interests of all stakeholders in the territories of traditional nature use [10].
\nThe impact of climate change on indigenous peoples is diverse. This is especially reflected in health and the traditional way of life. Health as a factor in the well-being of indigenous peoples worsens, which shows itself in a high level of mortality with relatively high birth rates, problems with alcoholism, and diseases of the digestive system due to poor-quality drinking water. Significant climate change resulting in the increase of natural disasters, abnormal winter and summer temperatures, floods, mudflows, and landslides increases the number of deaths from unnatural causes, injuries, and subsequent health problems. Climatic changes are also the cause of more serious phenomena, as the deterioration of the parasitic and epidemiological situation. Degradation of permafrost in areas where this type of soil has been preserved for centuries, and on the basis of which the habitat of indigenous peoples and their feeding systems has been formed, leads to catastrophic consequences. Moreover, changes in the permafrost sometimes have unexplained causes, which raise an active discussion in the scientific community. So, in 2014 in Yamal, a giant dip of a soil of unknown origin was discovered. A huge funnel was noticed by helicopter pilots who serve the oil and gas fields on the Yamal Peninsula. The fault is located next to the Bovanenkovo gas field (Yamal LNG), one of the largest in Yamal—the place of one of the most innovative projects of modern Russia for liquefied gas production jointly implemented with Italy, France, Japan, and China (Figure 3).
\nYamal hole in 30 km from the Bovanenkovo gas field. (source:
Later Russian scientists from Yamal managed to descend for the first time to the bottom of this dip—to a depth of 200 m. The hole has a cone-shaped view with dimensions of 60 and 40 m. They took more than a dozen samples for chemical analyses, including ice and soil. It turned out that the Yamal “black hole” from the inside is covered with a layer of ice of unknown composition, which has yet to be investigated in the laboratory. Analyses of air inside the funnel revealed the absence of harmful impurities and dangerous gases—on the basis of this fact, scientists concluded that in a mysterious earthly failure, a new life could arise in time. The scientists noted that they failed to solve the main riddle—how the process of a mysterious holes’ formation was going on in the Yamal land. The most authoritative experts consider these holes to be the result of the process of degassing the permafrost due to global warming [11]. Currently, the problem of tundra transformation under the climate change factors is becoming a significant threat to the traditional forms of economic activity, especially reindeer herding. The formation of thermokarst lakes, the degradation of biota, and the waterlogging of significant areas of the tundra during the summer period are risk factors and cause deer to change routes, and in the spring and autumn, a phenomenon such as ice, which is ruinous for reindeer herding, began to increase. Due to the steady increase in the amount of precipitation in recent years, a deeper snow cover is formed, creating difficulties for animals to hoof the reindeer moss. At the same time, the late arrival of colds led to difficulties in the transition of reindeers to winter pastures (Figure 4).
\nThermokarst lake in tundra with landscape degradation near Vorkuta, Komi Republic, Russia (photo: V. Gassiy).
In the northern regions of Russia in recent years, there have been no isolated cases in which thousands of reindeers perished from hunger. The increase in the mean annual temperature is detrimental to the regions of permafrost, where the centers of anthrax are revealed during thawing. In the summer of 2016 on the territory of Yamal, an outbreak of anthrax was caused by an abnormal heat. The most dangerous infection was safely suspended in the permafrost for 75 years. The most objective cause of the outbreak was called climate warming. Abnormal heat in the tundra to +35°C kept for more than a month. Comprehensive measures were taken to protect Yamal reindeer herders from dangerous diseases. All the livestock of the deer are vaccinated; the animals are fitted with chips. Vaccination is conducted among the tundra population and specialists from the risk group: in 2017, about 8.2 thousand people were vaccinated in the region, and the entire number of reindeer and more than 730 thousand animals were vaccinated against anthrax. Forty-two thousand representatives of the indigenous peoples of the North—14,000 of them live in a traditional nomadic way of life—and the largest reindeer herd in the world live in the territory of Yamal, so the ecological component plays an important role in preserving the traditional economic activities of indigenous peoples [12]. One of the main threats is the change in the water regime of rivers. Most of the modern settlements in the North are located on the banks of rivers. In recent years, spring floods have sharply increased, floods have become more frequent, and the processes of erosion of shores have accelerated, which bring great disasters to the population. For example, in the regions of northern Yakutia, the banks of the rivers Lena, Yana, and Anabar collapse under the influence of high temperatures and melting of permafrost, which leads to shallowing of rivers, a change in the relief of the bottom. As a consequence of these processes, boats of local fishermen cannot sail along the riverbed; the fish does not go far downstream; thus indigenous peoples are deprived of the type of product that forms the basis of their food ration. Reduction of fishing takes place together with a decrease in the level of production of hunting objects (wild reindeer changes migration routes; the number of fur-bearing animals decreases; because of warming, the meat of a wild animal is often affected by a viral infection or parasites), i.e., we are talking about the problem of access to traditional types of resources.
\nAccess to resources is closely linked to security, which is provided by traditional knowledge, accumulated for millennia. But the transformations that are taking place change the reality; the representatives of indigenous peoples are increasing in situations where their practice, experience, and knowledge cannot help them. This leads to an increase in the number of accidents, especially those associated with late freeze-up, ice, and early floods. One of the consequences is the restriction of access to traditional food. In addition to the above factors, one of the reasons is the deterioration of storage conditions. In recent years, the quality of food has sharply deteriorated. So, in the Bulunsky District of Yakutia, local residents often face the problem of phimosis (
It is also necessary to say about the impact of climate change on the health of indigenous peoples. In recent years there has been an increase in mortality in the Arctic. Almost every year there are floods, with every third year—with disastrous consequences and deaths. The number of hits to hospitals increased due to sunstroke, dehydration, pressure drop, etc. Surface water pollution increased, both from floods and melting of permafrost. This leads to an increase in intestinal diseases, especially in the period of floods. Also, in Arctic regions, there is increasing cases of oncological diseases [16]. Some experts attribute this to a more intensive chlorination due to the deterioration of water quality. The prolonged exposure to increased concentrations of chlorine and its constituents, according to doctors, increases the risk of cancer. Warming has widened the areas of spread of diseases, the carriers of which are insects or mites that spread to all new territories. One of the main risk groups for climate change is the children. In northern regions, up to 70% of children have deviations in health status. The incidence of children in the northern regions is significantly higher than the national average. Over the past 10 years, they tend to grow. Children of the North and children of other regions are in unequal starting conditions of life. Under the influence of unfavorable climatic factors and polluted environment, the age development of the immune system falls behind in children of the North for 2–5 years. Thus, for indigenous peoples of the Arctic, the warming of the climate and the associated lengthening of the season, during which the sea is not covered by ice, a decrease in the surface and thickness of sea ice, changes in the migration routes of wild reindeer and their food base, and a drop in the number of marine animals may lead to a reduction in traditional craft. This, in turn, will lead to a violation of traditional food. The indigenous inhabitants of Alaska and Greenland, Chukotka, and Yamal are already recording the negative effects of climate warming, which appeared in a decrease in thickness and an earlier opening of sea ice. These circumstances make it more difficult to hunt and lead to an increase in the number of injuries, which is already the cause of a significant number of deaths among indigenous peoples of the North [17].
\nFigure 5 shows the riverbed of the Anabar River near the village of Saskylakh in the northwestern part of Yakutia. Fishermen are forced to manually drag the boat a few kilometers downstream to reach the fairway (Figure 6).
\nShallowing of the Anabar River in Yakutia (photo: V. Gassiy).
Collapse of the riverbank of Yana due to permafrost melting, Yakutia (photo: V. Gassiy).
In 2017, an expedition aimed to the research on socioeconomic and environmental problems of the Arctic indigenous communities was organized by the financial aid of the Russian Fund for Basic Research (RFBR) to the Anabar National (Dolgan-Evenk) ulus (district) and Ust-Yanskiy region in Yakutia. These areas belonged to the compact residents of the indigenous peoples of the North. The study allowed to determine the attitude of the local population to traditional activities and to identify the socioeconomic problems of the territories and environmental threats to indigenous communities in the context of climate change. In the structure of the respondents in the Anabar area, representatives of indigenous peoples were Evenks 43 people (33%) and Dolgans 71 people (55%) (Figure 7) (Table 2).
\nRatio of men and women in the total number of respondents.
Education organizations, units | \n1735 | \n
Number of medical treatment and prophylactic organizations, units | \n2045 | \n
Number of cultural and leisure type organizations, units | \n834 | \n
Libraries and museums, units | \n542 | \n
Number of sports facilities, units | \n10,161 | \n
Hospitality facilities and accommodation | \n1123 | \n
Shops and supermarket, units | \n28,364 | \n
Restaurants and cafes | \n3773 | \n
Settlements with post office, units | \n1735 | \n
Commissioning of residential buildings, square meters | \n1,496,550 | \n
Number of people living in dilapidated houses | \n192,411 | \n
Extension of a street water supply network, meters | \n7,566,841.0 | \n
Including in need of replacement, meters | \n2,411,098.0 | \n
Number of enterprises for utilization and neutralization of domestic and industrial waste, units | \n151 | \n
Indicators of the social development level of territories of traditional nature use in Siberia and the Far East of the Russian Federation in 2017 [9].
Indigenous community | \nRespondents | \nShare of respondents from the total number, % | \n
---|---|---|
Yuryung-Khaya | \n29 | \n22 | \n
Saskylakh | \n101 | \n78 | \n
Total | \n130 | \n1000 | \n
Distribution of respondents who participated in the survey, by settlements in the district.
It is worth noting that this ratio between men and women, when the number of women prevails, is typical for indigenous communities, since it is associated with the high mortality of men engaged in traditional crafts: hunting, fishing, and reindeer herding. In addition, we can add problems of alcoholism reducing life expectancy, as well as chronic diseases caused by the harsh climate. As a result of the survey, residents of indigenous communities noted the following socioeconomic problems in their places of residence:
High prices for food products, 22.5%
The lack of jobs, 20.2%
Low level of income, 19.7%
Old state of housing and communal services, 19.1%
Poor transport accessibility, 9.0%
Low level of medical services, 6.5%
Low level of equipping educational institutions, 3.1%
As can be seen from the survey results presented, the majority of the respondents connect the socioeconomic problems of the territory with the lack of a stable income, the need for employment, and the underdeveloped infrastructure. In this regard, the implementation of investment projects for the industrial development of territories can create additional jobs for the local population. It should be noted that in the experience of some Russian regions, there are examples of the implementation of a targeted policy for the local labor market development. For example, for several years in the Republic of Sakha (Yakutia), JSC Almazy Anabara (Alrosa group) has been implementing the educational program, which provides training for the company’s interests and the residents of indigenous communities, where an investment project on the extraction of minerals starts. The survey made it possible to determine the list of sociocultural problems that concern the local population:
Increase in morbidity and mortality of the population, 20.7%
Loss of communication between people and their culture, traditions, 18.3%
Alcoholism, 18.3%
The lack of organized forms of leisure, 14.1%
Problems of selling traditional craft products, 12.3%
Outflow of youth, 12.0%
Crime rate, 4.5%
It should be noted that the majority of respondents attributed an increase in morbidity and mortality of the population with active industrial development of territories of traditional nature use. However, these are often only subjective assessments, since the problem of early diagnosis of diseases in the Arctic regions of Russia is particularly acute, and not only instruments and specialists are available in the district centers that could conduct regular medical checkups of the population but even a morgue, i.e., in rural settlements there is no way to establish reliably the cause of death. In most cases, early and sudden deaths, the local population refers to oncological diseases as the consequences of the activity of an industrial enterprise in the territory of their living. In the course of a poll among the inhabitants of indigenous communities, it was found that a high mortality rate is also associated with the problem of alcoholism and crimes committed under the influence of alcohol. The traditional types of economic activity associated with hunting and fishing also endanger life: water safety rules are not followed as well as dealing with weapons.
\nAmong environmental problems, the majority of respondents noted the decline in traditional craft facilities, which is directly attributed to climate change (e.g., the wild reindeer changes its migration routes under the influence of this factor and, as in the case of the Republic of Sakha (Yakutia), goes to the Krasnoyarsk Territory). According to observations of indigenous peoples, winters become warmer, which is expressed in heavy snowfalls and increased winter temperatures. This leads to river spill in spring, flooding of villages, and loss of the fishing opportunity in the traditional way, as the fish goes deeper. Flood threatens another serious problem for traditional craft—broken trees, which the river carries, can break the seines, which means that an indigenous individual and his family can be deprived of food. Many of the representatives of indigenous communities also note the man-made factor—pollution of rivers due to the implementation of industrial projects, shipping, etc.
\nThe Ust-Yanskiy region, the second researched area, has specificity concluded in a huge accumulated damage due to a previous gold extractive mine Kular and closed settlements (Vlasovo, Severniy) caused by mass outflow migration since 1998 when this mine was closed. The barbaric way of extracting gold from only the large and medium fractions, the pursuit of the indicators, led to the fact that there is still enough gold in the recycled dumps that can be produced. Since 2017, the license for processing and restoring Kular mine has been transferred to Arctic Capital LLC, which has undertaken the task of eliminating the accumulated environmental damage, recultivation of soil, employment of the local population among indigenous peoples in the newly discovered deposit, and procurement of traditional products (venison, fish, etc.). The concept of social responsibility of business comes to the Russian part of the Arctic, and it becomes one of the few ways to preserve indigenous community and people on the place of their original habitat (Figure 8).
\nAccumulated environmental damage in Vlasovo, Ust-Yanskiy region, Yakutia (photo: V. Gassiy).
The specificity of the researched territory is its inaccessibility, which has a negative impact on the development of traditional spheres of economic activity. Producing objects of traditional nature use (fish, berries, furs) involves not only consumption for personal purposes but also the need to transport them to the market in larger settlements. The lack of roads and the high cost of transportation by air or auto trucks make economic activity (trade) by-products of traditional nature use almost impossible. In the Ust-Yanskiy area, the main source of income is the extraction of the mammoth tusk, which brings a significant income to the tribal communities and individual entrepreneurs. However, this type of activity requires special training (traditional knowledge, physical form, etc.) and technical equipment (pumps, boats, etc.). Although there are widespread cases of attempts by local residents to obtain tusks and without the necessary equipment, which leads to lethal incidents. On average, according to local residents, the “washing” season is about 100 days, for which one well-trained person can collect from 500 to 800 kg of tusks. In monetary terms, such a “crop” can fluctuate from 10 to 15 million rubles or 160,000–230,000 US$. Moreover, a hot summer with anomalous temperatures is considered by local hunters for tusks as a blessing, since actively melting permafrost itself gives away the hidden remains of ancient animals hidden for thousands of years. It should be noted that in the villages where the main activity is the extraction of the mammoth tusk, one can see expensive modern machinery that local authorities do not always have (Figure 9).
\nType of transport vehicle in a Kazachye indigenous community, Ust-Yanskiy region (photo: V. Gassiy).
The purchased transport equipment allows local residents to develop trade between settlements within the region. Given their remoteness from each other, and the impossibility of year-round traffic, this is an important factor in actually helping people survive in such a harsh terrain. This fact makes indigenous peoples to adapt to the climate change in tundra in a unique way. For example, it is often possible to meet indigenous peoples who are using a winter mode of transport during the summer period, since flooded areas of the tundra do not allow movement on motorized wheeled vehicles, Figure 10.
\nSnowmobile in summer tundra on the way to Khayyr (even community), Ust-Yanskiy region, Yakutia (photo: V. Gassiy).
Figure 10 shows a group of Evens moving on a snowmobile to their native village. In their opinion, in recent years the climate in the tundra has changed considerably: “Winters have become warmer, and summer is unstable: there can be both hot days and cold months when berries do not have time to ripen” (reindeer herder Nikolai, 43); “The deer goes North and does not come here because of the midges, which is very much due to the heat” (hunter Michael, 52) (Figure 11).
\nExample of private household in Kazachye (even community), Ust-Yanskiy region, Yakutia (photo: V. Gassiy).
As a survey of the indigenous community showed, the traditional economy for the majority of local population ceases to be the basic criteria for determining the ethnic characteristics of the people. The high level of unemployment among indigenous peoples of the North, including the Evenks, Evens, and Dolgans, is complicated by the peculiarities of the sectoral structure of employment and the qualification and educational level of the economically active population. The succession of generations in the traditional sectors of the North is gradually disappearing. Young people, being witnesses to the everyday, problematic life of the older generation, are of the opinion that work in reindeer husbandry, hunting, and fishing is not prestigious and does not bring sufficient income to create the corresponding financial situation of the family. The studied living conditions of indigenous communities on the territories of traditional nature use testify to the low level of social, communal, transport infrastructure development, which affects the behavior of the younger generation, their desire to go to the city or find work in extractive companies. “The benefits of civilization” in the form of the Internet, social web sources, and public amenities, along with climate changes, form challenges to the traditional way of life, undermining the age-old foundations of tribal communities. The domestic problems of indigenous peoples are one of the main reasons for the reluctance to remain on their land, to lead a traditional way of life, especially nomadic. Often villages in the territories of traditional residence are not provided with drinking water, and the only sources are river, rain water, or snow (Figure 12).
\nRainwater harvesting for personal consumption, Khayyr (even community), Ust-Yanskiy region, Yakutia (photo: V. Gassiy).
Thus, climate change in the Arctic for indigenous communities is not a prospect of the future, but a real threat to the traditional way of life, food security, and their habitat. We believe that ensuring the social status, decent level, and quality of life of the indigenous communities depends on the ways of preserving and developing the traditional economy on a new material, technical, and technological basis. Market relations in reindeer husbandry and hunting are constrained by the peculiarities of the nomadic way of life and the mentality of indigenous peoples. The theory and practice of managing changes in the territories of the traditional nature use of the Arctic require a critical rethinking of established views. In the coming years, new management approaches will be needed to quickly respond to changes in the Arctic territories, as climate change and global warming lead to the biggest social problem—changing the traditional way of life of indigenous peoples. On the other hand, industrial development expands the area of its presence in the Arctic, which creates not only challenges for the indigenous population but also the opportunities to preserve their culture, traditions, and crafts. In this regard, it is necessary to introduce into the practice of public administration the decision-making model for choosing investment projects based on the priorities of local development, the interests not only of the state and business but also of the indigenous communities [18]. Therefore, in order to solve the problem of survival and adaptation of Arctic indigenous communities in the context of climate change, a proactive reaction of science and practice is needed, based on complex sociological, ethno-cultural, ecological-economic, and statistical studies of traditional nature-use territories.
\nOve Odredbe i uvjeti ističu pravila i regulacije u svezi korištenja IntechOpenove stranice www.intechopen.com i svih poddomena u vlasništvu IntechOpena, tvrtke sa sjedištem u 5 Princes Gate Court, London, SW7 2QJ, Ujedinjeno Kraljevstvo.
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\\n\\nSljedeća terminologija odnosi se na Odredbe i uvjete, te na sve naše ugovore:
\\n\\nKlijent, stranka, vi, vaš odnosi se na vas, osobu koja pristupa ovoj stranici i prihvaća IntechOpenove Odredbe i uvjete;
\\n\\nKompanija, tvrtka, mi, naše odnosi se na tvrtku IntechOpen;
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\\n\\nIntechOpen nije formalno povezan niti s jednom vanjskom stranicom čije poveznice vode na www.intechopen.com, osim ako to nije izravno navedeno. Iz tog razloga IntechOpen nije odgovoran za sadržaj koji se pojavljuje na takvim stranicama. Poveznica na IntechOpenovu stranicu ne implicira povezanost sa IntechOpenom. Korištenje takvih poveznica isključiva je odgovornost korisnika.
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\\n\\nAko smatrate da je bilo koja poveznica na našoj stranici sumnjiva iz bilo kojeg razloga, molimo vas da nas kontaktirate. U tom slučaju razmotrit ćemo micanje poveznice s naše stranice, iako nismo obvezni to napraviti.
\\n\\nBez prethodne privole i izričite pisane dozvole, ne možete stvarati okvire oko naših stranica ili koristiti druge tehnike koje na bilo koji način mogu promijeniti prezentaciju ili izgled naše stranice.
\\n\\nIntechOpen može ove Odredbe izmijeniti u bilo koje vrijeme i bez prethodne obavijesti. Koristeći ovu stranicu vi se slažete s trenutnim Odredbama i uvjetima koje su na snazi.
\\n\\nOve Odredbe i uvjeti su sastavljeni u skladu s odredbama prava Ujedinjenog Kraljevstva, a za sve sporove nadležan je sud u Londonu, Ujedinjeno Kraljevstvo.
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\n\nSljedeća terminologija odnosi se na Odredbe i uvjete, te na sve naše ugovore:
\n\nKlijent, stranka, vi, vaš odnosi se na vas, osobu koja pristupa ovoj stranici i prihvaća IntechOpenove Odredbe i uvjete;
\n\nKompanija, tvrtka, mi, naše odnosi se na tvrtku IntechOpen;
\n\nStranke, strane odnosi se na klijenta i na nas, ili samo na klijenta ili nas.
\n\nSve odredbe koje se odnose na ponudu, prihvat ili razmatranje plaćanja, a za koja mi pružamo asistenciju klijentu, bilo na ugovoreni ili fiksni način, a s ciljem da se ostvare potrebe i želje klijenta u svezi s našim uslugama, su podložne zakonskim odredbama Ujedinjenog Kraljevstva.
\n\nOsim ako nije suprotno navedeno, IntechOpen i/ili svi davatelji licence vlasnici su intelektualnog vlasništva nad svim materijalima na www.intechopen.com. Sva prava intelektualnog vlasništva su pridržana. Stranice sa www.intechopen.com možete gledati, preuzimati, dijeliti, dijeliti poveznice i printati za osobnu uporabu, a temeljem pravila sadržanih u ovim Odredbama i uvjetima.
\n\nMi koristimo kolačiće. Korištenjem IntechOpenove stranice slažete se s korištenjem kolačića u skladu s IntechOpenovom Politikom privatnosti. Većina modernih, interaktivnih stranica koristi kolačiće kako bi omogućila ponovno pronalaženje korisničkih detalja kod svakog posjeta. Na našoj stranici kolačići se uglavnom koriste kako bi omogućili funkcionalnost i olakšali posjetiteljima korištenje stranice.
\n\nIntechOpen ili njegovi suradnici niti u jednom slučaju neće biti odgovorni za štete (štete uključuju gubitak podataka ili profita, druge poslovne prekide, te sve ostale štete) koje nastanu zbog korištenja materijala na IntechOpenovoj stranici ili nemogućnosti da se iste koriste, čak i ako je IntechOpen ili njegov predstavnik o takvoj šteti obaviješten pismenim ili usmenim putem. Neke jurisdikcije ne dozvoljavaju ograničenja garancija ili ograničenja obveza za posljedične ili slučajne štete pa se u tom slučaju ova ograničenja možda ne odnose na vas.
\n\nMaterijali koji se pojavljuju na IntechOpenovoj stranici mogu sadržavati manje greške, tipfelere ili fotografske greške. IntechOpen može napraviti promjene na bilo kojem materijalu koji se nalazi na stranici u bilo koje vrijeme.
\n\nIntechOpen nije formalno povezan niti s jednom vanjskom stranicom čije poveznice vode na www.intechopen.com, osim ako to nije izravno navedeno. Iz tog razloga IntechOpen nije odgovoran za sadržaj koji se pojavljuje na takvim stranicama. Poveznica na IntechOpenovu stranicu ne implicira povezanost sa IntechOpenom. Korištenje takvih poveznica isključiva je odgovornost korisnika.
\n\nZadržavamo pravo vlasništva nad cjelokupnom stranicom www.intechopen.com i nad svim materijalom na toj stranici. Koristeći se našim uslugama, slažete se da maknete sve poveznice na našu stranicu odmah nakon što to od vas zatražimo. Također, zadržavamo pravo da ove Odredbe i uvjete, i politiku o poveznicama izmjenimo u bilo koje vrijeme. Koristeći se poveznicama na naše stranice slažete se s ovim Odredbama i uvjetima.
\n\nAko smatrate da je bilo koja poveznica na našoj stranici sumnjiva iz bilo kojeg razloga, molimo vas da nas kontaktirate. U tom slučaju razmotrit ćemo micanje poveznice s naše stranice, iako nismo obvezni to napraviti.
\n\nBez prethodne privole i izričite pisane dozvole, ne možete stvarati okvire oko naših stranica ili koristiti druge tehnike koje na bilo koji način mogu promijeniti prezentaciju ili izgled naše stranice.
\n\nIntechOpen može ove Odredbe izmijeniti u bilo koje vrijeme i bez prethodne obavijesti. Koristeći ovu stranicu vi se slažete s trenutnim Odredbama i uvjetima koje su na snazi.
\n\nOve Odredbe i uvjeti su sastavljeni u skladu s odredbama prava Ujedinjenog Kraljevstva, a za sve sporove nadležan je sud u Londonu, Ujedinjeno Kraljevstvo.
\n"}]},successStories:{items:[]},authorsAndEditors:{filterParams:{sort:"featured,name"},profiles:[{id:"6700",title:"Dr.",name:"Abbass A.",middleName:null,surname:"Hashim",slug:"abbass-a.-hashim",fullName:"Abbass A. Hashim",position:null,profilePictureURL:"https://mts.intechopen.com/storage/users/6700/images/1864_n.jpg",biography:"Currently I am carrying out research in several areas of interest, mainly covering work on chemical and bio-sensors, semiconductor thin film device fabrication and characterisation.\nAt the moment I have very strong interest in radiation environmental pollution and bacteriology treatment. The teams of researchers are working very hard to bring novel results in this field. I am also a member of the team in charge for the supervision of Ph.D. students in the fields of development of silicon based planar waveguide sensor devices, study of inelastic electron tunnelling in planar tunnelling nanostructures for sensing applications and development of organotellurium(IV) compounds for semiconductor applications. I am a specialist in data analysis techniques and nanosurface structure. 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After obtaining a Master's degree in Mechanical Engineering, he continued his PhD studies in Robotics at the Vienna University of Technology. Here he worked as a robotic researcher with the university's Intelligent Manufacturing Systems Group as well as a guest researcher at various European universities, including the Swiss Federal Institute of Technology Lausanne (EPFL). During this time he published more than 20 scientific papers, gave presentations, served as a reviewer for major robotic journals and conferences and most importantly he co-founded and built the International Journal of Advanced Robotic Systems- world's first Open Access journal in the field of robotics. Starting this journal was a pivotal point in his career, since it was a pathway to founding IntechOpen - Open Access publisher focused on addressing academic researchers needs. Alex is a personification of IntechOpen key values being trusted, open and entrepreneurial. Today his focus is on defining the growth and development strategy for the company.",institutionString:null,institution:{name:"TU Wien",country:{name:"Austria"}}},{id:"19816",title:"Prof.",name:"Alexander",middleName:null,surname:"Kokorin",slug:"alexander-kokorin",fullName:"Alexander Kokorin",position:null,profilePictureURL:"https://mts.intechopen.com/storage/users/19816/images/1607_n.jpg",biography:"Alexander I. Kokorin: born: 1947, Moscow; DSc., PhD; Principal Research Fellow (Research Professor) of Department of Kinetics and Catalysis, N. Semenov Institute of Chemical Physics, Russian Academy of Sciences, Moscow.\r\nArea of research interests: physical chemistry of complex-organized molecular and nanosized systems, including polymer-metal complexes; the surface of doped oxide semiconductors. 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