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Isolation of parasites (promastigotes) by culture of appropriate tissue specimens in specialized media may take days to medications john frew buy meldonium cheap several weeks but should be attempted when possible treatment juvenile rheumatoid arthritis cheap generic meldonium canada. Knowledge of the infecting species may affect prognosis and infuence treatment decisions symptoms 6 weeks purchase meldonium 500 mg fast delivery. Investigational polymerase chain reaction assays are available at some reference laboratories treatment of gout buy 250mg meldonium overnight delivery. Serologic test results usually are positive in cases of visceral and mucosal leishmaniasis if the patient is immunocompetent but often are negative in cutaneous leishmaniasis. False-positive results may occur in patients with other infectious diseases, especially American trypanosomiasis. Treatment always is indicated for patients with mucosal or visceral leish maniasis. Because of the high prevalence of primary antimonial resistance in India and Nepal, sodium stibogluconate should not be used for patients with visceral leishmaniasis infected in South Asia; liposomal amphotericin B or conventional amphotericin B desoxycholate should be used instead. Paromomycin intramuscular injection is approved for the treatment of visceral leishmani asis in several countries. Treatment of cutaneous leishmaniasis should be considered, especially if skin lesions are or could become disfguring or disabling (eg, facial lesions or lesions near joints), are persistent, or are known to be or might be caused by leishmanial species that can disseminate to the naso-oropharyngeal mucosa (see Drugs for Parasitic Infections, p 848). Local wound care and treatment of bacterial superinfection also must be considered in cutaneous leishmaniasis. Miltefosine has demonstrated degrees of effcacy in visceral leishmaniasis and in New and Old World cutaneous lesions but is contraindicated in pregnancy. Meglumine antimoniate by injection is supported by the World Health Organization for treatment of leishmani asis but is not available in the United States. Avoid outdoor activities, especially from dusk to dawn, when sand fies are most active. If possible, a bed net that has been soaked in or sprayed with permethrin should be used. The permethrin will be effective for sev eral months if the bed net is not washed. Sand fies are smaller than mosquitoes and, therefore, can get through smaller holes. Fine-mesh netting (at least 18 holes to the inch) is needed for an effective barrier against sand fies. This particularly is important if the bed net has not been treated with permethrin. However, sleeping under such a closely woven bed net in hot weather can be uncomfortable. The clini cal forms of leprosy refect the cellular immune response to Mycobacterium leprae and the organism’s unique tropism for peripheral nerves. In the United States, the Ridley-Jopling scale is used and has 5 classifcations that correlate with histologic fndings: (1) polar tuberculoid; (2) borderline tuberculoid; (3) borderline; (4) borderline lepromatous; and (5) polar lepromatous. The cell-mediated immunity of most patients and their clinical presentation occur between the 2 extremes of tuberculoid and lepromatous forms. Leprosy lesions usually do not itch or hurt; they lack sensation to heat, touch, and pain. The classic presenta tion of the “leonine facies” and loss of lateral eyebrows (madarosis) occurs in patients with end-stage lepromatous leprosy. A simplifed scheme introduced by the World Health Organization, for situations in which there is no doctor, classifes leprosy involving 1 patch of skin as (1) paucibacillary single lesion; (2) paucibacillary (2-5 lesions; usually tubercu lous leprosy); and (3) multibacillary (>5 lesions, usually lepromatous leprosy). Serious consequences of leprosy occur from immune reactions and nerve involvement with resulting anesthesia, which can lead to repeated unrecognized trauma, ulcerations, fractures, and bone resorption. Injuries can have a signifcant effect on quality of life, because leprosy is a leading cause of permanent physical disability among communicable diseases worldwide. A diagnosis of leprosy should be considered in any patient with hypoes thetic or anesthetic skin rash. Leprosy Reactions: Acute clinical exacerbations refect abrupt changes in immu nologic balance, especially common during initial years of treatment but can occur in the absence of therapy. Two major types are seen: type 1 (reversal reaction) is predominantly observed in borderline tuberculoid and borderline lepromatous leprosy and is the result of a sudden increase in effective cell-mediated immunity. Acute tenderness and swelling at the site of cutaneous and neural lesions with development of new lesions are major manifestations. Tender, red dermal papules or nodules resembling erythema nodosum along with high fever, migrating polyarthralgia, painful swelling of lymph nodes and spleen, iridocyclitis, and rarely, nephritis can occur. It is weakly acid-fast on standard Ziehl-Nielsen staining and is best identifed using the Fite stain. Approximately 5% of people genetically are susceptible to infection with M leprae; several genes now have been identi fed that are associated with susceptibility to M leprae. Accordingly, spouses of leprosy patients are not likely to develop leprosy, but biological parents, children, and siblings who are household contacts of untreated patients with leprosy are at increased risk. The major source of infectious material probably is nasal secretions from patients with untreated infection. There are approximately 6500 leprosy cases in the United States; approximately 3300 require active medical management. As of early 2009, the World Health Organization new case detection rate for the United States was less than 0. More than 65% of the world’s leprosy patients reside in South and Southeast Asia—the majority of these patients reside in India. High endemicity remains in some areas of Angola, Brazil, Central African Republic, Democratic Republic of Congo, India, Madagascar, Mozambique, Nepal, Republic of the Marshall Islands, the Federated States of Micronesia, and the United Republic of Tanzania. The infectivity of lepromatous patients ceases within 24 hours of the frst administra tion of multidrug therapy, the standard antimicrobial treatment for leprosy. The incubation period of the tuberculoid form appears to be shorter than that for the lepro matous form. Symptoms can take up to 20 years to develop and are most likely to appear in individuals 20 to 30 years of age. Acid-fast bacilli can be found in slit-smears or biopsy specimens of skin lesions but rarely from patients with tuberculoid and indeterminate forms of disease. The primary goal of therapy is prevention of permanent nerve damage, which can be accomplished by early diagnosis and treatment. It is important to treat M leprae infections with more than 1 antimicrobial agent to mini mize development of antimicrobial-resistant organisms. This consideration is important to avoid monotherapy of active tuberculosis with rifampin while treating active leprosy. Leprosy reactions should be treated aggressively to prevent peripheral nerve dam age. Program (888-771-0141) and is used under strict supervision because of its teratogenicity. Rehabilitative measures, including surgery and physical therapy, may be necessary for some patients. All patients with leprosy should be educated about signs and symptoms of neuritis and cautioned to report signs and symptoms of neuritis immediately so that corticosteroid therapy can be instituted. Patients should receive counseling because of the social and psychological effects of this disease. Self-examination is criti cal for any patient with loss of sensitivity in the foot. When it does occur, relapse usually is attributable to reactivation of drug-susceptible organisms. Disinfection of nasal secretions, handkerchiefs, and other fomites should be considered until treatment is established. Household contacts, particularly contacts of patients with multibacillary disease, should be examined initially and then annually for 5 years. Local public health department regulations for leprosy vary and should be consulted. The frst commercially available leprosy vaccine was approved in India in January 1998. This vaccine was approved as an immunotherapeu tic adjuvant to be used with multidrug therapy; it is not available in the United States. The severity of disease ranges from asymptomatic or subclinical to self-limited systemic illness (approximately 90% of patients) to life threatening illness with jaundice, renal failure, and hemorrhagic pneumonitis. Clinical presentation typically is biphasic, with an acute septicemia phase usually lasting 1 week, followed by a second immune-mediated phase. Regardless of its severity, the acute phase is characterized by nonspecifc symptoms, including fever, chills, headache, nausea, vom iting, and a transient rash.

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In this case medicine escitalopram cheap meldonium 500mg on-line, simultaneous regeneration and aber Not all findings are present or prominent upon adduction medications canada buy generic meldonium 500mg on-line, there will also be lid rant resprouting of fibers to symptoms als order meldonium on line incorrect in every case treatment xeroderma pigmentosum buy meldonium on line. With attempted abduction, the of diplopia or ptosis, or even be aware of Pathophysiology medial rectus and the levator will be the changes occurring. Here, the lid assumes a ptotic mass, such as a meningioma within the subnuclear complex that arises in the state when the eye abducts. Fascicles the inferior rectus may also share fibers tial for causing morbidity or mortality. Primary aberrant oculomo tor nerve regeneration from a posterior communicating artery the posterior communicating artery have aneurysm. Primary aberrant aberrant regeneration may also occur from regeneration of the oculomotor nerve. Occurrence in a patient Diabetic papillopathy is a unilateral or oculomotor neuromyotonia, an episodic with abetalipoproteinemia. A case of primary involuntary contraction of one or more aberrant oculomotor regeneration due to intracavernous aneu less optic disc edema occurring in patients of the extraocular muscles resulting from rysm. Primary aberrant aculo diabetic papillopathy has been reported to Secondary aberrant regeneration follow motor regeneration. Aberrant regeneration of or only minimally reduced, though the oculomotor nerve followed by intracranial aneurysm: case presumed ischemic vascular palsy, neu report. Aberrant panied by intraretinal hemorrhages and regeneration of the third nerve (oculomotor synkinesis). Oculomotor neuromyoto noted on the disc surface, giving the optic the chiasm, cavernous sinuses and para nia with lid ptosis on abduction. J hyperfluorescence of the disc will be seen consultation will be necessary if imaging Neuroophthalmol. Prognosis of oculomotor palsy in patients with aneurysms of the posterior communicating artery. Bilateral aberrant regeneration of the third Contrary to initial speculation, diabetic papillopathy can occur in both type 1 and type 2 diabetes, and has cranial nerve following trauma. A case of bilateral diabetic papil lopathy related to rapid hemoglobin A1c decrease in type I dia defects may be present and consist of an other than close monitoring for worsening betes mellitus. Diabetic papillopathy in pregnancy: a marker for progression to proliferative retinopa dysfunction occurs; there is typically no ever, there is no treatment to prevent this thy. Nonarteritic anterior ischemic optic neuropathy: clinical characteristics in diabetic patients ver even in unilateral or asymmetric cases, Several anecdotal case reports and sus nondiabetic patients. Diabetic papillopathy usually due to concurrent diabetic macular diabetic papillopathy from several months with macular edema treated with intravitreal bevacizumab. Resolution of diabetic papillopathy with a single intravitreal injection of bevacizumab combined with Diabetic papillopathy has been asso In these cases, therapy was being directed triamcinolone acetonide. It also appears that diabetic erative retinopathy and not to diabetic papillopathy after a single intravitreal injection of ranibizumab. Intravitreal triamcino progression of nonproliferative diabetic no clinically proven benefit of these treat lone acetonide for the management of diabetic papillopathy. Periocular cor not advocated, as risk does not appear to ticosteroids in diabetic papillopathy. If vision is anterior optic nerve or a possible disrup significantly decreased, macular edema is Signs and Symptoms tion of the parapapillary vasculature. Diabetic papillopa extends more than 2mm into preretinal thy: an uncommon cause of bilateral optic disc swelling. In most cases, less than half of the ease, infectious neuroretinitis (Bartonella), 5. Response of diabetic papillopathy with melanocytoma of the optic disc, and disc ischemia (ischemic optic neu to intravitreal bevacizumab. Diabetic papillopathy with macular in 99% of patients, with whites affected limiting course over several months; edema treated with intravitreal ranibizumab. Bilateral dia though other reports and observations and patients tend to be minimally symp betic papillopathy and metabolic control. Nerve fiber bun nal nerve fiber layer bundles and major secluded from direct observation but can dle defects, enlarged blind spot, central vessels with resultant variable complica produce vision losses ranging from 20/50 and paracentral scotomas, or peripheral tions, such as acuity decrease, visual field to hand motion, vascular compression field constriction are all potential visual loss, relative afferent pupil defect and and axonal swelling. Circumpapillary subretinal fluid may occur, producing retinal striae, optic disc swelling and peripapillary swell ing. Clinicians usually fall back on long-term observation and careful documentation as a conservative Melanocytoma is one of five cellular dis management approach. Peripapillary choroidal neovascularization associated with melanocytoma of the optic tional period are considered benign by visual dysfunction progress or any signs disc: a clinicopathologic case report. Graefes Arch Clin Exp circumstantial evidence, though some of malignant transformation be identi Ophthalmol. The patient should be treatment for rare choroidal neovascular melanocytoma in a 10-month-old infant. Central retinal artery occlusion sec Doppler imaging, can help to differentiate Clinical Pearls ondary to optic disk melanocytoma. Clinical and histopathological studies of mela noma and is indicated if visual symptoms brown (vs. Case reports of three patients showing optic nerve head melanocytoma and face solid mass with a high amplitude of into the optic nerve head and peripapillary systemic hypertension. Fluorescein and indocyanine green Clinicopathological findings in a growing optic nerve melanocy associated with cat-scratch disease has also toma. It should be included in Melanocytomalytic glaucoma in eyes with necrotic iris melanocy toma. Iridociliochoroidal mela Recently, fundus autofluorescence system dysfunctions, systemic evaluation is noma arising from melanocytoma in a black teenager. Lipofuscin formation is an indirect marker should be referred for evaluation by a reti 29. Melanocytoma and reduced visual evoked potentials due to melanocytoma of optic disc in 115 cases: the 2004 Samuel Johnson Memorial of the optic disc. Autofluorescence lular nevus) of the ciliary body: report of 10 cases and review of and spectral-domain optical coherence tomography of optic subtle ophthalmoscopically, but appears the literature. Optical coherence the brain and oculodermal melanocytosis (nevus of Ota): case tomography study of optic disc melanocytoma. Optical coherence tomogra notic lesion of the iris as a presenting feature of ciliary body phy for surveillance of optic disc melanocytoma. Bull Soc Belge cating that there is little or no lipofuscin melanocytoma: report of a case and review of the literature. A clinical dilemma at optic disc associated with visual field defects: clinical features presentation with a review of the literature. Melanocytoma of the optic nerve head, the point of fixation and thirty-month follow-up. Optic disc melanocytoma report of 5 right or left, assuming patients from Singapore with a review of the literature. Autofluorescence with a shimmering, imaging in the differential diagnosis of optic disc melanocytoma. Successful treatment of melanocytoma associ ated choroidal neovascular membrane with intravitreal bevaci loss is transient by defini zumab. The vascular Genetics are believed to play a significant ing or sudden head movements may exac theory of migraine, first described in the role in migraine; about 50% of migraineurs erbate the pain. According to may persist from four hours to 72 hours in tion of perivascular sensory nerves. This describes a (in women), emotional stress, lack of eat meninges and their associated large blood clinical scenario in which headache occurs ing and sudden changes in weather. Ironically, chronic slowly propagating wave of depolarization with acute migraine episodes. Now rec the neurophysiological correlate of aura; of migraine subclasses and variants can ognized as a distinct subcategory of the the fact that it often begins in the occipital be equally confusing. A classification disease, complications include severe and cortex is consistent with the high preva scheme has been developed to categorize unusual sequelae associated with migraine, lence of visual auras in migraineurs.

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Medication causing daytime drowsiness While some medication can cause insomnia symptoms qt prolongation buy meldonium master card, other drugs can cause drowsiness all day long medications affected by grapefruit cheapest meldonium. It is therefore important to treatment 1st line order meldonium with visa be aware that any medication could potentially either cause insomnia or daytime drowsiness or exacerbate existing chronic fatigue treatment yellow fever buy meldonium master card. Physical (organ-based) diseases Diseases causing tiredness include anaemia, hypothyroidism, heart failure, low blood pressure, infectious diseases including glandular fever. They always feel that pain or irritation in the bladder and are exhausted by continually going to and from the bathroom. Chronic fatigue A special role is played here by systemic autoimmune diseases such as systemic lupus erythematosus and Sjögren’s syndrome in which true chronic fatigue can be a totally disabling symptom. When no identifiable disease or cause of the fatigue can be found, it is known as chronic fatigue syndrome. A difference with the tiredness caused by lack of sleep is that autoimmune tiredness has no bearing on whether you have slept well or not. Chronic fatigue may fluctuate from week to week, month to month and year to year and it may wax and wane during the day with flares at specific times when you then feel flu-like, shivering, with a headache, total exhaustion and inability to think. You no longer have the energy to take any kind of action, to talk to people, pick up the phone or take a decision. With chronic fatigue, you lose your drive, your motivation, you may have memory lapses, no concentration and experience confusion. While rest may sometimes alleviate the fatigue for a short time, as soon as you are busy again the fatigue returns. Advice to patients with chronic fatigue Work out how to plan your routine each day depending on how you feel. With chronic fatigue, you have to learn how to pace yourself, learn how to manage physical and emotional stress. Avoid overdoing things at times when you feel a bit more energetic since this can cause rapid burnout. At those rare moments when you have a window of energy, it is so tempting to try to catch up with all those tasks that have been neglected and piled up. International Painful Bladder Foundation 2019 57 All patients should bear in mind that fatigue or daytime drowsiness can make driving or use of machinery dangerous. Psychological disorders While depression can cause fatigue, chronic fatigue can itself cause depression. Impact on the whole family Fatigue impacts not only the patient but the whole family and can cause disruption of the life of everyone in the family, including children. It can make the patient unable to run the household, keep to any routine, create a normal environment for the family, lead a normal social life or have a normal relationship. The financial impact of chronic fatigue is a very important aspect for the patient since people with chronic fatigue may not be able to hold down a job. Physical (organ-based) diseases Anaemia Hypothyroidism Heart failure Low blood pressure Infectious diseases Systemic autoimmune diseases Cancer D. Diseases without proven physical and psychological cause Chronic fatigue syndrome Fibromyalgia F. General Excessive activity, over-exercising International Painful Bladder Foundation 2019 59 References and Further Reading Diagnosis & Treatment of Interstitial Cystitis in Women (in Russian) Bladder Pain Syndrome – an Evolution. A Practical Treatise on the Surgical Diseases of the Genito-Urinary Organs, including Syphilis. Controlling & Resolving Interstitial Cystitis through Natural Medicine History: Philip Weeks, Singing Dragon, 2012. Interstitial cystitis: Report of 223 cases (204 women pain-syndrome-(2011-amended-2014) and 19 men) J Urol 1949;61:291-310. The standardisation of International Journal of Urology, Vol 10 Supplement October terminology of lower urinary tract function: report from the 2003, Blackwell Publishing. Eur Urol 2005 Suppl 3:6 1-7 International Nocturia workshop, 6-8 June 2003, Malta. A randomized, double-blind, placebo controlled trial bmed&pubmedid=17864270 available free online of adalimumab for interstitial cystitis/bladder pain syndrome. Assessment of patient outcomes Pain in Urological Chronic Pelvic Pain Syndrome at Baseline: A following submucosal injection of triamcinolone for treatment Mapp Research Network Study. Interstitial cystitis/bladder pain syndrome / to the novel botulinum toxin injections. International Painful Bladder Foundation 2019 61 -Mücke M1, Phillips T, Radbruch L, Petzke F, Häuser W. Interstitial women with interstitial cystitis/painful bladder syndrome: a key cystitis/bladder pain syndrome and nonbladder syndromes: to classification and potentially improved management. Continuous intravesical Nocturia in interstitial cystitis/painful bladder syndrome. In: Practical observations on strangulated hernia and some of the diseases of the urinary organs. Retrospective chart review of vaginal diazepam suppository use in high-tone pelvic floor dysfunction. Intravesical liposome and antisense treatment for detrusor overactivity and interstitial cystitis/painful bladder syndrome. Interstitial Cystitis: a review of immunological aspects of the aetiology and pathogenesis, with a hypothesis. Diagnostic Criteria, classification, and Nomenclature for Painful Bladder International Painful Bladder Foundation 2019. Government Printing Office, April 2014 Research Advisory Committee on Gulf War Veterans’ Illnesses James H. Epidemiologic Research: Gulf War Illness and Other Health Issues Affecting 1990-1991 Gulf War Veterans. Other Health Issues Associated with Gulf War Service 1) General Health Status of Gulf War Veterans 2) Other Medical Conditions Affecting Gulf War Veterans: Neurological Disorders, Cancer, Sleep Dysfunction, Adverse Reproductive Outcomes 3) Multisymptom Illnesses: Chronic Fatigue Syndrome, Fibromyalgia, Multiple Chemical Sensitivity 4) Psychiatric and Psychological Disorders in Gulf War Veterans 5) Hospitalization Rates E. Methodological Issues for Epidemiologic Research on Gulf War Illness: Data Collection Techniques G. Etiological Investigations: Research on Persistent Health Effects of Gulf War Experiences and Exposures. Research on Persistent Health Effects in Gulf War Veterans in Relation to Deployment Experiences and Exposures 1) Additional Information on Possible Chemical Exposures During the Gulf War 2) Health Outcomes in Relation to Exposures in Theater a. Studies Evaluating Effects of Nerve Gas Agents, Chemical Weapons, Vaccines, Pyridostigmine Bromide, Pesticides, Kuwaiti Oil Fires in Gulf War Veterans b. Pathobiology of Gulf War Illness: Biological Findings in Gulf War Veterans. Membership includes veterans of the 1990-91 Gulf War, scientists who have studied illnesses affecting these veterans, clinicians who care for ill Gulf War veterans and a member of the general public. The Committee periodically releases reports that summarize research to date on the health of veterans of the 1990-1991 Gulf War. The most recent report was published in 2008, and the current report updates knowledge from that time by reviewing published scientific papers that appeared after the last report and through December 2013. The first summarizes the new information available on rates of Gulf War illness and other illnesses and disabilities that affect groups of veterans from the Gulf War (Section 1, Epidemiologic Research). The second reviews the human and animal research that has been carried out to identify the causes of Gulf War illness and other health problems in Gulf War veterans (Section 2: Etiologic Investigations). The third section focuses on studies of the disruptions in normal body functions that underlie the symptoms of Gulf War illness and other health problems (Section 3: Pathobiology of Gulf War illness). And the fourth reviews clinical trials that are underway to treat Gulf War illness (Section 4: Gulf War illness treatment research). Research has begun to identify probable underlying mechanisms, promising treatments and biomarkers. Gulf War illness refers to the chronic symptoms that affect veterans of the 1990-1991 Gulf War at markedly elevated rates compared to other veteran groups and to the U. The individual symptoms experienced by ill Gulf War veterans can vary from person to person, but overall the types of symptoms reported are similar in the many groups of ill veterans that have been studied since the Findings in Brief | 1 war. Symptoms typically include some combination of widespread pain, headache, persistent problems with memory and thinking, fatigue, breathing problems, stomach and intestinal symptoms, and skin abnormalities. In the early years after the war, this disorder was commonly called “Gulf War Syndrome” by the media and has since been referred to by a variety of names such as undiagnosed illness, Gulf War illness, chronic multisymptom illness and other terms. Based on its review of the research that has been published since 2008, the Committee concludes that Gulf War illness has been consistently reported in all studies of Gulf War veterans and that it is seen in about 25-30% of Gulf War veterans, or about 175,000 to 250,000 of the 700,000 troops deployed to the war in 1990-91.

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Genetics is an integral part of medicine today and a detailed description of the presently Ramanjit Sihota known genetic associations and their possible utility in the Radhika Tandon management of ocular diseases was considered important vii this page intentionally left blank Acknowledgements the authors remain deeply indebted to treatment 2 prostate cancer cheap 500 mg meldonium mastercard the faculty symptoms juvenile diabetes meldonium 250mg without a prescription, residents Dr medications causing pancreatitis discount meldonium 500 mg free shipping. Rajendra Prasad Centre for Ophthalmic Professor and Head Sciences medications adhd purchase meldonium in india, Chief of the Centre, and Director of All India Department of Ophthalmology Institute of Medical Sciences for the rich academic and Bharati Vidyapeeth Deemed University Medical College clinical milieu provided to nurture our work. Department of Ophthalmology We acknowledge and greatly appreciate the efforts and Pt. Medical College invaluable comments of our reviewers, we would especially Raipur like to thank the following: Dr. Chaitra Jayadev Consultant Pediatric Ophthalmologist Consultant, Vitreoretina Services Dr. Shroff Senior Consultant, Glaucoma Services Medical Director, Shroff Eye Centre Glaucoma Department and Research Director Past President, Vitreo Retinal Society of India Sankara Nethralaya, Chennai New Delhi Dr. Jaya Devendra Assistant Professor Associate Professor Gandhi Medical College Department of Ophthalmology Bhopal Rohilkhand Medical College and Hospital Bareilly Our special thanks to Dr. Niharika Pant, Professor, Department of Ophthalmology Veer Chandra Singh Garhwali Government Medical Sciences Padmashree Dr. Specialist Ophthalmologist Last but not the least, we would like to make an endear Uveitis and Ocular Immunology ing mention of our families who with their loyal forbearance New Medical Centre Specialty Hospital allowed us to spend our spare time and devote our attention Abu Dhabi to this work without which it would have been impossible to achieve. Rao Professor and Head Ramanjit Sihota Department of Ophthalmology Radhika Tandon Kasturba Medical College & Hospital Manipal Dr. Mathew Kurian Medical Superintendent Senior Consultant, Cataract and Refractive Lens Surgery Nararyana Nethralaya Bangalore ix this page intentionally left blank Contents Preface to the Twenty-Second Edition v 12. Examination of the Posterior Preface to the Nineteenth Edition vii Segment and Orbit 131 Acknowledgements ix 13. From this pair of diverticula from while the surface ectoderm remains as the corneal and con the sides of the forebrain and the mesodermal and junctival epithelium. In the surrounding region, folds grow ectodermal structures in contact with it, the two eyes over in front of the cornea, unite and separate again to form develop. After it meets the surface ectoderm, the primary optic Summary of ocular embryogenesis is given in Table 1. The inner layer of the cup forms the main structure of the retina, the nerve fbres from (i) the neural ectoderm derived from the neural tube and which eventually grow backwards towards the brain. At the the wall of the globe is composed of a dense, imperfectly point where the neural ectoderm meets the surface ecto elastic supporting tissue—the transparent cornea and the derm, the latter thickens to form the lens plate, invaginates opaque sclera (Fig. The stromal collagen fbrils are of regular diameter, arranged as a lattice with an interfbrillar b spacing of less than a wavelength of light so that tangential rows of fbres act as a diffraction grating resulting in b c destructive interference of scattered rays. The primary mechanism controlling stromal hydration is a function of the corneal endothelium which actively pumps out the electrolytes and water fows out passively. The endothe lium is examined by a specular microscope at a magnifca C D tion of 5003. Endothelial cells become less in number with age and the residual individual cells may enlarge to compensate. Blood Supply and Innervation the cornea is avascular with no blood vessels with the excep tion of minute arcades, extending about 1 mm into the cornea at the limbus. It is dependent for its nourishment upon diffu sion of tissue fuid from the vessels at its periphery and the aqueous humour. The cornea is very richly supplied with unmyelinated nerve fbres derived from the trigeminal nerve. In each case the solid black Sclera is the neural ectoderm, the hatched layer is the surface ectoderm and its derivatives, the dotted area is the mesoderm: a, cavity of the forebrain; the sclera is the ‘white’ supporting wall of the eyeball and b, cavity of the optic vesicle; c, cavity of the optic cup (or secondary is continuous with the clear cornea. The outer anterior part of the forebrain and optic vesicles of a 4 mm human embryo. Lining the inner aspect of is formed from the posterior cells of the lens vesicle. The cavity contains concerned with the reception and transformation of light a clear watery fuid called aqueous humour. The anterior chamber is a space flled with fuid, the aque ous humour; it is bounded in front by the cornea, behind Cornea by the iris and the part of the anterior surface of the lens the cornea is the transparent front part of the eye which which is exposed in the pupil. Its peripheral recess is known resembles a ‘watchglass’ and consists of different layers as the angle of the anterior chamber, bounded posteriorly and regions: by the root of the iris and the ciliary body and anteriorly by the corneosclera (Fig. It is made up of circumferentially disposed fattened bands, each perforated by numerous oval stomata through Optic vesicle and cup which tortuous passages exist between the anterior chamber Iris epithelium and Schlemm’s canal. The extracellular spaces contain both Ciliary epithelium a coarse framework (collagen and elastic components) and Part of the vitreous a fne framework (mucopolysaccharides) of extracellular Retina materials, which form the probable site of greatest resis Retinal pigment epithelium tance to the fow of aqueous. Fibres of the optic nerve the endothelial cells of Schlemm’s canal are connected Surface ectoderm Conjunctival epithelium to each other by junctions which are not ‘tight’ but this Corneal epithelium intercellular pathway accounts for only 1% of the aqueous Lacrimal glands drainage. The major outfow pathway appears to be a series Tarsal glands of transendothelial pores, which are usually found in out Lens pouchings of the endothelium called ‘giant vacuoles’. Sclera Iris Lens Vascular endothelium of eye and orbit the lens is a biconvex mass of peculiarly differentiated Choroid epithelium. It has three main parts the outer capsule lined Part of the vitreous by the epithelium and the lens fbres and is developed from Neural crest* Corneal stroma, keratocytes and an invagination of the surface ectoderm of the fetus, so endothelium that what was originally the surface of the epithelium Sclera comes to lie in the centre of the lens, the peripheral cells Trabecular meshwork endothelium corresponding to the basal cells of the epidermis. Just as the Iris stroma epidermis grows by the proliferation of the basal cells, the Ciliary muscles old superfcial cells being cast off, so the lens grows by Choroidal stroma the proliferation of the peripheral cells. The old cells, how Part of the vitreous ever, cannot be cast off, but undergo changes (sclerosis) Uveal and conjunctival melanocytes analogous to that of the stratum granulosum of the epider Meningeal sheaths of the optic nerve mis, and become massed together in the centre or nucleus. The Ciliary ganglion lens fbres have a complicated architectural form, being Schwann cells of the nerve sheaths arranged in zones in which the fbres growing from oppo Orbital bones site directions meet in sutures. Without going into details, it Orbital connective tissue is important to bear in mind that the central nucleus of the Connective tissue sheath and muscular lens consists of the oldest cells and the periphery or cortex layer of the ocular and orbital blood vessels the youngest (Fig. The fbres of the lens are split into regions depending on *During the folding of the neural tube, a ridge of cells comprising the age of origin. The central denser zone is the nucleus the neural crest develops from the tips of the converging edges and migrates to the dorsolateral aspect of the tube. The oldest and innermost is the this region subsequently migrate and give rise to various structures central embryonic nucleus (formed 6–12 weeks of embry within the eye and the orbit. Outside this embryonic nucleus, successive nuclear zones are laid down as development proceeds, called, Schlemm, which is of great importance for the drainage of depending on the period of formation, the fetal nucleus the aqueous humour. At the periphery of the angle between (3–8 months of fetal life), the infantile nucleus (last month the canal of Schlemm and the recess of the anterior cham of intrauterine life till puberty), the adult nucleus (corre ber there lies a loosely constructed meshwork of tissues, the sponding to the lens in early adult life), and fnally and most trabecular meshwork. This has a triangular shape, the apex peripherally, the cortex consisting of the youngest fbres. It is lium which constitutes the lens is surrounded by a hyaline held in place by the suspensory ligament or zonule of membrane, the lens capsule, which is thicker over the Zinn. This is not a complete membrane, but consists of anterior than over the posterior surface and is thinnest at bundles of strands which pass from the surface of the cili the posterior pole; the thickest basement membrane in the ary body to the capsule where they join with the zonular body it is a cuticular deposit secreted by the epithelial lamella. The strands pass in various directions so that the cells having on the outside a thin membrane, the zonular bundles often cross one another. The anterior layer consists of fattened cells and the posterior of cuboidal cells. From the epithelial cells of the former, two unstriped muscles are developed which control the movements of the pupil, the sphincter pupillae, a circular bundle running round the pupillary margin, and the dilator pupillae, arranged radially near the root of the iris. The anterior surface of the iris is covered with a single layer of endothelium, except at some minute depressions or crypts which are found mainly at the ciliary border; it usually atrophies in adult life. The iris is richly supplied by sensory nerve fbres derived from the trigeminal nerve. The sphincter pupillae is supplied by parasympathetic autonomous secretomotor nerve fbres derived from the oculomotor nerve, while the motor fbres of the dilator muscle are derived from the cervical sympathetic chain. The iris is attached about the middle of the base, so that a back as the ora serrata; these lie in contact with the ciliary small portion of the ciliary body enters into the posterior body for a considerable distance and then curve towards the boundary of the anterior chamber at the angle (Fig. A third group blending with the ‘spur’ of the sclera and related to the passes from the summits of the processes almost directly trabecular mesh work. Most of the remaining fbres run Uveal Tract obliquely in interdigitating V-shaped bundles so as to give the uveal tract consists of three parts, of which the two the impression of running in a circle round the ciliary posterior, the choroid and ciliary body, line the sclera while body, concentrically with the base of the iris. The portion of the muscle is composed of a few tenuous iridic plane of the iris is approximately coronal; the aperture of fbres arising most internally from the common origin and the diaphragm is the pupil. Situated behind the iris and in fnding insertion in the root of the iris just anterior to the contact with the pupillary margin is the crystalline lens.

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