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Leonard Kaban, DMD, MD, FACS

  • Walter C Guralnick Professor and Chairman
  • Department of Oral and Maxillofacial Surgery
  • Harvard School of Dental Medicine
  • Chief, Department of Oral and Maxillofacial Surgery
  • Massachusetts General Hospital
  • Boston, Massachusetts

If the baby does not turn anxiety symptoms weight loss purchase 40mg cymbalta with visa, she may need your emotional support to cope with her disappointment anxiety symptoms during pregnancy order discount cymbalta online. Simply put anxiety symptoms weak legs cymbalta 20 mg low price, it is the collection of bacteria anxiety 10 things effective 30 mg cymbalta, viruses anxiety symptoms in 5 year old boy order cymbalta amex, fungi anxiety symptoms 247 cheap cymbalta 20mg online, and other organisms that live in and on the body. We have about 10 tril lion human cells in our bodies and about 100 trillion microbes. For example, the bacteria found in our mouths is diferent than the bacteria on our skin, which is diferent than in our intestines. Good bacteria can aid digestion, provide vitamins (K and B12), regulate the bowels, stimulate the development of the immune system, protect against infection, and more. For example, a vaginal yeast infection may occur when healthy bacteria are reduced by anti biotics, allowing yeast to overgrow. Many studies have shown that the absence of specifc microbes can cause lifelong changes in immunity. Disruption of the gut microbiota has been linked to infammatory bowel disease, diabetes, obesity, allergies, asthma, and some cancers. However, microbes are found in the placenta, amniotic fuid, and in meconium (the waste that accumulates in the fetal bowels). For example, if the mother lived or worked on a farm, that might protect against allergies and asthma. In the third trimester, these are especially high in lactobacilli, which help the baby to digest milk. Studies comparing the microbiomes of vaginally born babies with those born via cesarean have shown dif ferences in their gut bacteria as much as seven years after delivery. The longer the duration of antibiotics, the harder it is for the microbiome to recover. Early use of anti biotics or prolonged use can have long-term side efects, increasing risk of obesity or infammatory bowel disease in later life. Taking probiotic supplements (such as lactobacillus acidophilus and bifdobacteria) may improve gut diversity (for mom and baby), may reduce gestational diabetes, and may reduce risk of allergy and eczema for the baby. If they are needed, then you could consume probiotics or prebiotics while taking antibiotics or after the course of antibiotics is complete. Studies have shown probiotics reduce ear infections and recurrent colds in formula-fed babies. Caution: People who are critically ill or immune-suppressed should consult with a caregiver before taking probiotics. Ask us again what we most need: we may need help washing dishes, starting the laundry, watching the baby while we shower or nap, or we may just need someone to sit and listen to us talk. Name Phone Number What day(s) of the week are you most likely to be able to helpfi Try to fnd out which ones are used by your health care provider at your place of birth. Most of the following tests are routinely performed and a few are only used when medically indicated. The infant should (temperature, heart rate and appear pink and breathe easily without grunting, faring nostrils, or retracting her chest respiration) to be sure your (pulling in her chest under her ribs). If the heart rate or rhythm is cause for concern or if baby is adjusting to life as a there is a breathing problem, your baby will be assessed by her health-care provider or newborn and to detect any admitted to the nursery. If she is still cool after 20 or 30 minutes, she may be wrapped warmly in several blankets and placed under a special radiant warming light or admitted to the nursery and placed in a special bed or isolette for warming. The intention is to prevent also not fully effective at preventing complications from chlamydia and gonorrhea. The infection and possible blind Canadian Paediatric Society recommends against its routine use, saying that a more ness if the newborn is exposed effective prevention method would be to screen and treat mothers during pregnancy. Side effects are fairly minimal: When ointment is given, it causes mild eye irritation, and temporary blurring of vision. Delaying the procedure up to the allowed one hour gives you some time with the baby when she is alert and can see more clearly. Septic workup Blood is drawn and cerebro these are done if baby has a fever or other signs of a possible infection. If the blood and (not routinely by spinal tap; samples are sent cerebrospinal fuid are found to be normal, antibiotics will be discontinued. Pregnancy, Childbirth, and the Newborn Pregnancy, Childbirth, and the Newborn Test or procedure What it is Comments Test for Blood obtained by a heel prick Hypoglycemia is most common in babies over 8 pounds 13 ounces or under 5 pounds, if hypoglycemia is tested for hypoglycemia (low the baby is chilled, or the baby is preterm or postterm. Treatment includes frequent breastfeeding or formula feeding and/or feedings of sugar water (5 or 10 percent dextrose solution). Infant security Babies are given wrist and Learn about the infant security policy at your hospital or birth center. There should be a ankle bands at birth that written plan for safeguarding against switching babies and kidnapping (both very rare match their mothers. Having your baby in your room with you at the should wear easy-to-read hospital (or birth center) and being sure that you never leave her unattended at the identifcation badges. Newborn hearing Newborn hearing is assessed Three in one thousand babies have hearing loss. Infants who are born prematurely, screening in the frst days after birth for who have a family history of hearing defcits or deafness, or who have been exposed to a period of about 10 minutes pathogens or medications that put them at risk for hearing loss or deafness are tested. Low oxygen levels may indicate congenital testing skin (usually on the hand or heart disease, which can be treated with surgery. However, or during the procedure, and states and provinces vary in what they target. Here are some questions the doctor or nurse may ask, so be sure you have the answers ready before you call. This wordless board book tells of a sibling going with mom to the doctor, helping to prepare for the baby and meeting the baby at the hospital. A small paperback with simple illustrations and brief text about the details of home birth. Discusses fetal development, explaining the umbilical word, using the word uterus, and so on. A book about fetal development, month by month, that the pregnant parent can hold up to her body to show the child how big the baby is at each stage. Not really about siblings but does show how children can interact and enjoy the new baby. Positive portrayal of sibling relations, where problems are presented and solutions are found. A beautifully illustrated account of a home birth through the eyes of a young child.

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Systemic corticosteroids are given starting with high doses and gradually reducing to maintenance dose anxiety 300mg discount cymbalta american express. Extreme corneal marginal ulceration or keratolysis may require corneal grafting usually as lamellar graft anxiety quotes funny discount 40mg cymbalta overnight delivery. Etiology Staphylomas are formed due to thinning of the sclera often associated with raised intraocular tension anxiety 8 year old daughter buy generic cymbalta 20 mg. Posterior staphyloma can be treated by reinforcement surgery by fascia lata or silicon band in cases of high myopia anxiety 8 year old son generic cymbalta 20 mg without prescription. Anatomically anxiety jar order cymbalta in india, they are continuous and so disease of one part may spread to the other anxiety symptoms anger cymbalta 20 mg low price. When pupil is constricted, more of the posterior surface of the iris is in contact with the lens capsule. It divides the space between the cornea and lens into the anterior and posterior chambers of eye. At the periphery, the iris is attached to the middle of anterior surface of the ciliary body. Parts Anterior surface of the iris can be divided into two zones by a zigzag line called the collarette. It is supplied by the cervical parasympathetic nerves via third cranial nerve and causes constriction of the pupil. The outer side of the triangle lies against the sclera with the suprachoroidal space in between. It is relatively avascular therefore posterior segment of the eye is entered through the pars plana incision 3-5 mm behind the limbus. The outer layers of retina are dependent for their nutrition the Uveal Tract 163 Structure of choroid upon the choroid. The potential space between this membrane and sclera is known as suprachoroidal space. The inner side of the choroid is covered by at thin elastic membrane lamina vitrea or membrane of Bruch. The Blood Supply the blood supply of the uveal tract is almost entirely derived from the posterior ciliary and anterior ciliary arteries. However, there is always associated inflammation of the adjacent structures such as retina, vitreous, scleral and cornea. Inflammation is insidious in onset, chronic in nature with minimum clinical features. It is characterized by the presence of fine keratic precipitates which are composed of lymphoid cells and polymorphs. Clinical features Features of low grade Features of acute inflammation inflammation i. There is severe neuralgic pain referred to forehead, scalp, cheek, malar bone, nose and teeth (as the iris is richly supplied by sensory nerves from the ophthalmic division of 5th nerve). Lacrimation and photophobia may be present (without any mucopurulent discharge) due to associated keratitis. Photophobia is due to pain induced by pupillary constriction and ciliary spasm because of inflammation. There is plasmoid aqueous containing leucocytes, minute flakes of coagulated proteins and fibrinous network. They are characteristic of granulomatous uveitis with predominance of macrophages. It reacts sluggishly to light due to irritation of the third nerve endings in iris. Ectropion of uveal pigment is due to the contraction of exudates upon the iris so that the posterior surface of iris folds anteriorly. Intraocular pressure may rise when 3/4 circumference or more of the angle of anterior chamber is blocked. Hypertensive iridocyclitis may be present due to increase pressure in dilated capillaries and outpouring of leucocytes. The sticky albuminous aqueous drains Acute iridocyclitis with difficulty thus raising the tension. Late glaucoma (postinflammatory glaucoma) is the results of pupil block (seclusio-pupillae due to ring synechiae formation or occlusio-pupillae due to organised exudates) not allowing the aqueous to flow from anterior to posterior chamber. Investigations Series of tests should be done because of varied etiology of uveitis. Radiological investigations include X-rays of chest, paranasal sinuses, sacroiliac joints and lumbar spine. Modern broad-spectrum antibiotics which cross the blood-aqueous barrier are given in cases of infections. Atropine It is the most powerful, longest acting (2 weeks) and commonly used mydriatic and cycloplegic. Slit-lamp examination Normal Aqueous flare and kp Corneal oedema and anterior synechiae i. Thus, it also relaxes the ciliary muscle spasm which is always associated with iritis. It prevents formation of posterior synechiae and breaks down recently formed synechiae which are not firmly attached by dilating the pupil. In case of atropine allergy, other mydriatics like phenylephrine, cyclopentolate or tropicamide may be used. In milder cases weaker, short-acting agents such as cyclopentolate 1% or homatropine 2% thrice daily may be used. Dark glasses or an eyeshade may also be used to avoid glare, discomfort and lacrimation specially in sunlight. Heat Application Heat application in the form of hot fomentation or local dry heat is very soothing. Due to their anti-allergic and anti-fibrotic activity they reduce fibrosis and thus prevent disorganisation and destruction of tissues. It is better to use full strength topical steroids for 6 weeks to make sure that patient is not having side effects such as raised intraocular pressure. Analgesics and Anti-inflammatory these are useful in relieving pain and discomfort. Antibiotics the modern broad-spectrum third generation antibiotics are of immense value particularly in fulminant cases of purulent uveitis.

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For pigmented lesions that reside deeper in tissue and for lesions that are more densely populated in an area anxiety test order cheap cymbalta line, a deeper penetrating filter should be chosen anxiety 4 hereford bull order cymbalta toronto. Fluence Refer to Pigmented Lesion Treatment Starting Parameters for appropriate fluence selection anxiety symptoms eyes buy 40mg cymbalta mastercard. Therefore anxiety symptoms xanax 20mg cymbalta sale, darker anxiety 6 letters purchase cymbalta on line, more concentrated pigmented lesions require less fluence than lighter colored anxiety 60 mg cymbalta 90 mg prozac purchase genuine cymbalta on line, less concentrated pigmented lesions to reach the same therapeutic level. Pulse Width Refer to Pigmented Lesion Treatment Starting Parameters for appropriate pulse width selection. Pulse width should be shorter than the cooling time of the target to make sure that all the energy is confined to the target. Therefore, the smaller the lesion being treated, the less time on or a shorter pulse width needed. Conversely, when treating a larger lesion, a longer pulse width should be selected to provide for a longer period of heat delivery. Pigmented lesions with low concentrations of pigment will cool down quicker than densely pigmented ones. Darker skin absorbs more light and heats to a higher temperature, therefore pulse width should be longer for darker skin. Cooling Refer to Pigmented Lesion Treatment Starting Parameters for appropriate temperature selection. The amount of cooling required will vary with skin type, amount of target present, and area treated. When treating body tissue, temperature should be colder, as well as when treating darker skin types. Treatment fi Apply thin layer of colorless gel fi Select appropriate settings fi Treat test area to establish safe treatment parameters and desired endpoint. This results in slow elimination of the vascular lesion by the macrophages of the immune system. Filter Selection Refer to Vascular/Skin Treatment Starting Parameters for appropriate filter selection. For vascular lesions, flushing, blushing and/or rosacea that resides deeper in tissue and for areas where these conditions are more densely populated, a deeper penetrating filter should be chosen. Therefore, a deeper penetrating filter should be chosen for patients with darker skin types. Fluence Refer to Vascular/Skin Treatment Starting Parameters for appropriate fluence selection. Targets that have more dense vascularity absorb more energy/heat and will reach higher temperatures. Therefore, redder, more concentrated areas of vascular lesions require less fluence than lighter colored, less concentrated areas of vascular lesions to reach the same therapeutic level. Pulse Width Refer to Vascular/Skin Treatment Starting Parameters for appropriate pulse width selection. Pulse width should be shorter than the cooling time of the target to make sure that all of the energy is confined to the target. Therefore, the smaller the vascular lesion being treated the less time on, or a shorter pulse width. Conversely, when treating a larger vascular lesion, a longer pulse width should be selected to provide for a longer period of heat delivery. Vascular lesions with less dense vascularity will cool down quicker than more densely pigmented ones. Prolonged cold air on skin can cause vasoconstriction of the targeted vessels resulting in an ineffective treatment. A small bead of gel should be placed on the sapphire glass on the underside of the adapter, prior to snapping it on to the full crystal. Multiple treatments are necessary over a time span of typically 4-8 week intervals to remove hair from most areas. Hair Growth Cycle anagen: the phase of the hair cycle during which synthesis of hair takes place. Filter Selection Refer to Hair Reduction Treatment Starting Parameters for appropriate filter selection. Therefore darker more concentrated areas of hair growth require less fluence than lighter colored, less concentrated areas of hair growth to reach the same therapeutic level. Pulse Width Refer to Hair Reduction Treatment Starting Parameters for appropriate pulse width selection. Therefore, the smaller or finer the hair being treated the less time on, or a shorter pulse width. Conversely, the larger or coarser the hair being treated the more time on with the heat, or a longer pulse width should be selected. Therefore hair that is finer and in areas with less dense growth should be treated with shorter pulse widths and coarser more concentrated areas of hair growth should be treated with longer pulse widths. Cooling Refer to Treatment Starting Parameters for appropriate temperature selection. There are 6 Area Size Selections: 25 cm, 50 cm, 75 cm, 100 cm, 125 cm and 2 150 cm. Treatment Size Template Squares Number of Crystal Widths 2 25 cm 1 3 2 50 cm 2 6 2 75 cm 3 9 2 100 cm 4 12, or 2 rows of 6 2 125 cm 5 15 2 150 cm 6 18, or 2 rows of 9 Each square is 25 sq cm. Hair Color Selection Light brown, dark brown or black may be selected as hair color. Manual Mode this softkey permits the user to bypass selected preset parameters and enter desired parameters manually. Target Energy this displays the range of target energy required to be delivered based upon the preset selection. In the Accumulated Energy (J) section in 2 the treatment screen above it recommends 1633 to 2333 J for the 50 cm selected area. The lower end of the range is for more comfortable application of energy whereas the higher end is for more efficacious treatment. Once the Target Energy has been achieved, an audible tone will sound to signal the completion of treatment of that area. When treating the patient, move the handpiece from one end of the treatment area, to the other end of the treatment area, while keeping the handpiece in contact with the skin, moving 2 3 crystal widths per second. Once the other side of the treatment area is reached, reverse the direction and begin moving from the top of the treatment area to the bottom. When the Accumulated Energy (J) has reached half of the Target Energy, the process can be repeated but this time changing orientation direction of handpiece to blend coverage and slight overlap. First Direction Second Direction Moving the handpiece too slowly within a treatment area may cause a burn or dermal injury. Patients routinely find the motion procedure more comfortable than other Hair Removal technology. However, if the patient is uncomfortably warm in the treatment area and the recommended Total Energy has not been delivered, then adjustments to the speed, temperature, or rate should be considered. If the patient is uncomfortable and the target energy has not been reached, proceed to the next area. Note: Check with manufacturer for guidelines on using injectables in conjunction with hair removal treatment. Touching the Manual Mode softkey allows the user to set the energy, rate and temperature as desired. Apply Settings Touching this softkey will permit the user to apply the selected preset parameters and advance to the next screen. Return to Previous Screen Touching this softkey permits the user to return to the previous screen. Input this information by pressing corresponding softkey in the above Preset Parameter Screen. Temperature Indicator this provides a visual guage of the temperature of the sapphire crystal. Static Hair Preset Parameters the preset parameters for hair treatment are displayed. Reset To reset the counter to zero, touch the reset softkey until the system beeps 4 times. SkinTyte treatments utilize optimized cut-off filters which emit energy with wavelengths in the visible to infrared spectrum, and provide dermal heating for the purpose of elevating tissue temperature for firmer skin. This proprietary technology is used to selectively heat the water within the dermal collagen matrix. Discuss selective heating of skin using photothermal energy and the factors that determine safe start parameters 2. Thermal profile as the handpiece is pulled away Tight, firm skin requires good elasticity. Elasticity means the ability of the skin to snap back or tighten after it has been displaced or pulled away from the body. Good elasticity depends on healthy collagen and elastin fibers that lie very deep, near the bottom of the dermis. Collagen and elastin fibers act like small rubber bands that hold the skin tight against our body, and pull the loose tissue back when it is stretched or pulled. Although it is located beneath the epidermis, it is changes to the dermis that cause the outer skin to wrinkle and lose elasticity. As we grow older, the amount of fat found in our lower layer of skin decreases, our glands produce less oil, and collagen and elastin fibers lose their elasticity. The natural process of cell reproduction in the dermal layer also decreases, resulting in a slower rejuvenation of our skin cells. The epidermis is a robust and resilient structure that is at the surface of the skin. As a result of cooling by the sapphire crystal the highest temperature will occur below the epidermis in the more hydrated dermis. The immediate response to this thermal exposure is a contraction of the collagen and elastin fibrils. Longer term, fibroblasts are activated stimulating the production of new collagen, elastin and other components of the extracellular matrix in response to wound healing which takes place up to six months after the initial heating. This tissue remodeling results in a thickening of the dermis and the shrinking of the elastin fibers, resulting in improvement of skin firmness. Fluence In light based medicine, fluence is referred to as radiant exposure or the measurement of energy over area. Collagen strands are denatured and elastin will contract in response to high temperatures. When assessing for the appropriate amount of fluence, test pulses should be performed and fluence or intensity should be adjusted incrementally until appropriate endpoints are met. SkinTyte modifies the normal temperature gradient in skin by heating a subsurface layer while cooling the surface. The major challenge when trying to heat this area in tissue is to get enough heat deep down in the dermis without burning the surface of the skin as the heat passes through the more superficial layers. All patients and areas treated will then have similar temperature profiles regardless of their normal skin temperature. Infrared light from SkinTyte is applied to the surface of the skin and penetrates down below. The pre-cooled region stays cool while a layer several millimeters below the surface is preferentially heated. Managing Patient Expectations Patients should understand that to experience optimal results with SkinTyte a minimum of 4 treatments are required and that optimal results are not seen for 3 6 months after the last treatment. It takes this amount of time for dermal changes from fibroblast activity to be evident. The goal when treating with SkinTyte using the Motion Technique is to heat the target to a temperature that is sufficient to stimulate collagen, but not to the point that the heat damages skin 2 and surrounding tissue. The following are performance factors when providing a SkinTyte motion technique procedure. The higher the intensity selected, the higher the temperature of the target, the surrounding tissue and the epidermis. Patient response can vary, so the intensity setting should begin low and be increased gradually after assessing the individual patient response and observation of endpoints desired. Press the Motion SkinTyte softkey on the Broadband Light Application screen and the system will enter the SkinTyte application screen. Filter wavelength indicator Filter wavelength indicator shows which wavelength is being used for the treatment. Spot size adjustment softkey Spot size adjustment softkey allows the user to toggle between the 15x45 mm spot and the 15x15 mm spot.

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Further development consists in differentiation of the individual optic structures anxiety symptoms reddit purchase cheapest cymbalta. In general anxiety blog 40 mg cymbalta for sale, differentiation of the optic structures occurs more rapidly in the posterior than in the anterior segment of the eye during the early stages and more rapidly in the anterior segment during the later stages of gestation anxiety symptoms quotes purchase cymbalta 60mg with amex. The lid buds are first seen at 6 weeks growing in front of the eye anxiety heart palpitations discount cymbalta line, where they meet and fuse by 8 weeks anxiety symptoms one side discount 60mg cymbalta otc. The lashes and meibomian and other lid glands develop as downgrowths from the epidermis anxiety symptoms paranoia cheap 30mg cymbalta mastercard. The lacrimal and accessory lacrimal glands develop from the conjunctival epithelium. The structures of the lacrimal drainage system (canaliculi, lacrimal sac, and nasolacrimal duct) are also surface ectodermal derivatives, which develop from a solid epithelial cord that becomes buried between the maxillary 60 and nasal processes of the developing facial structures. Sclera & Extraocular Muscles the sclera and extraocular muscles are formed from condensations of mesenchyme encircling the optic cup and are identifiable by 7 weeks. Anterior Segment the anterior segment of the globe is formed by the invasion of the neural crest mesenchymal cells into the space between the surface ectoderm, which develops into the corneal epithelium, and the lens vesicle, which has become separated from it. The invasion occurs in three stages: the first is responsible for formation of the corneal endothelium, the second for formation of the iris stroma, and the third for formation of the corneal stroma. The anterior chamber angle is formed from a residual condensation of mesenchyme at the anterior rim of the optic cup. The corneal epithelium and endothelium are first apparent at 6 weeks, when the lens vesicle has separated from the surface ectoderm. The double row of iris epithelium is a forward extension of the anterior rim of the optic cup. This grows forward during the third month to lie posterior to the neural crest cells that form the iris stroma. These two epithelial layers become pigmented in the iris, whereas only the outer layer is pigmented in the ciliary body. By the fifth month, the sphincter muscle of the pupil is developing from the anterior epithelial layer of the iris near the pupillary margin. Soon after the sixth month, the dilator muscle appears in the anterior epithelial layer near the ciliary body. The iris, which in the early stages of development is quite anterior, gradually lies relatively more posteriorly as the chamber angle recess develops, most likely because of the difference in the rate of growth of the anterior segment structures. The trabecular meshwork develops from the loose mesenchymal tissue lying originally at the margin of the optic cup. Lens Soon after the lens vesicle lies free in the rim of the optic cup (6 weeks), the cells of its posterior wall elongate, encroach on the empty cavity, and finally fill it (7 weeks). Secondary lens fibers elongate from the equatorial region and grow forward under the subcapsular epithelium, which remains as a single layer of cuboidal epithelial cells, and backward under the lens capsule. These fibers meet to form the lens sutures (upright Y anteriorly and inverted Y posteriorly), which are complete by the seventh month. At 3fi weeks, a network of capillaries encircles the optic cup and develops into the choroid. By the third month, the intermediate and large venous channels of the choroid are developed and drain into the vortex veins to exit from the eye. Retina the outer layer of the optic cup remains as a single layer and becomes the pigment epithelium of the retina. The inner layer of the optic cup undergoes a complicated differentiation into the other nine layers of 62 the retina. By the seventh month, the outermost cell layer (consisting of the nuclei of the rods and cones) is present as well as the bipolar, amacrine, and ganglion cells and nerve fibers. The macular region is thicker than the rest of the retina until the eighth month, when the macular depression begins to develop. Anteriorly, the firm attachment of the secondary vitreous to the internal limiting membrane of the retina constitutes the early stages of formation of the vitreous base. The hyaloid system develops a set of vitreous vessels as well as vessels on the lens capsule surface (tunica vasculosa lentis). The hyaloid system is at its height at 2 months and then atrophies from posterior to anterior. This consists of vitreous fibrillar condensations extending from the future ciliary epithelium of the optic cup to the equator of the lens. Condensations then form the suspensory ligament of the lens, which is well developed by 4 months. Mesenchymal elements enter the surrounding tissue to form the vascular septa of the nerve. Myelination extends from the brain peripherally down the optic nerve and at birth has reached the lamina cribrosa. Blood Vessels Long ciliary arteries bud off from the hyaloid system at 6 weeks and anastomose around the optic cup margin with the major circle of the iris by 7 weeks. The hyaloid artery gives rise to the central retinal artery and its branches (4 months). Buds arise in the region of the optic disk and gradually extend to the peripheral retina, reaching the ora serrata at 8 months. This would make the eye markedly myopic rather than the usual mild hyperopia if it were not for the greater refractive power due to steeper corneal curvature and more spherical lens. Cornea the newborn infant has a relatively large cornea that reaches adult size by the age of 2 years. It is steeper than the adult cornea, and its curvature is greater at 64 the periphery than in the center. The lens grows throughout life as new fibers are added to the periphery from lens epithelial cells, making it flatter. At birth, it may be compared with soft plastic; in old age, the lens is of a glass-like consistency. This accounts for the greater resistance to change of shape for accommodation with age. Iris At birth, there is little or no pigment in the stroma of the anterior iris, but the epithelium, particularly the posterior layer, is heavily pigmented. Nevertheless, reflection of light by the stroma gives the eyes of most infants a bluish color. Iris color is subsequently determined by pigmentation and thickness of the stroma, the latter influencing visibility of the epithelial pigment. The external anatomy of the eye is visible to inspection with the unaided eye and with fairly simple instruments. With more complicated instruments, the interior of the eye is visible through the clear cornea. The eye is the only part of the body where blood vessels and central nervous system tissue (retina and optic nerve) can be viewed directly. Important systemic effects of infectious, autoimmune, neoplastic, and vascular diseases may be identified from ocular examination. The location, severity, and circumstances surrounding its onset are important, as is identifying any other ocular and nonocular symptoms that may require specific enquiry. The family history is pertinent for ocular disorders, such as strabismus, 66 amblyopia, glaucoma, or cataracts, and retinal problems, such as retinal detachment or macular degeneration. One should also determine what therapeutic measures have been tried and to what extent they have helped. Have similar instances occurred before, and are there any other associated symptomsfi Representative examples of some causes are given here and discussed more fully elsewhere in this book. One must therefore consider refractive (focusing) error, lid ptosis, clouding or interference from the ocular media (eg, corneal edema, cataract, or hemorrhage in the vitreous or aqueous space), and 67 malfunction of the retina (macula), optic nerve, or intracranial visual pathway. A distinction should be made between decreased central acuity and peripheral vision. The latter may be focal, such as a scotoma, or more expansive, as with hemianopia. Abnormalities of the intracranial visual pathway usually disturb the visual field more than central visual acuity. Transient loss of central or peripheral vision is frequently due to circulatory changes anywhere along the neurologic visual pathway from the retina to the occipital cortex, for example amaurosis fugax and migrainous scotoma. For example, uncorrected nearsighted refractive error may seem worse in dark environments. This is because pupillary dilation allows more misfocused rays to reach the retina, increasing the blur. In this case, pupillary constriction prevents more rays from entering and passing around the lens opacity. Blurred vision from corneal edema may improve as the day progresses owing to corneal dehydration from surface evaporation. Visual Aberrations Glare or halos may result from uncorrected refractive error, scratches on spectacle lenses, excessive pupillary dilation, and hazy ocular media, such as corneal edema or cataract. Visual distortion (apart from blurring) may be manifested as an irregular pattern of dimness, wavy or jagged lines, and image magnification or minification. Causes may include the aura of migraine, optical distortion from strong corrective lenses, or lesions involving the macula and optic nerve. Flashing or flickering lights may indicate retinal traction (if instantaneous) or migrainous scintillations that last for several seconds or minutes. It must be determined whether diplopia (double vision) is monocular or binocular (ie, disappears if one eye is covered). Causes include uncorrected refractive error, such as astigmatism, or focal media abnormalities, such as cataracts or corneal irregularities (eg, scars, keratoconus). Binocular diplopia (see Chapters 12 and 14) can be vertical, horizontal, diagonal, or torsional. The latter can be caused by subconjunctival hemorrhage or by vascular congestion of the conjunctiva, sclera, or episclera (connective tissue between the sclera and conjunctiva). Causes of such congestion may be either external surface inflammation, such as conjunctivitis and keratitis, or intraocular inflammation, such as iritis and acute glaucoma (see Inside Front Cover). Color abnormalities other than redness may include jaundice and hyperpigmented spots on the iris or outer ocular surface. Other changes in appearance of the globe that may be noticeable to the patient include focal lesions of the ocular surface, such as a pterygium, and asymmetry of pupil size (anisocoria). The lids and periocular tissues may be the source of visible signs, such as edema, redness, focal growths, and lesions, and abnormal position or contour, such as ptosis. Finally, the patient may notice bulging or displacement of the globe, such as with exophthalmos. Examples of periocular pain are tenderness of the lid, tear sac, sinuses, or temporal artery. Certain locations of inflammation, such as optic neuritis or orbital myositis, may produce pain on eye movement. Causes may include fatigue from ocular accommodation or binocular fusion or referred discomfort from nonocular muscle tension or fatigue. Ocular pain itself may seem to emanate from the surface or from deeper 69 within the globe. Corneal epithelial damage typically produces a superficial sharp pain or foreign body sensation exacerbated by blinking. Deeper internal aching pain occurs with acute glaucoma, iritis, endophthalmitis, and scleritis. This discomfort is markedly improved by instillation of cycloplegic/mydriatic agents (see Chapter 22). Eye Irritation Superficial ocular discomfort usually results from surface abnormalities. Symptoms of dryness, burning, grittiness, and mild foreign body sensation can occur with dry eyes or other types of mild corneal irritation. Severe amounts of discharge that cause the lids to be glued shut upon awakening usually indicate viral or bacterial conjunctivitis. More scant amounts of mucoid discharge can also be seen with allergic and noninfectious irritations.

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