Medical Genetics Institute, Cedars-Sinai Medical Center
Department of Pediatrics, Harbor-UCLA Medical Center
David Geffen School of Medicine at UCLA
Los Angeles, California
The axons of the optic nerve acquire myelin sheaths proximal to the lamBlood Circulation of the Optic Nerve ina cribrosa and do not possess a neurilemma spasms near tailbone buy generic ponstel pills. Direct injury by penetrating trauma or indirect injury by concussional and rotational forces muscle relaxant medications ponstel 250mg low price, and/or 6 muscle relaxant medications purchase ponstel 500 mg without a prescription. Clinical Features Diseases affecting the optic nerve give rise to visual disturbances but can sometimes be asymptomatic and remain unnoticed (as in early papilloedema) muscle relaxant benzodiazepine order genuine ponstel line. Localization of a lesion producing visual disturbance to the optic nerve can almost always be made by careful clinical examination including visual acuity muscle relaxant commercial order discount ponstel online, colour vision muscle relaxant prescriptions order 250 mg ponstel fast delivery, pupillary reactions spasms vs spasticity cheap ponstel online visa, visual feld and ophthalmoscopic appearance of the optic nerve head muscle spasms 9 weeks pregnant buy ponstel 250 mg line. Sometimes visual disturbance in diseases affecting the optic nerve may be more subtle and may affect aspects of visual function other than visual acuity such as loss of contrast sensitivity, diminished stereoacuity and decrease in brightness of objects. Retinal diseases affecting the macula generally have normal pupillary reactions and an abnormal photostress test (see Chapter 10). Systematic Approach to Differential Diagnosis this can be made by categorizing the patient on the basis of: l Whether one or both eyes are affected l the pattern of visual field loss l the appearance of the optic nerve head or optic disc. Visual feld defects are best detected by Goldmann kinetic perimetry (full feld) and Humphrey automated centrocaecal scotomas (Fig. The feld defects caused by the appearance of the optic disc may be normal, swolvarious optic neuropathies are of different patterns but they len or oedematous, hyperaemic or pale, in different disorcan be broadly classifed as either (i) central (Fig. Swollen optic disc or disc oedema (true acquired disc papillomacular bundle) oedema must be distinguished from pseudo swelling) A. Unilateral l Papillitis or optic neuritis involving the nerve head l Optic neuritis (sudden visual loss) (sudden loss of vision with subsequent improvement) l Compressive lesion (slowly progressive visual loss) l Anterior ischaemic optic neuropathy (sudden loss of B. This occurs due l Other systemic diseases such as anaemia and to compression of the posterior optic nerve and anterior chiasma from below, affecting the anterior crossing fbres (or von Willebrand knee) hypoxaemia from the inferior nasal retina of the fellow eye. Unilateral change with time and any optic neuropathy may eventually l Retrobulbar neuritis result in optic atrophy (Table 22. Bilateral Papilloedema l Tobaccoand alcohol-related neuropathy l Nutritional Papilloedema is defned as oedema of the optic disc or l Drugs nerve head due to raised intracranial pressure. Atrophic optic disc* tinuous with those around the brain, any rise in the intracraA. No signifcant cupping Pathogenesis l Any optic neuropathy the genesis of papilloedema has been disputed and ascribed to several factors. It was considered to be due to *Optic atrophy is also a consequence of lesions of the retina, optic chiasma and optic tract, all of which comprise axons arising from the compression of the central retinal vein as it crosses the retinal ganglion cells. Chapter | 22 Diseases of the Optic Nerve 351 subdural and subarachnoid spaces, causing its collapse, and ultimately degenerate. They show numerous cytoid bodies while the thicker-walled artery continued to transmit blood. Electron microsthe principal pathophysiology of optic disc swelling is now copy shows engorgement of axons in the laminar portion of recognized to be blockage of axoplasmic transport. The stasis in the optic nerve head leading to swelling of the mitochondria are structurally swollen and disrupted. The neuoptic disc and secondary vascular changes at the disc surroglia proliferates and the mesoblastic tissue around the vesface. There is subpial oedema distal but not access between the meningeal spaces within the cranium proximal to the site of entry of the central vessels, and the suband around the optic nerve, and if the optic nerve sheath is arachnoid space is frequently distended. Pathological changes opened surgically in patients with increased intracranial are also seen in the surrounding retina and macular region. Retinal exudates distributed radially along the folds may be present in the macular region corresponding Pathology to the clinical appearance of a macular fan or macular star. The pathology of papilloedema shows signs of passive oethe outer plexiform layer may be oedematous, but there are no dema without evidence of infammation; the oedematous large cystic spaces as seen in hypertensive retinopathy. The nerve fbres in the optic nerve head are swollen By defnition, papilloedema is disc oedema due to increased and axoplasmic stasis is noted in them. An intracranial tumour in any position, gets flled in and the internal limiting membrane is raised may induce it, the highest percentage being found with tumours (Fig. The nerve fbres become swollen and varicose, of the mid-brain, parieto-occipital region and cerebellum. Papilloedema due to tumours of the anterior fossa is relatively rare and occurs late in the course of the disease. In general, Choroid those tumours which tend to produce internal hydrocephalus Optic disc are most likely to cause papilloedema. Other intracranial causes include a brain abscess, thrombosis of the cavernous sinus or other intracranial veins, aneurysm, Optic subarachnoid haemorrhage, pseudotumour cerebri and hydronerve cephalus. Central retinal vein Pseudotumour cerebri, previously often termed as beMeningeal sheath nign intracranial hypertension, is a disorder associated with A raised intracranial pressure in the absence of an intracranial space-occupying lesion. It tends to occur in obese females in the second or third decades, producing headache with tranChoroid Increased sient blurring of vision and occasional photopsia. Transient obscurations (blurring) of vision and the presence of opticociliary shunts are bad Swollen Optic prognostic factors for vision. Other risk factors, particularly optic disc nerve in the older age group, are anaemia and high myopia. Episodes of transient attacks and mushrooms out so that the vessels bend sharply over its of blurred vision, or transient obscurations of vision, usumargins. At this stage, relative scotomata, and in the neighbouring retina where they may be both frst to green and red, may be present. Severe loss of that this tissue is thrown into folds, and the veins, now tortucentral visual acuity can occur with chronic papilloedema. Other symptoms include headache, which becomes and becomes opaque, and exudates begin to appear on its worse in a recumbent position or is worst in the early mornsurface and in the retina itself. The radiating, oedematous ing when the patient wakes up, but may improve during the folds around the macula take on the appearance of a macular day. Patients may complain of nausea and vomiting and star, usually incomplete and fan-shaped on the side towards diplopia (double vision) due to non-specifc paresis of the the disc, while fuffy patches (cotton-wool spots due to retinal sixth nerve caused by raised intracranial pressure. At this stage the ophthalmoscopic picture may Signs be indistinguishable from that of malignant hypertension. Signs vary but one of the frst is a blurring of the margins With increasing pressure in the tissue of the swollen of the optic disc. The blurring starts at the upper and lower disc, the vascular supply gets compromised leading to focal margins and extends around the nasal side, while the teminfarcts, ischaemia and direct pressure-induced axonal poral margin is usually still visible and sharp. Frequently, the swelling begins to subside before comes hyperaemic and gradually, progressive oedema exthis fnal stage is reached, but in all cases subsidence eventends over the surface of the disc reducing the size of the tually occurs, a process preceded by atrophic changes when physiological cup, blurring the temporal margin and spreadthe nerve fbres can no longer withstand the pressure and ing into the surrounding retina (Fig. When this process commences, the vascularity swells the veins become congested and turgescent; their of the disc diminishes so that it appears pale grey in colour; pulsations may be absent even on applying pressure on the and eventually, even though the increase in intracranial globe. Differential Diagnosis If the edges of the disc appear clearly defned with any lens in the ophthalmoscope, there is no papilloedema, but it does not follow that there is papilloedema if they appear blurred. Moreover, papilloedema may be simulated in three conditions: (i) pseudoneuritis or pseudo disc swelling due to drusen of the nerve head; (ii) hypermetropia and (iii) a true optic neuritis involving the optic nerve head (papillitis). The distinthis tissue obscures the lamina cribrosa and flls in the atroguishing features of some of these conditions are given below: phic cup. It extends over the edges, which are thus ill-defned, and along the vessels as a thickening of the perivascular l Ischaemic optic neuropathy: this usually produces sheaths. Further, it throttles the vessels, especially the arteries, profound, sudden visual loss and could be (i) arteso that they become markedly contracted. Meanwhile, owing ritic, associated with giant cell arteritis, or (ii) nonto the widespread exudative deposits, the surrounding retina arteritic, associated with vasculopathy related to often shows permanent changes, chiefy manifested by piggeneralized atherosclerotic disease and diabetes melmentary disturbances, which are most common at the macula. The swollen disc has a characteristically pallid the amount of reactionary organization or gliosis varies appearance in both conditions and, in some patients, greatly from case to case and, over time. The tissue laid down can be localized to one sector of the disc with a is gradually absorbed to some extent. Giant cell or marked they suggest the previous occurrence of papilloetemporal arteritis is a self-limiting disease affecting dema, but their absence cannot justify the conclusion that people over the age of 55 years, particularly women. In frontal tumours and bilateral (70%), and inherited as an irregular dominant middle ear disease, however, the swelling is usually greater trait. The appeartant indication than the amount of swelling, the localizing ance of the disc may mimic that of papilloedema assovalue being attached to the side frst affected. Thus, the ciated with visual defects, which may not correspond swelling may be actually less on the side frst affected to the position of the drusen. Optic disc drusen may be associthe diagnosis is easy in severe cases, but may be very ated with angioid streaks, subretinal neovascular memdiffcult in mild cases as the colour of the disc is not a defnite branes, vitreous haemorrhage and retinitis pigmentosa. Along with relief of the tropic eyes when the lamina cribrosa is small and the general symptoms of raised intracranial pressure (headache, crowded nerve fibres are heaped up as they enter the vomiting, stupor, etc. The ophthalnerves have been irretrievably damaged) and papilloedema moscopic appearance of swelling and blurred margins subsides. The recovery of vision may be faster than the subis largely due to ophthalmoscopic reflexes. On the other hand, vision may ing is never more than 2 D, there is no venous engorgedeteriorate after operation, probably because of progressive ment, oedema or exudates and the blind spot is not sclerosis at the disc, especially if surgical intervention has enlarged. If signs of subsidence and commencing atrol In optic neuritis due to inflammation (papillitis) phy are present, further diminution of vision is to be antici(Fig. Subsidence of the papilloedema is usually rapid after is often ophthalmoscopically indistinguishable from operation and a marked change may be seen in a week to a that in papilloedema. The swelling is usually moderfortnight, but this varies considerably from case to case. Vitreous opacities are usual although they and decompression urged from the ophthalmological point may be very fine. The visual symptoms are usually of view before peripheral constriction becomes evident. The acute depression of central this indicates that the optic nerve fbres have reached the vision, presence of a definite afferent pupillary defect stage when they are unable to withstand the effects of comor a relative afferent pupillary defect and the absence pression any further. Once atrophy becomes clinically visof signs of an intracranial space-occupying lesion ible at the disc, further visual deterioration will probably form the most important differentiating features. Disturbances of the Circulation Treatment Anterior Ischaemic Optic Neuropathy For papilloedema, this is essentially the relief of the causal Aetiopathogenesis pressure; if this cannot be relieved, the prognosis is bad Ischaemic optic neuropathy, producing an altitudinal feld and blindness the normal outcome. Chapter | 22 Diseases of the Optic Nerve 355 of severe anaemia or after a massive haemorrhage. Patients suffering from a neglected acute attack of angle-closure glaucoma are also likely to develop ischaemic neuropathy with subsequent optic atrophy. The condition, however, may arise spontaneously and the clinical entity comprises sudden loss of vision, initially associated with swelling of the optic disc (Fig. It is due to interference with the blood supply of the posterior ciliary artery to the anterior part of the optic nerve, producing a post-laminar infarct, without necessarily involving the central retinal artery. Based on this, ischaemic optic neuropathy is broadly classifed into two categories: (i) arteritic and (ii) non-arteritic. Clinical Features the typical features of giant cell arteritis are constant headaches, which may be unilateral or bilateral, in the temporal area with prominent vessels which are tender. Pulsation in the temporal artery, which is often palpably thickened, may be present or absent. The syndrome is self-limiting but may lead to blindness due to vascular occlusion, often heralded by intermittent attacks of loss of vision in one eye or an extraocular muscle palsy. Non-arteritic cases may have no overt symptoms of systemic vasculopathy or may be known to have diabetes, hypertension or atherosclerotic disease. Ocular symptoms include sudden profound vision loss which is usually unilateral at presentation in both types. The left fundus photograph of the same patient is shown in interpreted as an infarct of the disc or due to an accumulation Fig. Generally an inferior attitudinal field defect is seen as the supeof opaque axoplasmic debris in the optic nerve head. Fluorescein angiography is helpful in demonstrating Management hypoperfusion of a sector of the underlying choroid and the triggering factor for an attack of acute ischaemic optic poor flling of a portion of the optic disc (Fig. If a cilioretinal or Management, therefore, presents complicated problems central retinal artery is compromised, there may be an associbecause ischaemic optic neuropathy is not a diagnosis but ated infarction of a sector or of the entire retina, respectively. The disc may appear oedematous, disc tory and microcirculatory systems, specifc examination to haemorrhage may also be seen and clinically it resembles exclude any form of arteritis (erythrocyte sedimentation ischaemic optic neuropathy. In the presence of temporal arteritis, pallor or even cupping may occur, mimicking glaucoma. The eye itself Infammation of the Optic Nerve should be carefully assessed for raised intraocular pressure (Optic Neuritis) and for a low ophthalmodynamometric reading in the ophthalmic artery. Patients with arteriosclerotic disease may An infammation of the optic nerve is known as optic neuhave an optic nerve head which just survives despite miniritis. The optic nerve may be affected by infammation in mal perfusion from the posterior ciliary arteries. Corticosteroid l Papillitis, or therapy should be started as soon as possible to relieve the l Neuroretinitis, and headache. An intravenous loading dose of 200 mg hydrocortil Those which attack the nerve proximal to this region sone or 500 mg methylprednisolone administered slowly over and therefore show no ophthalmoscopic changes, so that one hour is recommended, followed by high doses of oral the diagnosis has to be made on the basis of symptoms prednisolone (1 mg/kg/day) given daily for the frst week. Posterior optic nerve ischaemia is believed pathic or associated with other local or systemic diseases. In to occur due to disorders affecting the small pial vessels most cases, whatever be the underlying aetiology, the pathowhich supply the intraorbital portion of the optic nerve genesis of optic neuritis is presumed to be demyelination in away from the eyeball. The commonest associated cause is a demyelinating disorder of the nerve as occurs in other tracts of the white Clinical Features matter of the central nervous system (multiple sclerosis). Vision loss with an afferent pupillary defect may be the the occurrence of retrobulbar neuritis should always arouse only clinical feature. ElOther diseases of the central nervous system in which derly people with compromised circulation may be more optic neuritis occurs are neuromyelitis optica (of Devic), Chapter | 22 Diseases of the Optic Nerve 359 meninges, sinuses or orbit. Meningitis may affect the nerve, primarily causing a perineuritis, as may be seen in both syphilis and tuberDemyelinating disorders culosis. Sinusitis, particularly of the sphenoid and ethmoid, l Isolated and orbital cellulitis may act similarly. Parasitic infestation l Associated with multiple sclerosis by cysticercosis in the orbit or within the optic nerve is l Neuromyelitis optica another cause. Associated with infections Endogenous infections may also produce an optic neuLocal ritis; these include acute infective diseases such as infuenza, malaria, measles, mumps, chicken pox and infectious l Endophthalmitis l Orbital cellulitis mononucleosis. Systemic granulomatous infammations l Sinusitis such as tuberculosis, syphilis, sarcoidosis, toxoplasmosis l Contiguous spread from meninges, brain, base of skull and fungal infections such as cryptococcosis have also been Systemic known to cause optic neuritis. Immune-mediated disorders Here the appearance of the fundus may be typical with a white lumpy swelling of the optic nerve head and the loss Local of vision may vary from no loss to severe loss. Optic nerve inl Sympathetic ophthalmitis volvement could either be isolated or combined with ocular Systemic or central nervous system involvement. The effect of exogenous toxins is discussed under the heading of toxic optic neuropathy. The importance of a Metabolic disorders careful history and thorough systemic and ophthalmic exl Diabetes amination cannot be overemphasized in evaluating a patient l Anaemia with optic neuritis. This will help in arriving at a clinical diagnosis and avoid unnecessary, elaborate and expensive *In children it is not unusual for bilateral neuritis with disc swelling to follow viral illnesses. The more important several months and is ultimately usually restored to 6/6 of these are discussed in Chapter 31 but one condition (20/20). More detailed inspection, however, Optic neuritis due to local or systemic infections or other will show that although the pupil of the affected eye reacts disorders will have similar visual symptoms but will differ to light, the contraction is not maintained under bright ilin their clinical course and have other associated symptoms lumination so that instead of remaining contracted the pupil and signs in accordance with the underlying disease. Marcus Gunn pupil is of greater diagnostic signifcance, indicating a defect in the afferent limb of the pupillary light Symptoms refex due to a pathological lesion in the optic nerve. The predominant symptom in a patient suffering from optic the feld defects may be relative or absolute for colours. It may be infamed with involvement of the neighbouring the visual loss can be subtle or profound (there may retina showing a stellate pattern of retinal exudates in neuroeven be complete blindness in a few patients); it is usually retinitis (Fig.
Relaxation of ciliary muscle by atropine for a few weeks and prohibition of near work allow prompt recovery from spasm of accommodation spasms left shoulder blade generic ponstel 500mg line. Signs: erythema muscle relaxant dosage order ponstel 500 mg with amex, edema muscle relaxant brands cheap ponstel online mastercard, pain when pressed near the base of the eyelashes spasms order cheap ponstel line, as small abscess picture spasms icd 9 code buy ponstel uk. Clean your eyelids with clean water or with soap or shampoo that does not cause irritation gas spasms in stomach buy ponstel discount, such as baby soap muscle relaxant hyperkalemia 500mg ponstel with amex. Avoid using makeup on the eyes muscle relaxant use in elderly buy ponstel 500 mg otc, because of the possibility that it can cause infection. Systemic antibiotics: given if there are signs of bacteremia or the signs of enlarged lymph nodes in the preauricular. In the case of hordeolum internum with moderate to severe cases: Dicloxacilin can be given or cephalexin 500 mg orally four times daily for 7 days. If allergic to penicillin or cephalosporin, clindamycin 300 mg can be administered orally four times daily for 7 days, or claritromycin 500 mg 2 times daily for 7 days. Surgery: if the treatment does not respond well, then a surgical procedure may be required to make drainage of hordeolum. External incisions may lead to scarring, so making external eyelid incisions or punctures is less desirable. Internal incisions may be made vertically to reduce the area of the cornea swept by the irregular healing tissue during blinking and prevent lid contracture that may contribute to malposition; external incisions may be made horizontally for optimal post-operative cosmesis. The incision is left open with clean margins to allow for drainage of any residual material within the lesion. Complications: the most common is one lash trichiasis and the most serious is cavernous sinus thrombosis. It is a chronic painless swelling behind the grey line, while stye is an acute painful swelling in front of the grey line. Chalazion (Meibomian Cyst) Chalazion or meibomian cyst is chronic lipogranulomatous inflammation of one of the meibomian glands. Etiology Chalazion occurs after gland blockage, which can be associated with the following: poor eyelid hygiene, seborrheic dermatitis, rosacea, chronic blepharitis, high blood lipid concentrations, leishmaniasis, tuberculosis, immunodeficiency, viral infection, carcinoma, stress (casualty has not been proven, and the mechanism by which it might act is unknown), trachoma, eyelid trauma and eyelid surgery. Treatment Small chalazion: local steroid ointment for 1 week (usually not effective). Multiple chalazions are removed in different sessions and vitamin A is used for support. Marginal chalazion: shaving by scalpel while the eye is protected by the lid spatula. Infected Chalazion (Hordiolum Internum) It is a suppurative inflammation of the meibomian gland associated with blockage of the duct. Etiology It may occur as primary staphylococcal infection of the meibomian gland or due to secondary infection in a chalazion (infected chalazion). Symptoms and signs Symptoms: dull aching pain and diffuse swelling of the lid; throbbing pain (pus under tension), and a localized lid swelling. Treatment It is similar to hordeolum externum, except when the pus is formed, it should be drained by a vertical incision from the tarsal conjunctiva. Molluscum Contagiosum It is a viral infection of the lids, commonly affecting children. Its typical lesions are multiple, pale, waxy, umbilicated swellings scattered over the skin near the lid margin. These may be complicated by chronic follicular conjunctivitis and superficial keratitis. Treatment the skin lesions should be incised and the interior cauterized with tincture of iodine or pure carbolic acid. The glands of Zeiss secrete abnormal excessive neutral lipids which are split by Corynebacterium acne into irritating free fatty acids. Lid hygiene: the lid margins are scrubbed with neutral pH shampoo or special preparations. Local steroids (dexamethasone or betamethasone) are embrocated with the lashes only in severe cases. Etiology Chronic conjunctivitis and dacryocystitis may act as predisposing factors. Symptoms and signs Symptoms: hyperemia, red shedding of lashes, crusts, severe itching, burning sensation, lacrimation, photophobia and blepharospasm. Complications and sequelae these are seen in longstanding (non-treated) cases and include chronic conjunctivitis, madarosis (sparseness or absence of lashes), trichiasis, poliosis (greying of lashes), tylosis (thickening of lid margin) and eversion of the punctum leading to epiphora. Crusts should be removed after softening and hot compresses with solution of 3 percent soda bicarb. Antibiotic ointment (tobramycin, ofloxacin, gentamicin, erythromycin or tetracyclines) should be applied at the lid margin, immediately after removal of crusts, at least twice daily. Oral anti-inflammatory drugs (diclofenac, indomethacin, voltaren, nimesil, ibuprofen) can be used to help in reducing the inflammation. Chronic meibomitis is a meibomian gland dysfunction, seen more commonly in middle-aged persons with acne rosacea and seborrhoeic dermatitis. It is characterized by white frothy (foam-like) secretion on the eyelid margins and canthi (meibomian seborrhea). On eversion of the eyelids, vertical yellowish streaks shining through the conjunctiva are seen. At the lid margin, openings of the meibomian glands become prominent with thick secretions. Treatment of meibomitis consists of expression of the glands by repeated vertical lid massage, followed by embrocating the lid margin with antibiotic-steroid ointment. Antibiotic ointment (tobramycin, ofloxacin, gentamicin, erythromycin or tetracycline) should be applied at the lid margin, immediately after removal of crusts, at least twice daily. Oral anti-inflammatory drugs (diclofenac, indomethacin, voltaren, nimesil, and ibuprofen) help in reducing the inflammation. In addition to features of chronic blepharitis, it is characterized by presence of nits at the lid margin and at roots of eyelashes Symptoms and signs: itching and lacrimation; the parasite is seen on the lashes and the black nests of eggs are also seen. The use of yellow mercurial ointment, sulphur ointment, camphorated oil, crotamiton, choline esterase inhibitors, sulfacetamide, steroids, antibiotics, as well as antimycotic drugs offers some improvement. A good response has been observed after oral application of ivermectin along with topical application of cream permethrin. However, the best results were obtained after applying 2 % metronidazole gel or ointment treatment. The inward turning of lashes along with the lid margin (seen in entropion) is called pseudotrichiasis. Etiology Common causes of trichiasis are: cicatrizing trachoma, ulcerative blepharitis, healed membranous conjunctivitis, hordeolum externum, mechanical injuries, burns, and operative scars on the lid margin. Complications these include recurrent corneal abrasions, superficial corneal opacities, corneal vascularization and non-healing corneal ulcer. Treatment A few misdirected cilia may be treated by any of the following methods: 1. In this technique, infiltration anesthesia is given to the lid and a current of 2 mA is passed for 10 seconds through a fine needle inserted into the lash root. The loosened cilia with destroyed follicles are then removed with epilation forceps. Surgical correction: when many cilia are misdirected operative treatment similar to cicatricial entropion should be employed. Symptoms and signs Occur due to rubbing of cilia against the cornea and conjunctiva and are thus similar to trichiasis. Complications these are similar to trichiasis Treatment Surgical treatment Ectropion It is outward rolling of the lid margin, so that the posterior lid margin will not be in contact with the surface of the eyeball. This malposition will disturb tear spreading over the surface of cornea and conjunctiva. Also the lacrimal 89 punctum will not be in contact with tears, so that epiphora will occur. The posterior lid margin is seen to be rolled outward away from the globe, so that the punctum can be seen. Complication Prolonged exposure may cause dryness and thickening of the conjunctiva and corneal ulceration (exposure keratitis). Treatment Surgical treatment Symblepharon In this condition lids become adherent with the eyeball as a result of adhesions between the palpebral and bulbar conjunctiva. Fibrous adhesions between palpebral conjunctiva and the bulbar conjunctiva and/or cornea may be present only in the anterior part (anterior symblepharon), or fornix (posterior symblepharon) or the whole lid (total symblepharon). During the stage of raw surfaces, the adhesions may be prevented by sweeping a glass rod coated with lubricant around the fornices several times a day. A largesized, therapeutic, soft contact lens also helps in preventing the adhesions. The raw area created may be covered by mobilising the surrounding conjunctiva in mild cases. Ankyloblepharon It refers to the adhesions between margins of the upper and lower lids. It may occur as a congenital anomaly or may result after healing of chemical burns, thermal burns, ulcers and traumatic wounds of the lid margins. Treatment Lids should be separated by excision of adhesions between the lid margins and kept apart during the healing process. When adhesions extend to the angles, epithelial grafts should be given to prevent recurrences. Blepharophimosis In this condition the extent of the palpebral fissure is decreased. Lagophthalmos this condition is characterized by inability to voluntarily close the eyelids. Etiology It occurs in patients with paralysis of orbicularis oculi muscle, cicatricial contraction of the lids, symblepharon, severe ectropion, proptosis, following over-resection of the levator muscle for ptosis, and in comatose patients. Physiologically some people sleep with their eyes open (nocturnal lagophthalmos) Clinical picture It is characterized by incomplete closure of the palpebral aperture associated with features of the causative disease. Treatment To prevent exposure keratitis artificial tear drops should be instilled frequently and the open palpebral fissure should be filled with an antibiotic eye ointment during sleep and in comatose patients. Blepharospasm It refers to the involuntary, sustained and forceful closure of the eyelids. It is a rare idiopathic condition involving patients between 45 and 65 years of age. It usually occurs due to reflex sensory stimulation through branches of the fifth nerve, in conditions such as: phlyctenular keratitis, interstitial keratitis, corneal foreign body, corneal ulcers and iridocyclitis. It is also seen in excessive stimulation of retina by dazzling light, stimulation of facial nerve due to central causes and in some hysterical patients. Clinical features Persistent epiphora may occur due to spasmodic closure of the canaliculi which may lead to eczema of the lower lid. Spastic entropion (in elderly people) and spastic ectropion (in children and young adults) may develop in long-standing cases. Blepharophimosis may result due to contraction of the skin folds following eczema. Treatment In essential blepharospasm botulinum toxin, injected subcutaneously over the orbicularis muscle, blocks the neuromuscular junction and relieves the spasm. In reflex blepharospasm, the causative disease should be treated to prevent recurrences. Congenital ptosis It is associated with congenital weakness (maldevelopment) of the levator palpebrae superioris. As a part of blepharophimosis syndrome, comprising congenital ptosis, blepharophimosis, telecanthus and epicanthus inversus. In this condition there occurs retraction of the ptotic lid with jaw movements, i. Acquired ptosis Depending upon the cause it can be neurogenic, myogenic, aponeurotic or mechanical. Neurogenic ptosis: it is caused by innervational defects such as third nerve palsy, Hornerfis syndrome, ophthalmoplegic migraine and multiple sclerosis. Myogenic ptosis: it occurs due to acquired disorders of the levator palpebrae superioris muscle or of the myoneural junction. It may be seen in patients with myasthenia gravis, dystrophia myotonica, ocular myopathy, oculo-pharyngeal muscular dystrophy and following trauma to the levator palpebrae superioris muscle. Aponeurotic ptosis: it develops due to defects of the levator aponeurosis in the presence of a normal functioning muscle. It includes involutional (senile) ptosis, postoperative ptosis (which is rarely observed after cataract and retinal detachment surgery), ptosis due to aponeurotic weakness 94 associated with blepharochalasis, and in traumatic dehiscence or disinsertion of the aponeurosis. Mechanical ptosis: it may result due to excessive weight on the upper lid as seen in patients with lid tumours, multiple chalazia and lid oedema. It may also occur due to scarring (cicatricial ptosis) as seen in patients with ocular pemphigoid and trachoma. Measurement of amount (degree) of ptosis In unilateral cases, difference between the vertical heights of the palpebral fissures of the two sides indicates the degree of ptosis. In bilateral cases it can be determined by measuring the amount of cornea covered by the upper lid and then subtracting 2 mm. In severe ptosis, surgery should be performed at the earliest to prevent stimulus deprivation amblyopia. Acquired ptosis: efforts should be made to find out the underlying cause and if possible treat it. In neurogenic ptosis conservative treatment should be carried out and surgery deferred at least for 6 months. Surgical procedures (when required) are essentially the same as described for congenital ptosis. However, the amount of levator resection required is always less than the congenital ptosis of the same degree. Benign tumours: these include simple papilloma, nevus, angioma, haemangioma, neurofibroma and sebaceous adenoma. Pre-cancerous conditions: these are solar keratosis, carcinoma-in-situ and xeroderma pigmentosa. Malignant tumours: commonly observed tumours include squamous cell carcinoma, basal cell carcinoma, malignant melanoma and sebaceous gland adenocarcinoma. Congenital coloboma: it is a rare condition characterized by a full thickness triangular gap in the tissues of the lids. Congenital distichiasis is a rare anomaly in which an extra row of cilia occupies the position of Meibomian glands which open into their follicles as ordinary sebaceous glands. These cilia are usually directed backwards and when rubbing the cornea, should be electro epilated or cryoepilated. Cryptophthalmos: it is a very rare anomaly in which lids fail to develop and the skin passes continuously from the eyebrow to the cheek hiding the eyeball 6. Occasionally the lids may be very small or virtually absent and the condition is called ablepharon.
Report of the Expert Committee on the International Classification of Diseases 10th Revision: First Meeting spasms prednisone safe ponstel 500mg. Report of the Expert Committee on the International Classification of Diseases 10th Revision: Second Meeting spasms paraplegic discount ponstel 250 mg without a prescription. For example: Abscess (embolic) (infective) (metastatic) (multiple) (pyogenic) (septic) brain (any part) G06 spasms with spinal cord injury order ponstel toronto. Cross-references Some categories spasms going to sleep order ponstel cheap online, particularly those subject to notes linking them with other categories muscle relaxant iv purchase generic ponstel on line, require rather complex indexing arrangements spasms verb buy 500 mg ponstel with visa. This may take a number of forms muscle relaxer kidney purchase 500mg ponstel mastercard, as in the following examples: Inflammation bone see Osteomyelitis this indicates that the term "Inflammation muscle relaxant for bruxism purchase ponstel once a day, bone" is to be coded in the same way as the term "Osteomyelitis". Paralysis shaking (see also Parkinsonism) G20) If the term "shaking paralysis" is the only term on the medical record, the code number is G20, but if any other information is present which is not found indented below, then reference should be made to "Parkinsonism". Bladder see condition Hereditary see condition As stated previously, anatomical sites and very general adjectival modifiers are not usually used as lead terms in the Index and one is instructed to look up the disease or injury reported on the medical record and under that term to find the site or adjectival modifier. For other abdominal conditions, one should look up the disease or injury reported. It is one disease entity with different clinical presentations and often with unpredictable clinical evolution and outcome. Most patients recover following a self-limiting non severe clinical course like nausea, vomiting, rash, aches and pains, but a small proportion progress to severe disease, mostly characterized by plasma leakage with or without haemorrhage, although severe haemorrhages or severe organ impairment can occur, with or without dengue shock. Most of the causal fungi are normally saprophytic in soil and decaying vegetation. Primary, ill-defined, secondary and unspecified sites of malignant neoplasms Categories C76-C80 include malignant neoplasms for which there is no clear indication of the original site of the cancer or the cancer is stated to be "disseminated", "scattered" or "spread" without mention of the primary site. Functional activity All neoplasms are classified in this chapter, whether they are functionally active or not. Cancer is a generic term and may be used for any of the above groups, although it is rarely applied to the malignant neoplasms of lymphatic, haematopoietic and related tissue. In a few exceptional cases morphology is indicated in the category and subcategory titles. Morphology codes have six digits: the first four digits identify the histological type; the fifth digit is the behaviour code (malignant primary, malignant secondary (metastatic), in situ, benign, uncertain whether malignant or benign); and the sixth digit is a grading code (differentiation) for solid tumours, and is also used as a special code for lymphomas and leukaemias. Malignant neoplasms of ectopic tissue Malignant neoplasms of ectopic tissue are to be coded to the site mentioned. In addition to site, morphology and behaviour must also be taken into consideration when coding neoplasms, and reference should always be made first to the Alphabetical Index entry for the morphological description. It is therefore recommended that agencies interested in identifying both the site and morphology of tumours. This departure from the principle that categories should be mutually exclusive is deliberate, since both forms of terminology are in use but the resulting anatomical divisions are not analogous. This system of grading has been extended to other organs, such as vulva and vagina. Such neoplasms are assigned behaviour code /1 in the classification of the morphology of neoplasms. D37 Neoplasm of uncertain or unknown behaviour of oral cavity and digestive organs D37. Excludes: hypothyroidism resulting from administration of radioactive iodine (E89. When one or more previous measurements are available, lack of weight gain in children, or evidence of weight loss in children or adults, is usually indicative of malnutrition. When only one measurement is available, there is a high probability of severe wasting when the observed weight is 3 or more standard deviations below the mean of the reference population. Includes: starvation oedema E44 Protein-energy malnutrition of moderate and mild degree E44. When only one measurement is available, there is a high probability of moderate protein-energy malnutrition when the observed weight is 2 or more but less than 3 standard deviations below the mean of the reference population. The dysfunction may be primary, as in diseases, injuries, and insults that affect the brain directly and selectively; or secondary, as in systemic diseases and disorders that attack the brain only as one of the multiple organs or systems of the body that are involved. The impairments of cognitive function are commonly accompanied, and occasionally preceded, by deterioration in emotional control, social behaviour, or motivation. The disorder is usually insidious in onset and develops slowly but steadily over a period of several years. The duration is variable and the degree of severity ranges from mild to very severe. Some features suggestive of schizophrenia, such as bizarre hallucinations or thought disorder, may be present. None of these symptoms is so severe that a diagnosis of either dementia (F00-F03) or delirium (F05. Impairment of cognitive and thought functions, and altered sexuality may also be part of the clinical picture. The principal difference between this disorder and the organic personality F09 disorders is that it is reversible. Includes: Cognitive impairment with head injury Post-traumatic brain syndrome, nonpsychotic Postcontusional syndrome (encephalopathy) Excludes: current concussion, brain (S06. Complications may include trauma, inhalation of vomitus, delirium, coma, convulsions, and other medical complications. Includes: Pathological intoxication Trance and possession disorders in psychoactive substance intoxication Excludes: intoxication meaning poisoning (T36-T50) F12. Immediate recall is usually preserved and recent memory is characteristically more disturbed F13. Disturbances of time sense and ordering of events are usually evident, as are difficulties in learning new material. The disturbances are directly related to the acute pharmacological effects of the substance and resolve with time, with complete recovery, except where tissue damage or other complications have arisen. Flashbacks may be distinguished from psychotic state partly by their episodic nature, frequently of very short duration, and by their duplication of previous alcoholor other psychoactive substance-related experiences. Includes: "Bad trips" (drugs) Pathological intoxication Trance and possession disorders in psychoactive substance intoxication Excludes: intoxication meaning poisoning (T36-T50) F14. Excludes: alcoholor other psychoactive substance-induced residual and late-onset psychotic disorder (F10-F19 with common fourth character. The damage may be physical (as in cases of hepatitis from the self-administration of injected psychoactive F17. Onset of the disorder should be directly related to the use of the psychoactive substance. Other cognitive functions are usually relatively well preserved and amnesic defects are out of proportion to other disturbances. Immediate recall is usually preserved and recent memory is characteristically more disturbed than remote memory. F20 Schizophrenia Note: the schizophrenic disorders are characterized in general by fundamental and characteristic distortions of thinking and perception, and affects that are inappropriate or blunted. Clear consciousness and intellectual capacity are usually maintained although certain cognitive deficits may evolve in the course of time. Nor should schizophrenia be diagnosed in the presence of overt brain disease or during states of drug intoxication or withdrawal. Similar disorders developing in the presence of epilepsy or other brain disease should be classified under F06. Disturbances of affect, volition and speech, and catatonic symptoms, are either absent or relatively inconspicuous. Includes: Atypical schizophrenia Excludes: acute schizophrenia-like psychotic disorder (F23. Includes: Chronic undifferentiated schizophrenia Restzustand (schizophrenic) Schizophrenic residual state F20. The symptoms may include a cold or inappropriate affect; anhedonia; odd or eccentric behaviour; a tendency to social withdrawal; paranoid or bizarre ideas not amounting to true delusions; obsessive ruminations; thought disorder and perceptual disturbances; occasional transient quasi-psychotic episodes with intense illusions, auditory or other hallucinations, and delusion-like ideas, usually occurring without external provocation. There is no definite onset and evolution and course are usually those of a personality disorder. Delusional disorders that have lasted for less than a few months should be classified, at least temporarily, under F23. Acute onset is defined as a crescendo development of a clearly abnormal clinical picture in about two weeks or less. Complete recovery usually occurs within a few months, often within a few weeks or even days. Emotional turmoil with intense transient feelings of happiness or ecstasy, or anxiety and irritability, is also frequently present. Includes: Bouffee delirante without symptoms of schizophrenia or unspecified Cycloid psychosis without symptoms of schizophrenia or unspecified F23. If the delusions persist the diagnosis should be changed to persistent delusional disorder (F22. Only one of the people suffers from a genuine psychotic disorder; the delusions are induced in the other(s) and F29 usually disappear when the people are separated. This category should be used for both a single episode and a recurrent disorder in which the majority of episodes are schizoaffective, depressive type. Includes: Schizoaffective psychosis, depressive type Schizophreniform psychosis, depressive type F25. Most of these disorders tend to be recurrent and the onset of individual episodes can often be related to stressful events or situations. F30 Manic episode Note: All the subdivisions of this category should be used only for a single episode. Hypomanic or manic episodes in individuals who have had one or more previous affective episodes (depressive, hypomanic, manic, or mixed) should be coded as bipolar affective disorder (F31. Increased sociability, talkativeness, over-familiarity, increased sexual energy, and a decreased need for sleep are often present but not to the extent that they lead to severe disruption of work or result in social rejection. Elation is accompanied by increased energy, resulting in overactivity, pressure of speech, and a decreased need for sleep. Self-esteem and self-confidence are almost always reduced and, even in the mild form, some ideas of guilt or worthlessness are often present. The lowered mood varies little from day to day, is unresponsive to circumstances and may be accompanied by so-called "somatic" symptoms, such as loss of interest and pleasurable feelings, waking in the morning several hours before the usual time, depression worst in the morning, marked psychomotor retardation, agitation, loss of appetite, weight loss, and loss of libido. Depending upon the number and severity of the symptoms, a depressive episode may be specified as mild, moderate or severe. The patient is usually distressed by these but will probably be able to continue with most activities. Includes: Agitated Major depression single episode without psychotic symptoms Vital F32. The first episode may occur at any age from childhood to old age, the onset may be either acute or insidious, and the duration varies from a few weeks to many months. The risk that a patient with recurrent depressive disorder will have an episode of mania never disappears completely, however many depressive episodes have been experienced. Includes: Endogenous depression without psychotic symptoms Major depression, recurrent without psychotic symptoms Manic-depressive psychosis, depressed type without psychotic symptoms Vital depression, recurrent without psychotic symptoms F33. This disorder is frequently found in the relatives of patients with bipolar affective disorder. Whether two diagnoses, phobic anxiety and depressive episode, are needed, or only one, is determined by the time course of the two conditions and by therapeutic considerations at the time of consultation. Depressive and obsessional symptoms and social phobias are also commonly present as subsidiary features. Avoidance of the phobic situation is often prominent, and some agoraphobics experience little anxiety because they are able to avoid their phobic situations. Though the triggering situation is discrete, contact with it can evoke panic as in agoraphobia or social phobia. Includes: Acrophobia Animal phobias Claustrophobia Simple phobia Excludes: dysmorphophobia (nondelusional) (F45. Depressive and obsessional symptoms, and even some elements of phobic anxiety, may also be present, provided that they are clearly secondary or less severe. As with other anxiety disorders, the dominant symptoms include sudden onset of palpitations, chest pain, choking sensations, dizziness, and feelings of unreality (depersonalization or derealization). Panic disorder should not be given as the main diagnosis if the patient has a depressive disorder at the time the attacks start; in these circumstances the panic attacks are probably secondary to depression. The dominant symptoms are variable but include complaints of persistent nervousness, trembling, muscular tensions, sweating, lightheadedness, palpitations, dizziness, and epigastric discomfort. Neither type of symptom is severe enough to justify a diagnosis if considered separately. They are, however, recognized as his or her own thoughts, even though they are involuntary and often repugnant. Compulsive acts or rituals are stereotyped behaviours that are repeated again and again. They are not inherently enjoyable, nor do they result in the completion of inherently useful tasks. Their function is to prevent some objectively unlikely event, often involving harm to or caused by the patient, which he or she fears might otherwise occur. Underlying the overt behaviour is a fear, usually of danger either to or caused by the patient, and the ritual is an ineffectual or symbolic attempt to avert that danger. In contrast, the disorders brought together here are thought to arise always as a direct consequence of acute severe stress or continued trauma. Individual vulnerability and coping capacity play a role in the occurrence and severity of acute stress reactions. Autonomic signs of panic anxiety (tachycardia, sweating, flushing) are commonly present. The symptoms usually appear within minutes of the impact of the stressful stimulus or event, and disappear within two to three days (often within hours). There is usually a state of autonomic hyperarousal with hypervigilance, an enhanced startle reaction, and insomnia. Anxiety and depression are commonly associated with the above symptoms and signs, and suicidal ideation is not infrequent. In a small proportion of cases the condition may follow a chronic course over many years, with eventual transition to an enduring personality change (F62. Individual predisposition or vulnerability plays an important role in the risk of occurrence and the shaping of the manifestations of adjustment disorders, but it is nevertheless assumed that the condition would not have arisen without the stressor. These disorders have previously been classified as various types of "conversion hysteria". Medical examination and investigation do not reveal the presence of any known physical or neurological disorder. In addition, there is evidence that the loss of function is an expression of emotional conflicts or needs. Only disorders of physical functions normally under voluntary control and loss of sensations are included here. Disorders involving pain and other complex physical sensations mediated by the autonomic nervous system are classified under somatization disorder (F45. The possibility of the later appearance of serious physical or psychiatric disorders should always be kept in mind. The diagnosis should not be made in the presence of organic brain disorders, intoxication, or excessive fatigue. Excludes: alcoholor other psychoactive substance-induced amnesic disorder (F10-F19 with common fourth character. In addition, there is positive evidence of psychogenic causation in the form of recent stressful events or problems. There may be close resemblance to almost any variety of ataxia, apraxia, akinesia, aphonia, dysarthria, dyskinesia, seizures, or paralysis. The course of the disorder is chronic and fluctuating, and is often associated with disruption of social, interpersonal, and family behaviour. Short-lived (less than two years) and less striking symptom patterns should be classified under undifferentiated somatoform disorder (F45. Patients manifest persistent somatic complaints or a persistent preoccupation with their physical appearance. Normal or commonplace sensations and appearances are often interpreted by patients as abnormal and distressing, and attention is usually focused upon only one or two organs or systems of the body. Marked depression and anxiety are often present, and may justify additional diagnoses. The mental fatiguability is typically described as an unpleasant intrusion of distracting associations or recollections, difficulty in concentrating, and generally inefficient thinking. In the other type, the emphasis is on feelings of bodily or physical weakness and exhaustion after only minimal effort, accompanied by a feeling of muscular aches and pains and inability to relax. In both types a variety of other unpleasant physical feelings is common, such as dizziness, tension headaches, and feelings of general instability.
Meningioma Meningioma arises from the arachnoid villi and Neurofibroma is usually attached to the dura mater gas spasms in stomach order 250 mg ponstel fast delivery. The Neurofibromas are mainly composed of prolifesphenoidal ridge meningioma usually originates rating Schwann cells within the nerve sheath back spasms 33 weeks pregnant cheap ponstel amex. The disease is characterized by localized bone thickening associated with 434 Textbook of Ophthalmology Fig muscle relaxant drugs medication purchase ponstel 250mg with visa. Lymphoma of the orbit can occur either in Malignant Orbital Tumors isolation or as a part of systemic disease muscle relaxant indications 250mg ponstel overnight delivery. It is more common in orbital soft tissue and not from extraocular elderly females (50-70 years of age) infantile spasms 2012 cheap ponstel 250mg fast delivery. The tumor typically chemical studies help in establishing the diaginvolves the superonasal quadrant muscle relaxant bruxism purchase ponstel now, but it may nosis muscle relaxer x 500 mg ponstel with visa. Orbital lymphoma shows monoclonality to define the site and extension of the neoplasm spasms in intestines order ponstel canada. Malignant An excisional biopsy should be performed lymphoma have multiclonal infiltrates. Eye should be protected by metallic contact lens and a dose of 2000-2500 cGys is recommended. More aggressive lymphomas need chemotherapy or a combination of radiotherapy and chemotherapy. Secondary Orbital Tumors Tumors from contiguous structures such as the eyeball, eyelids, sinuses and brain may invade the orbit. Retinoblastoma and malignant melanoma of choroid often invade the orbit during the Fig. Squamous cell carcinoma and adenocarcinoma of the eyelid can secondarily invade the orbit. The primary tumor arises usually within the maxillary sinus or the nasopharynx causing Acute lymphoblastic leukemia can metastasize to the epiphora, epistaxis or nasal obstruction. Rarely, a leukemic orbital mass, Metastasis in the Orbit chloroma, is found in acute myeloid leukemia which represents a solid collection of immature Neuroblastoma and leukemia often metastasize malignant white blood cells. Carcinoma of the breast and lungs, and In neuroblastoma the primary tumor may be in the cutaneous malignant melanoma can metastasize abdomen, the mediastinum or the neck. Atlas of Clinical and Surgical Orbital Pain, proptosis, local bone destruction and Anatomy. Diseases of the Orbit: A Multidiscarcinoembryonic antigen level and fine needle ciplinary Approach. It is achieved by injecting 1 ml of 2% xylocaine with a fine long needle (5 cm) at Operations upon the eyeball can be performed the outer and lower angle of the orbit directed either under local or general anesthesia. This block causes a ophthalmic surgeons prefer local anesthesia as it temporary paralysis of extraocular muscles and is safe and free from the after-effects of general slight dilatation of pupil. Success of an intraocular surgery the retrobulbar injection of local anesthetic largely depends upon a perfect anesthesia and agents is not a benign procedure. Preoperative administration of systemic retrobulbar hemorrhage warranting postponesedatives such as alprazolam (0. The general anesthesia is required for complithe peribulbar anesthesia is safer than retrocated vitreoretinal surgeries, uncooperative bulbar anesthesia because the anesthetic agent is patients and children. Rise of intraocular pressure injected outside the muscle cone and thus chances and increased oozing of blood intraoperatively, of intraocular and optic nerve injuries are and postoperative cough, vomiting and straining minimized (Fig. Local Anesthesia 4 to 6 ml of the solution is injected just posterior to the local anesthesia consists of both surface and the equator. Sometimes, the superior rectus muscle may continue to pull the eyeball upwards despite the peribulbar injection. However, it is a simple frequent hot compresses and application of an and safe technique which also eliminates the facial block. Akinesia Akinesia during an ocular surgery can be obtained by the facial block which causes a temporary paralysis of orbicularis oculi. About 5 ml of xylocaine is injected down to the periosteum covering the neck of the mandible and local massage is applied. When pus is pointing and Cicatricial entropion is usually relieved by the condition not resolving, a small incision is plastic operations. The various operations are made over the pus point after giving local based on the following principles: anesthesia. Correction of the misdirection of eyelashes antibiotic ointment and a bandage can be applied. Transplanting the lashes to a higher level, and the bandage may be discarded after a few hours. Infiltration temporal end of intermarginal strip is divided by anesthesia is given in the area of chalazion. A vertical incision is made in the conjunctiva Jaesche-Arlt operation combines the principles of correction of the misdirection of lashes by splitting (Fig. The the lid along the gray line and transplantation of cavity is curetted by a chalazion scoop. If there is the zone of hair follicles to a slightly higher position a thick granulation tissue, it should be removed by removal of a crescentic piece of the lid skin. Nearly two-thirds thickness of the entire become subcutaneous, it can be incised from the upper tarsal plate is dissected and removed and skin side by giving a horizontal incision. Then the lid margin is mobilized upwards and outwards to cover the skin incision (video). The scar in the lower lid is removed by a V-shaped incision having its apex away from the lid margin. Blepharoplasty is indicated Senile ectropion of the lower lid is usually in extensive cicatricial ectropion. Shortening the lid and transplanting it to a carefully assessed, and depending on it one of higher level, and the following operative procedures may be utili3. Byron-Smith modification of Kuhnt-Szymanowski Fasanella-Servat operation is indicated in mild operation is a procedure wherein a triangular piece degree of ptosis with good levator function. The of the conjunctiva and the tarsus is excised from lid is everted and two hemostats are applied. Three double-armed sutures are passed through the tendon 18 to 20 mm above its insertion. The tendon is then cut distal to the sutures and the cut end is anchored to the tarsal plate 2 to 3 mm above the lash margin. Another set of double-armed sutures is threaded through the tendon 3 mm above the line of its present attachment, the sutures are brought out through the skin and tied just midway between the upper and lower limits of the lids to make the natural lid folds. The middle-third of the tendon of the superior rectus is transplanted to the upper border of the tarsal plate through a subconjunctival approach. The operation must not be performed in unilateral cases as it causes a varying degree of vertical muscle imbalance. The lid is anchored to the frontalis muscle muscle and the conjunctiva are excised (Fig. The tendon is freed from must be drawn tightly to obtain a full correction its attachment and the upper strip of tarsal plate is (Fig. The neck of the pterygium is lifted with a toothed forceps and it is shaved from the cornea with a knife. The body of pterygium is freed from the sclera and excised by giving two converging incisions by the scissors. The exposed sclera may be either covered by mobilizing the conjunctiva or left bare especially near the limbus. The subepithelial degenerative tissue is thoroughly dissected and the head, neck and about 2 mm of the body of the pterygium is excised in one triangular piece leaving an exposed area of the sclera, approximately 4 mm wide. Keratectomy Pterygium Surgery Superficial irregular corneal scars are shaved off A stationary thin pale pterygium seldom warrants with a diamond knife or using an excimer laser in excision. Pterygium needs removal when it is keratectomy and an amniotic membrane transprogressing and causing cosmetic disfigurement. The corneal epithelium If pterygium has already invaded the pupillary grows over the defect. Keratectomy is indicated in area it is advisable to wait till it crosses the area as recurrent corneal erosions, filamentary keratitis, the removal of the apex of the pterygium leaves a and multiple embedded foreign bodies in the thick scar. Operations Upon the Eyeball and its Adnexa 443 Keratoplasty In keratoplasty or corneal transplantation, the opaque corneal disk (Fig. Indications the indications for lamellar keratoplasty include superficial corneal scars, stromal corneal dystroFig. The size of the graft is determined, the grafts smaller than 6 mm are inadequate while grafts larger than 8. In spite of these complications, the results of keratoplasty Complications are gratifying in restoring the vision (Fig. Then the flap is Surgical interventions for the correction of the replaced (video). Different surgical techniques are being used to Surgical Correction of Hypermetropia correct myopia and hypermetropia. Intraocular lens implantation, at the time of or 16 radial corneal incisions are placed cataract surgery, is the most popular and safe (Fig. It anesthesia, the eyeball is steadied with a fixation is a satisfactory procedure to correct high forceps and a small incision is made nearly 2 mm degree of myopia. The posterior lip of the wound is effective surgical technique for the correction depressed by an iris repositor so that the aqueous of myopia. A hinged corneal flap is prepared or blood or pus escapes slowly from the anterior by using a microkeratome. For iridectomy the previous section is opened with the help of an iris Developmental glaucoma is usually managed by repositor. The results of surgery are excellent reposited with the iris repositor and the wound is when operation is performed prior to the developclosed by end-to-end sutures. Long-standing cases of Optical iridectomy was used to be performed developmental glaucoma with a corneal diameter to obtain visual improvement in central corneal of 15 mm or more are unsuitable for operative leukoma with a clear periphery, and zonular or interference. Generally, usual drainage of the aqueous through the the site of selection for optical iridectomy is trabeculum. The iridectomy should be as narrow as possible to anterior chamber is filled with viscoelastic. More than one goniotomy is performed in complicated cataract and subserequired in different segments of the angle of the quently the cataract is extracted. Iridotomy Indications Surgical iridotomy is employed for prevention of Trabeculotomy is indicated in following condiiris bombe. Since the iris is an elastic tissue, a small tions: surgical cut by scissors causes its retraction and 1. The iridotomy prevents an attack of elevated intraocular pressure either by increasangle-closure glaucoma. It can also be performed ing the drainage of aqueous humor or decreasing once the acute attack of angle-closure glaucoma the formation of aqueous. The drainage can be has been subsided by medication and goniosyneenhanced by following methods. Creating a communication between the Laser iridotomy is indicated in following condianterior chamber and the suprachoroidal tions: space. The In the early chronic congestive phase of angleangle that is closed by plateau iris will not open closure glaucoma, the angle of the anterior chamber by laser iridotomy, therefore, laser gonioplasty is performed. A spot size of 200-500 fim and 200-500 mW of In this operation, the iris is torn from its ciliary power are used for 0. Stromal burns attachment to obtain a broad opening at the are created in the peripheral iris to cause periphery. A small fullTrabeculectomy is indicated in chronic anglethickness piece of iris is excised. Operations Upon the Eyeball and its Adnexa 449 Combined Glaucoma and Cataract Surgery When cataract is associated with glaucoma, lens extraction should be considered in combination with trabeculectomy (video). It is not rare Filtration Operations to find that despite the normalization of intraocular pressure some patients continue to lose Filtering surgeries are fistualizing procedures vision and show progressive visual field defects which create a fistula for the flow of aqueous and cupping of the disk. Because produces shrinkage of the treated area and of lower incidence of postoperative complications, stretching of trabecular meshwork. The shrinkage it is the most preferred surgical procedure for the helps in opening the intratrabecular spaces and management of primary open-angle glaucoma. Topical apraclonidine 1% or Indications for trabeculectomy include: brimonidine 0. Maximal tolerable medical therapy when fails control the postoperative pressure rise. The patient is unable to comply with the glaucoma with an average 8 mm Hg reduction of medical regimen ocular tension. The medical therapy has to be discontinued cal therapy for glaucoma, but it can delay the owing to side effects surgical intervention. In spite of medical treatment, optic neuropathy laser can also be used for trabeculoplasty. Conjunctival flap: A fornix-based or limbalTrabeculectomy is performed under the following based conjunctival flap is fashioned. Trabeculectomy or excision of trabecular tissue: A narrow strip of deeper sclera near the cornea containing the trabecular meshwork is excised (Fig. Closure of the scleral flap: the scleral flap is in following conditions: reposited and sutured tightly to avoid early 1. Closure of the conjunctiva: the flow of the Complications aqueous should be tested around the flap Complications of filtering surgery may occur either before the conjunctiva is closed. The fornixbased flap is sutured by two interrupted Early complications include hyphema, uveitis, sutures at limbus while the limbus-based shallow or flat anterior chamber, cystoid macular by continuous sutures (Fig. The risk of endophthalmitis is underneath the lamellar flap of sclera and greater after the use of antifibrotic agent. The choice of surgery largely depends on the pathogenesis of glaucoma, for example, phacomorphic glaucoma is managed by extraction of the lens, angle recession glaucoma by trabeculectomy and neovascular glaucoma by setons or cycloablative Fig. Perkins, Madison) Setons scleral attachment forms a communication betSetons are silicone/silastic narrow tubes to shunt ween the anterior chamber and suprachoroidal the aqueous from the anterior chamber to the space. The cyclodialysis spatula is gently inserted between the sclera and Cyclodialysis the ciliary body. It is gradually pushed towards Cyclodialysis is an internal bypass surgery in the cornea until its tip appears in the anterior which disinsertion of the ciliary body from its chamber. The spatula is swept on either side to Operations Upon the Eyeball and its Adnexa 453 separate the ciliary body from the scleral spur. Hyphema is a common complication which can be prevented by injection of air in the anterior chamber. Cyclodiathermy the formation of aqueous humor can be reduced by inducing segmental atrophy of the ciliary body either by application of diathermy current or by cryopexy. An electrode of 2 mm diameter is used and a current of 50 to 60 milliCyclophotocoagulation amperes is passed at each point for about 15 seconds. In congenital cataracts at any time after the infant is this procedure transscleral freezing of the ciliary six weeks of age. The prognosis is good in patients body is accomplished by applications of a freezing with bilateral cataracts unassociated with probe over a segment of the ciliary body nystagmus. It is relatively a less destructive ment of congenital cataract such as: (i) optical procedure than cyclodiathermy. Because of the In congenital cataract, a good surgical result does inevitable danger of vitreous loss, intracapsular not necessarily mean a good vision.
