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Outcomes (list all outcomes) endothelial cell count treatment integrity checklist buy meclizine amex, central corneal volume symptoms wisdom teeth buy meclizine 25 mg fast delivery, phaco time medications causing dry mouth buy discount meclizine 25mg on-line, effective phaco time medicine 1975 lyrics buy meclizine 25 mg visa, phaco energy Notes (Funding source; Conflicts Funding: the authors did not receive funding for this study. The patient was assigned the phacoemulsification group (phaco) or the phacoemulsifi cation group with femtosec ond laser (femto). Selective reporting (reporting bias) Unclear risk Study protocol was not avail able. Nagy the Effect of Femtosecond Laser Capsulotomy on the De English Title: velopment of Posterior Capsule Opacification the Effect of Femtosecond Laser Capsulotomy on the De Original Title: velopment of Posterior Capsule Opacification Journal/Book/Source: J Refract Surg. Exclusion criteria Patients with previous ocular surgery, trauma, active ocular disease (eg, pseudoexfoliation syndrome and uveitis), poorly dilated pupils or known zonular weakness were excluded. Nagy, Donnenfeld, and Knorz are consultants of of Interest; trial registration num LenSx Lasers, Inc. The remaining authors have no financial ber; any other note) or proprietary interest in the materials presented herein. Allocation concealment (selection Unclear risk the only information bias) about randomization methods is to state that the study is randomized. Nagy Intraocular Lens Tilt and Decentration Measured By Scheimpfl ug Camera Following Manual or Femtosecond English Title: Laser–created Continuous Circular Capsulotomy Original Title: See English Title Journal/Book/Source: Journal of Refractive Surgery Date of Publication: 2012 Volume: 28 Issue: 4 Pages: 259-263 Methods (study design and unit of Prospective randomized study with 1 year follow up analysis (within person – paired Version 1. In laser group 2, the capsulotomy and lens fragmenta tion were performed using the femtosecond laser (Lensar). The surgeon and (performance bias) the operating room staff were aware of group assignment. Blinding of outcome assessment (de Low risk the patients and examiners tection bias) performing preoperative and postoperative assessments were masked to group as signment until the study was completed. Mursch-Edlmayr, Matthias Bolz, Nikolaus Luft, Mi Authors: chael Ring, Thomas Kreutzer, Christoph Ortner, Matthias Rohleder, Siegfried G. Priglinger Intraindividual comparison between femtosecond laser– English Title: assisted and conventional cataract surgery Original Title: Journal/Book/Source: J Cataract Refract Surg Date of Publication: November 26, 2016 Volume: 43 Issue: Pages: 215-222 Version 1. Inclusion criteria Inclusion criteria were a minimum age of 18 years and “bi lateral” age-related cataract. Intervention femtosecond laser cataract surgery (Victus femtosecond platform) Version 1. No author has a financial or proprietary interest in any material or method mentioned. Allocation concealment (selection Unclear risk No information on allocation bias) concealment was reported. Blinding of participants and per High risk Open trial sonnel (performance bias) Blinding of outcome assessment Low risk “All examiners at the postop (detection bias) erative follow-up visits were blinded to the randomization of the patient. Selective reporting (reporting bias) Unclear risk the study protocol is not available. Knorz Comparison of Intraocular Lens Decentration Parameters English Title: After Femtosecond and Manual Capsulotomies Comparison of Intraocular Lens Decentration Parameters Original Title: After Femtosecond and Manual Capsulotomies Journal/Book/Source: J Refract Surgery Date of Publication: June 20, 2011 Volume: 27 Issue: 8 Pages: 564-569 Version 1. Participants Total Number of Participants ran 105 domized Total Number of eyes randomized 111 Country of participants Hungary Data collection period N. Inclusion criteria Patients with cataract in one or both eyes with or without myopia. Exclusion criteria “Patients with previous ocular surgery, trauma, active ocular disease, poorly dilated pupils, or known zonular weakness were excluded from the study. Outcomes (list all outcomes) Axial length, Refractive state, Area of capsulotomy, Circu larity of capsulotomy, Complete and incomplete overlap. The remaining ber; any other note) authors have no proprietary interest in the materials pre sented herein. Blinding of participants and per High risk Open trial sonnel (performance bias) Blinding of outcome assessment Unclear risk No blinding of outcome as (detection bias) sessment has been de scribed but it is not clear whether the outcomes are likely to be influenced by lack of blinding. Allocation concealment (selection Unclear risk Not described bias) Blinding of participants and per High risk Open trial. Surgery was complet ed in both groups using standard phacoemulsification procedures, including removal of the lens cortex and Version 1. Outcomes (list all outcomes) free-floating capsulotomy, tears, and bridging tags, un corrected and corrected distance visual acuity and ante rior and posterior segment examination, postoperative refractive error, posterior capsular tears Notes (Funding source; Conflicts of the authors have no financial or proprietary interest in Interest; trial registration number; any the materials presented herein. Allocation concealment (selection bias) Unclear risk Not described Blinding of participants and personnel High risk Open trial. To evaluate the quality of the rhexis in terms of circulari ty and sizing, photographs were digitalized and ana lyzed by a single operator, ignoring the surgical pro cedure. Auffarth Effectiveness and safety of femtosecond laser–assisted English Title: lens fragmentation and anterior capsulotomy versus the manual technique in cataract surgery Original Title: Journal/Book/Source: J Cataract Refract Surg Date of Publication: May 23, 2013 Volume: 39 Version 1. Inclusion criteria Eligible patients were at least 18 years old with clear cor neal media and elected to have routine cataract surgery. Exclusion criteria All patients: Poorly dilating pupil or other pupil defect that pre vents iris from adequate retraction peripherally Lens/zonule instability such as, but not restricted to, Marfan syndrome, pseudoexfoliation syndrome Previous intraocular or corneal surgery of any kind, including any type of surgery for refractive or thera peutic purposes I either eye Known sensitivity to planned concomitant medica tions Disorders of the ocula muscle, such as nystagmus or strabismus Keratoconus Wound-healing disorders, such as connective tissue disease, autoimmune illnesses, immunodeficiency illnesses, ocular herpes zoster or simplex, endocrine diseases, lupus, rheumatoid arthritis Abnormal examination results from slitlamp, fundus, partial coherence interferometry Autoimmune disease, collagenosis, or clinically sig nificant atopy Pregnancy or nursing Patients Having Laser-Assisted Procedure: Minimal or Maximal K values in central 3. Reddy has received travel and research grants from Interest; trial registration number; Technolas Perfect Vision GmbH, Dr. Kandulla is an em any other note) ployee of Technolas Perfect Vision GmbH (a Bausch & Lomb company), and Dr. Auffarth has received travel and research grants as well as lecture fees from Technolas Perfect Vision GmbH/Bausch & Lomb. Blinding of participants and per High risk Open trial sonnel (performance bias) Blinding of outcome assessment High risk No blinding of outcome as (detection bias) sessment was reported. Incomplete outcome data (attrition High risk the number of patients en bias) rolled was 131 while the anal ysis included only 119 select ed patients. Exclusion criteria Children below the age of 18 years Patients already enrolled in another study Clinical contraindications for femtosecond laser assisted cataract surgery, such as Significant corneal opacities Small pupils (<4 mm) following pharmacological dila tation Patients unable to lie sufficiently flat so as to be posi tioned underneath the laser machine. Date of Publication: January 22, 2015 Volume: 31 Issue: 3 Pages: 146-152 Version 1. Exclusion criteria the exclusion criteria included corneal scars, corneal dis eases, corneal astigmatism of 1. Investiga tors ensured that the enve lopes were opened sequential ly and only after the partici pant’s name and other details were written on the appropri ate envelope. Nagy Central Corneal Volume and Endothelial Cell Count Follow English Title: ing Femtosecond Laser–assisted Refractive Cataract Sur gery Compared to Conventional Phacoemulsification Original Title: Journal/Book/Source: J Refract Surg. The remaining authors have no financial interest in the any other note) materials presented herein. Y2110784), ber; any other note) Zhejiang Provincial Foundation of China for Distinguished Young Talents in Medicine and Health (Grant No. Patients’ characteristics seem to adequately reflect the target population for cataract surgery: in spite of some heterogeneity among trials, in most, patients were aged over 65 and were excluded in case of glaucoma, astigmatism > 1. However, in some of the studies, inclusion and exclusion criteria have been poorly described. To complete the surgical procedure conventional ultrasound phacoemulsification technique was used. Mursch Edlmayr 2017 (31)(in Austria), Panthier 2017 (50)(in France) and Reddy 2013 (42)(in India) used the Victus ™laser platform (Bausch&LombTechnolas); Yu 2015, Yu 2016 (in China) and Mastropasqua 2014b used the Lensar platform (25,28,44). Safety Intraoperative complications; Anterior capsular tear; Posterior capsular tear; Vitreous loss. Postoperative complications: Elevated Intraocular Pressure (1 day 1 week); Endothelial cells loss; Central corneal thickness; Iridocyclitis; Cystoid macular oedema (within 90 days); Infections (within 90 days; Corneal endothelial decompensation (within 90 days); Surgically induced astigmatism; Retinal detachment; Posterior capsule opacification; Visual acuity loss post-cataract surgery (1 month;6 months); Surgical re-intervention (within 6 months); Secondary cataract (24 months) Other outcomes Patient satisfaction; Procedural time; Resource use. It should be noted that both effectiveness and safety outcomes described in the selected studies are quite heterogeneous in terms of measurements. Surgery techniques assessed adequately reflect the general modus operandi in cataract surgery in spite of differences of limited relevance in terms of technology producers and surgery protocols. It should be noted that in most studies, procedures were performed by very experienced surgeons. The intended intended use in capsulotomy penetrating and depth and the lamellar endothelium keratopasty (applicable to includes the capsulotomy creation single only); Resid plane and multi ual, recurrent, plane arc and active ocular circular or eyelid cuts/incisions in disease, the cornea. Intended uses in cataract surgery include anterior capsulotomy, phacofragmentatio n, and the creation of single plane and multi-plane arc cuts/incisions in the cornea, each of which may be performed either individually or consecutively during the same procedure. Intended uses in cataract surgery include anterior capsulotomy, laser phacofragmentatio n, and the creation Version 1. No additional costs for regional health services nor for patients, but provision of femtosecond laser assisted cataract surgery restricted until funds run out.
Signs suggestive of under lying chest malignancy include evidence of clubbing symptoms zinc deficiency adults purchase meclizine with amex, 2 medicine 9 minutes purchase meclizine 25 mg free shipping. Laryngeal framework surgery—Laryngeal frame which is seen in patients with bronchogenic carcinoma; work surgery (in the form of thyroplasty) involves the Horner syndrome; and a pleural effusion treatment high blood pressure cheap meclizine online american express. The Silastic nerve paralysis classically produces an immobile vocal displaces the vocal fold medially 5 medications for hypertension order genuine meclizine on-line, ensuring adequate cord in the paramedian position. Most unilateral cord pal the nerve is at the skull base, the brainstem, or the cere sies compensate within 6–18 months. Because of the inevitable loss of superior laryngeal pation, and preference as to how aggressively the vocal nerve function, there is a decreased sensation of the lar cord paralysis should be treated should all influence the ynx above the vocal cords on the affected side and a loss treatment plan. This loss of vagal nerve function leads to the paralyzed cord lying more laterally B. Among the surgical treatments available, the two pri mary surgical measures are injection laryngoplasty and Etiology laryngeal framework surgery. Rest Phonation Most procedures are performed both to prevent aspira tion and improve voice quality. Immediate percutaneous medialization for A acute vocal fold immobility with aspiration. Unilateral true vocal cord paralysis: cause of right encephalitis), (3) a brainstem infarction (eg, Wallenberg sided lesions. Vocal fold paralysis after anterior cervical spine surgery: incidence, mechanism, and prevention of injury. A prospective evaluation of recurrent laryngeal nerve paralysis Disruption of the vagus nerve at the skull base or at the during thyroidectomy. Outcome and changing cause of unilateral vocal Lesions of the skull base or brainstem may involve other cord paralysis. Injection laryngoplasty is often unsuccessful in cases of complete vagal nerve paralysis because the relatively abducted position of the vocal cord leads to failure of General Considerations injected materials to adequately displace the cord medially. Medialization laryngoplasty, using silicone implants, the patient may have a recent history of thyroid sur is the optimal treatment method. No change on phonation General Considerations A Bilateral, high vagal, or brainstem involvement is unusual Figure 31–3. Bilateral recurrent laryngeal nerve paralysis and often secondary to a neurologic cause. Vagal paralysis is often accompanied by the involvement of other cranial nerves, typically the glosso malignant thyroid tumor may be an underlying cause. A patient who presents with a bilateral recurrent laryn geal nerve palsy usually does so in an emergency situa Clinical Findings tion, following the development of stridor. Because the vocal folds of a weak, breathy voice associated with a history of chok are adducted, minimal swelling may precipitate stridor. Patients are short of breath on exertion Treatment and may develop stridor in the presence of respiratory In an emergency situation, tracheostomy is often the only tract infection. It is important to discuss with the patient signs of other cranial nerve involvement, such as paralysis the possible options for long-term treatment if decannula of the tongue and loss of a gag reflex. Bilateral vagal nerve tion is to be considered, since any operation to improve paralysis produces immobile vocal cords located in an the airway may make the voice worse and increase the risk intermediate position with a widened glottic aperture of aspiration. There may be passive glottic closure on tracheostomy tube on a long-term basis and a fenestrated, forced inspiration; therefore, it is important to correlate cuffless tube is suitable in most cases. Treatment Other lateralization procedures exist; however, though Treatment is directed at preventing aspiration and ensuring improving the airway, they carry the risk of increasing adequate nutrition. A after thyroid surgery: minimally invasive management of bilateral recurrent nerve injury. It may be inspira course without any long-term sequelae, the most severe tory, expiratory, or both (biphasic). The term stertor is cases, in which significant desaturation occurs, can result used to describe airway noise originating in the nose, in significant morbidity, such as pulmonary hypertension nasopharynx, and oropharynx; therefore, stridor is gener and cor pulmonale. As a general rule, the incidence of synchronous airway lesions associ inspiratory stridor originates from the supraglottis and ated with laryngomalacia has been reported in 12–45% glottis, expiratory stridor from the trachea, and biphasic of cases, although less than 5% of these cases require stridor from the subglottis. This chapter describes the more common laryngeal abnor Clinical Findings malities that can cause stridor. Spon • Intermittent, positional inspiratory stridor (usu taneous improvement then occurs and symptoms usually ally mild). Stridor is not constantly present; rather, it is intermittent and variable in intensity. General Considerations Although an infant with laryngomalacia usually has a nor Laryngomalacia is the most common cause of stridor in mal cry, stridor may be exacerbated by crying owing to a infants and is also the most common congenital laryngeal more forceful inspiratory effort. If the infant is sleeping or crying, then stri as being omega shaped and folded in upon itself so that dor is more likely to be observed and its associated signs, the lateral margins lie close to each other (Figure 32–1). Mucosal laryngomalacia and should raise the suspicion of some edema resulting from repeated vibratory trauma to the other pathology. Endoscopy—The use of a flexible fiberoptic endo muscular abnormalities, and gastroesophageal reflux. Congenital Acquired Supralaryngeal Choanal atresia Adenotonsillar hypertrophy Craniofacial abnormalities Foreign body Retrognathia Retropharyngeal abscess Macroglossia Ludwig’s angina Laryngeal Laryngomalacia Iatrogenic (surgical and intubation traumas) Laryngeal cysts Laryngeal webs Laryngeal webs Subglottic stenosis Posterior laryngeal cleft Vocal cord paralysis Vocal cord paralysis Inflammatory Cricoarytenoid joint fixation Epiglottitis Subglottic hemangioma Laryngotracheobronchitis Hereditary angioedema Neoplasms Respiratory papillomatosis Rhabdomyosarcoma External compression Thyroid Cystic hygroma Foreign bodies Burns (caustic and thermal) External trauma Tracheal Tracheobronchomalacia Laryngotracheobronchitis Stenosis Bacterial tracheitis Vascular compression Foreign bodies Aberrant innominate artery External compression Double aortic arch Thyroid Pulmonary artery sling Cystic hygromas Tracheal cysts Mediastinal tumors procedure is safe and allows a dynamic assessment of Surgical intervention is indicated for approximately the glottis and supraglottis and avoids the risks associ 10% of patients. A variety of procedures have bronchoscopy is often considered an essential study before a definitive diagnosis can be made in order to rule out any synchronous airway pathology. Polysomnography—In severe cases, polysomnog raphy can be performed to detect episodes of hypoxia or hypercapnia. The results of this study can influence Epiglottis the decision to undertake surgical management of the condition. Treatment Vocal fold In most patients, laryngomalacia is a self-limiting con dition that does not result in any harm to the patient; Arytenoid therefore, observation is all that is required. In the most severe cases of laryngomalacia, which is encountered in a small percentage of patients, a temporary tracheotomy Figure 32–1. Laryngeal cysts can usually be managed by endo (referred to as supraglottoplasty), which are largely aimed scopic de-roofing or excision. There is disagreement as to whether microdissection or laser surgery is the optimum treat (1) Unilateral Vocal Cord Paralysis ment modality. Complications of supraglottoplasty include bleed (2) Bilateral Vocal Cord Paralysis ing, aspiration, and supraglottic scarring. Scarring is particularly problematic in the interarytenoid region; therefore, an island of mucosa must be left in this area. High rates of reflux have been demonstrated in General Considerations patients with laryngomalacia, and it has therefore been Vocal cord paralysis in infants and children can be either implicated as a causative factor. It ship remains unproven; hence the controversy in the is the second most common congenital abnormality of antireflux medication for laryngomalacia. Int J Pediatr There are many causes of acquired vocal cord palsy Otorhinolaryngol. Extraesophageal reflux in vocal cord palsy, or the paralysis may result from surgery to pediatric patients with upper respiratory symptoms. In this situation, the left side is 14623753] (Review of the evidence for reflux in pediatric air more commonly affected because of the longer course of way pathologies. Rarely, esophageal surgery, such as repair of a tracheoesoph ageal fistula, can result in a bilateral palsy. Inflammatory conditions such as two main types of laryngeal cysts are ductal and saccular encephalopathies and Guillain-Barre usually produce bilat cysts. Neoplastic causes of vocal cord originate from obstruction of the submucous glands. Familial X-linked can arise anywhere in the larynx, but are most commonly vocal cord paralysis has been reported, but is extremely rare. Saccular cysts arise in the laryn geal ventricle and are usually congenital in infants. Unlike Clinical Findings laryngoceles, which usually present in adults, saccular cysts A. The most common symptoms arising from laryngeal the symptoms arising from vocal cord palsy vary widely. Etiology of acquired If a cause is not apparent, then a magnetic resonance vocal cord paralysis. In patients in whom aspira Idiopathic Central nervous system tion is suspected, a contrast swallow or videofluoroscopy Arnold-Chiari malformation can provide information on deglutition and laryngeal pen Hydrocephalus etration. Syringomyelia or syringobulbia Peripheral nervous system Treatment Myasthenia gravis Myotonic dystrophy the function of the glottis is to protect the lungs from Charcot-Marie-Tooth disease the aspiration of food while providing an adequate air Trauma way. Management decisions are influenced by the Head injury underlying cause (if known), the severity of symptoms, Endotracheal intubation and the likelihood of spontaneous recovery.
If both lobes are extensively injured there is occipital cortex—contralateral temporal crescentic field defect; 8 medications prescribed for anxiety buy genuine meclizine, lesion of complete blindness; often treatment kidney cancer symptoms discount meclizine, however medications purchase meclizine 25 mg visa, some portion of the occipital lobe—homonymous hemianopia (usually sparing the macula) treatment centers of america buy meclizine overnight. The frst sign of improvement is the perception of the movement of objects in the affected feld without recognition of their nature and details. The onset of hemianopia due to intrinsic disease of the cortex is more gradual, and careful investigation with the perimeter shows that the colour felds are often lost before the feld for white light, although this is always contracted. In corti cal and subcortical lesions the pupillary reactions are nor mal (see Chapter 4, the Neurology of Vision), and the fundi reveal no ophthalmoscopic changes, except in the case of tumours which may be associated with bilateral papilloedema. Cortical lesions are liable to be accompanied by word blindness, usually due to involvement of the angu lar gyrus. When the lesion is in the posterior part of the internal capsule hemianaesthesia, with or without hemiple gia, is likely to be present. Optokinetic testing in occipital lobe hemianopias should elicit a normal response to each side. For example, the association of right Riddoch phenomenon, in which appreciation of a dim homonymous hemianopia with left third nerve paralysis kinetic target is retained within the defective visual feld and right hemiplegia suggests a lesion affecting the left with loss of appreciation of a static bright target, is typical optic tract. Partial atrophy of both optic Rare cases of homonymous quadrantanopia have been nerves manifests itself by pallor of the discs in these cases, reported, in which corresponding quadrants of each feld— preceded in cases of raised intracranial pressure by papill the upper or lower half of one temporal, and the upper oedema. The lesion is usually syphilitic meningitis or a or lower half of the other nasal—have been lost. These may gumma, tuberculosis or tumour of the optic thalamus or be caused by cortical or subcortical partial lesions of one temporosphenoidal lobe; softening and haemorrhage are occipital lobe, destruction of the part above the calcarine rare. It is important that the patient is often subjectively fssure leading to loss of the lower quadrants and vice versa unaware of his visual defect in lesions above the geniculate (see Fig. A similar quadrantic defect occurs in lesions body, but is conscious of a hemianopic defect from genicu of the temporal lobe owing to the fact that a ventral band late or infrageniculate causes. Primary lesions of the optic of the optic radiations passes frst forwards and then back tract are very rare and the tract is usually disturbed by com wards in the temporal lobe in its course from the lateral pression. Chordomas, pituitary adenomas, tentorial menin geniculate body to the occipital lobe (Fig. Partial giomas, temporal lobe gliomas or aneurysms of the upper hemianopia of a quadrantic type is then commoner than basilar distribution or on the superior cerebellar arteries or the typical homonymous defect, usually greater on the posterior cerebral arteries are the common causes. Subjective sensations of smell occur in hemianopias are incongruous with a variation in density. Lesions of the Optic Chiasma Bitemporal hemianopia is usually caused by tumours in Lesions of the Optic Tract the region of the sella turcica, pressure by a suprasellar In these cases, since the afferent pupillary fbres part com aneurysm or by chronic arachnoiditis; these press upon pany with the visual fbres before the latter enter the lateral the chiasma, so that the fbres going to the nasal halves geniculate body, Wernicke hemianopic pupil reaction of each retina are destroyed (Fig. Tumours of should be present, but the reaction is always diffcult to the pituitary body are most common; but suprasellar elicit. More assistance in diagnosis is afforded by collateral tumours, particularly craniopharyngiomata derived from symptoms. Chapter | 31 Diseases of the Nervous System with Ocular Manifestations 509 must be considered. Other lesions are gliomas of the third chiasma so that the crossed fbres from the opposite side are ventricle, ectopic pinealomas, dermoid tumours and third involved as they loop forward into the nerve (Fig. X-rays may provide valuable information, the chiasma which lies immediately above it and upon the showing, for example, erosion of the sella, enlargement inner sides of the optic tracts. The earliest visual symptoms of the pituitary fossa or vascular calcifcation; simple may be a unilateral central scotoma simulating retrobulbar radiography should be supplemented by computerized neuritis, for one side is usually compressed before the other. If, as frequently occurs, vision progressively There may be contralateral superior quadrantanopia due deteriorates, transfrontal or nasopharyngeal extirpation to involvement of von Willebrand knee which consists of may be advisable in many cases, particularly of pituitary fbres from the inferonasal retina of the other side which tumours; the prognosis of operative removal, if undertaken loop forward slightly into the opposite optic nerve after in time, is reasonably good. Neurological disorders can affect the control of eye move More commonly, bitemporal hemiachromatopsia, passing ments by involving the higher cortical centres (supranuclear into a bitemporal hemianopia, supervenes. The feld does lesions), the cranial nerve nuclei or the nerve fasciculi not show the accurate delimitation characteristic of hom within the brainstem (brainstem syndromes), the nerve onymous hemianopia, but gradually contracts from the trunks, the neuromuscular junctions (myasthenia gravis, temporal side inwards and from above downwards, fnally Eaton–Lambert paraneoplastic syndrome) or the muscles involving the nasal feld from below upwards and leading themselves (myopathies). Many in children; trauma, demyelinating disease or tumours in patients may have a homonymous hemianopia, due to young adults and vascular lesions such as haemorrhage or pressure and traction on one optic tract. Lesions of the nerve type and progress of the visual defects are thus not uncom trunks could be anywhere along the intracranial course or mon. This often occurs because of variation in the site locally in the orbit and could be due to compression, isch of pressure and also anatomical variations in the position aemia or infammation. It necessitates two directions of gaze but equally often variable for different lesions, one on each side of the chiasma, destroying the directions of gaze. It may simulate palsies of individual fbres to the temporal halves of each retina while leaving vertically acting muscles and be differentiated from these the nasal fbres intact. It may be due to distension of the only through the absence of mid-brain or peripheral nerve third ventricle, causing the optic nerves to be pressed down disease. It is characteristically present with some loss in the temporal feld in one eye and depression unilateral internuclear ophthalmoplegia. It is found with cerebellar tumours, acoustic sensory-motor apparatus controlling normal binocular neuromas, compressive lesions, platybasia and vascular position. Nystagmus can be classifed into various types accidents of the pons and cerebellum (especially thrombosis (Table 31. It is infrequent with Congenital jerky nystagmus is not associated with any demyelinating lesions. The causative lesion probably lies in the complex nervous mechanisms in the brainstem, which are concerned in the centring and Nystagmus ‘steady fxation’ of the eyes. Nystagmus may be regarded as Nystagmus (to nod) is the term applied to rapid oscilla an exaggeration of the fne persistent movements of the tory movements of the eyes, independent of normal eye eyes (microsaccades, slow-motion random drifts, and rapid movements. The oscillations are involuntary, although impulsive saccades which correct the random drifts) which in rare cases normal persons can imitate them. They are are essential in the maintenance of a clear foveal projection usually lateral, but vertical, rotatory and mixed (rotatory of the retinal image. Nystagmus in adults occurs in diseases of the midbrain, the condition is almost always bilateral, although the cerebellum and vestibular tracts, and of the semicircular movements may be much more marked in one eye than canals. Toxic or metabolic (alcohol, lithium, barbiturates, phenytoin, l Albinism salicylates, benzodiazepines, phencyclidine, other l Aniridia anticonvulsants or sedatives, Wernicke encephalopathy, l Leber congenital amaurosis thiamine defciency) l Bilateral optic nerve hypoplasia c. Neurological disorders (tumour, trauma, multiple sclerosis, l Bilateral congenital cataracts not operated stroke, thalamic haemorrhage) within 6 months of age d. Pendular Chapter | 31 Diseases of the Nervous System with Ocular Manifestations 511 in extreme lateral position of the eyes. The rapid component is in the lesions cause coarse nystagmus towards the side of the direction of gaze. The fundamental cause is probably quite lesion and fne nystagmus to the opposite side. Nystagmus different from that of true nystagmus, although both may may also occur in adults as an ‘occupation neurosis,’ the occur together. Nystagmus may be congenital or early infantile, or Types and Clinical Features it may be acquired. These two groups of cases should In congenital and early infantile nystagmus the patient be carefully distinguished on account of their different is wholly unaware of the movements, since objects do not pathological foundations. To-and-fro movement is noticed by par nystagmus dating from birth or within a few weeks of ents or relatives. Vision is usually defective in spite of birth occurs in congenitally malformed eyes, in albinism, correction of errors of refraction which generally accom and in eyes with congenital or early acquired opacities pany the defect. Visual symptoms of oscillopsia are usually of the media (such as leucoma or cataract) or macular absent when the onset is less than 8 years of age. The cause in these cases is inability to develop cases of acquired nystagmus in adults, objects appear normal fxation. Oscillopsia is the perception of the frst few weeks of life, the eyes being moved aimlessly the environment appearing to oscillate horizontally, verti and independently before it is acquired. Others may complain of blurred or tive at this period seriously diminishing the acuity of unstable vision. Nystagmus is present cases the movements are very fne and not easily detect in most cases of total colour blindness in which vision is able. In such cases it may be necessary to examine the eye carried out by the rods alone, and there is therefore a cen very carefully with an ophthalmoscope because the pres tral scotoma. In some congenital cases it is impossible ence of nystagmus can be demonstrated in the magnifed to discover any cause. This form occurs in the frst mus can be slow, fast; fne, coarse; horizontal, vertical, year of life as spasmus nutans, in which it is associated rotatory, mixed; jerky (slow drift in one direction as slow with nodding movements of the head.
Syndromes
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The collagen is pro Clinical trials are in progress for many prod cessed in a laboratory and kept frozen until ucts medications 2355 buy generic meclizine canada. Product availability varies widely medicine woman buy cheap meclizine on line, and a ready for injection medicine used during the civil war meclizine 25mg with mastercard, which occurs within 48 h of variety of products are being used off-label treatment works order cheap meclizine on-line. Because the collagen is autolo Dermatologists and cosmetic surgeons should gous, no allergy test is required [4, 8]. The cadaver’s dermis, muscle fascia, or tissue-derived colla gen is harvested and brought to a special labor 6. Fat transfer remains a popular treatment op tion because there is no cost for materials and no risk of rejection. The donor Injectable collagen has been used since the ear site is infused with tumescent local anesthesia ly 1980s to improve facial rhytids. Collagen is a for collection of the adipose tissue, which is as naturally occurring fibrous protein found in pirated or manually excised and placed in stor humans and animals. At a later date, a saline suspension of this rhytids will replenish collagen matrix and re tissue is injected into the cutaneous layer for store the face to a more youthful appearance. In rare cases, however, problems Hyaluronic acid is a natural cosmetic dermal arise. In addition, the patient’s body absorbs filler that restores volume to moderate to severe these natural fillers over time [8] (Table 6. Hyaluronic acid is found in all tissues of human and animal species and is biodegradable and biocompat 6. Hyaluronic acid is currently obtained from biofermentation or from the combs of roosters. The use of autologous fat in soft tissue augmen Depending on the source, allergy testing may tation dates back to 1893 when Neuber reported be required. Current studies show that hyalu the harvesting of blocks of free fat from the ronic acid products last twice as long as colla arms to reconstruct depressed facial defects. The technique was further advanced in the ear ly 1900s by Lexer, who treated a malar depres sion and receding chin using single large block 6. It has been approved in Europe since investigation of other techniques for soft tissue 1999 for soft tissue augmentation and is cur augmentation [8]. These include abdominoplasty, face into the patient where they work as a biocata lift, breast reduction, breast lift, etc. The effect reportedly is indefinite, al is sterile-packed and frozen until it is processed though the collagen is susceptible to natural ag for use. Autologous fillers Filler Indications Treatment Complications and potential adverse reactions Fat transfer Fat transfer: Injected into the Prolonged edema,bruising, subcutaneous fat layer and/or under-/ overcorrection,migra muscle. Tiny puncture wounds scarring,and dyspigmentation are made at the superior cen [5] tral forehead at the hairline, zygomatic arches,oral com missures, and lateral chin. The effect is perma nent or long lasting [5] Autologen Stimulates cutaneous Soft tissue defects should be No risk for disease transmis cultured collagen formation overcorrected by at least sion or allergic reaction be human 20–30%. Injections are more cause material is autologous fibroblasts painful,and nerve blocks or [10] local or topical anesthesia may be needed. Effect lasts 3–6 months [10] the process of clinical trials in the United States 6. Pre served proteoglycans and proteins direct the patient’s own cells to initiate revascularization 6. An acellular allogeneic dermis (example: Allo Derm) is composed of cadaveric dermis and an 6. Another preparation contains lyophilized hu man particulate fascia lata (example: Fascian) Soft Tissue Augmentation Chapter 6 99 Table 6. The allograft instrument is passed from of this is minimized by the scaffold is also used for one incision to the other to physicianfully understand burn injuries and cancer make a tunnel. The implant is ing the patient’s expectations excisions and to correct passed from one end of the [14] soft tissue defects [8] incision toward the other end [14]. Double allergy testing is recommended [15], and patients shown to be allergic to bovine collagen might find this preparation to be a feasible alternative. Its longevity is normally 3–6 months Injectable,micro Augmentation reportedly particulate acel lasts longer than does bovine lular allogenic collagen [16]. The larger particle sizes appear to be associated with side effects that are more persistent [4]. With age, the body’s collagen weakens and loses its elas ticity, leading to, among other effects, the vari 100 Cheryl M. Bovine collagen is very similar to the human molecule, with specific differences only Bovine Dermal Collagen Dispersed in the end peptides (telopeptides). These re in Phosphate-Buffered Physiological gions can be removed in processing, leaving a Saline Containing 0. These substances (example: Zyderm) are com posed of highly purified bovine dermal colla Table 6. Infil Bovine collagen Bovine dermal rection of facial rhytids, trated into the superficial may induce an al collagen dispersed in scars,and lip augmenta papillary dermis. The low second skin test on the con physiological saline concentration filler is used tralateral arm [15]. Requires second [10] and suspended used as a foundation in the skin test on the contralateral in saline and nasolabial folds or oral arm. Overcorrection cross-linked bovine colla is mandatory because water gen injected as an overlay. Longevity is rarely,palpable generally 3–6 months lumps [9] Soft Tissue Augmentation Chapter 6 101 Table 6. Continued Implants Indications Treatment Complications and potential adverse reactions Restylane Perlane: 20 mg/ml stabilized Perlane: Injected into the deep Temporary skin Hyaluronic acid hyaluronic acid with ap layer of the dermis and/or reactions [23],in derived from bacterial proximately 10,000 gel par surface layer of the subcutis cluding redness, biofermentation ticles/ml is recommended swelling,localized process for nasolabial folds and lips granulomatous (fullness and pouting) reactions,bacterial infection,acneiform, Restylane: 20 mg/ml stabi Restylane: Injected into the and cystic lesions. Various injec tion techniques apply, depend ing on the type of correction and product used. These tech niques include linear threading, serial puncture, fanning,and cross-hatching [23] Juvederm [18,24,30] 18 mg/g,designed for the the first is designed for injec Temporary skin re Viscoelastic, superficial dermis,specifi tion in the superficial dermis, actions [23] includ nonanimal hyaluronic cally for fine lines and the second is designed for in ing redness,swelling, acid gel rhytids jection in the mid dermis,and localized granuloma the third is designed for injec tous reactions,bacte 24 mg/g,designed for the tion in the mid to deep dermis. Eventually form,and cystic le deeper rhytids absorbs into the body; typical sions. Takes and more marked furrows effect in 4–6 weeks,lasts 12–18 or creases,as well as for the weeks [17] augmentation of the tissue volume in certain areas of the face (cheek bones,cheek depressions,chin,etc. Concentrations include 35 mg/ml and 65 mg/ml of purified bovine dermal colla Human-Based Collagen Isolated gen. The source material is isolated from human fibroblast cells grown under controlled Another injectable bovine collagen (example: laboratory conditions. Two forms of this hu Zyplast) is cross-linked with glutaraldehyde man-based collagen are available and differ by and suspended in saline and 3 mg/ml lidocaine. The implant will re Human-Based Collagen Cross-Linked tain its integrity and its inherent water content with Glutaraldehyde to a greater degree than is the case for non cross-linked bovine collagen [18]. Another highly purified human-based collagen (example: CosmoPlast) is cross-linked with Soft Tissue Augmentation Chapter 6 103 glutaraldehyde and dispersed in phosphate of molecules, the more biocompatible the hyal buffered physiological saline containing 0. In a randomized, double-blind, multicenter comparison of the efficacy and tolerability of nonanimal hyaluronic acid versus bovine colla 6. Moreover, both patients was first used commercially in 1942 when En and investigators judged hyaluronic acid more dre Balazs applied for a patent to use it as a sub effective in maintaining cosmetic correction stitute for egg white in bakery products [20]. As humans age, cells lose their ability to Viscoelastic, Nonanimal Hyaluronic produce hyaluronic acid, and the skin becomes Acid Gel Derived from Bacterial drier, thinner, and looser, leading eventually to Biofermentation wrinkling, among other changes. Two main sources of hyaluronic acid have Another family of products containing a visco been developed to create a filling agent able to elastic nonanimal hyaluronic acid gel (example: correct moderate rhytids and folds and aug Juvederm) is available in three different con ment lips: (1) nonanimal hyaluronic acid de centrations (18 mg/ml, 24 mg/ml, and 30 mg/ rived from bacteria in a biofermentation pro ml) to address different correction needs. Hyal cess, and (2) hyaluronic acid from the combs of uronic acid gel is eventually absorbed into the roosters. Although the effect of hyalu ronic acid is temporary, it is very long lasting Viscoelastic Hyaluronic Acid Gel [8]. Hyaluronic acid is cross-linked with ester from Rooster Combs and ether linkages to stabilize the molecule for dermal purposes. The amount of cross-linking Another hyaluronic viscoelastic gel contains of the molecule affects biocompatibility of hyaluronic acid derived from the combs of hyaluronic acid: Less cross-linking of the mole roosters (example: Hylaform). It has 20% cross-linking as a re Hyaluronic Acid Derived sult of using glutaraldehyde and vinyl sulfone from Bacterial Biofermentation Process for hyaluronic acid stabilization. According to the manufacturer, the product’s high molecular weight makes it more viscous and longer last Several preparations of nonanimal hyaluronic ing than the hyaluronic acid produced from acid (example: Restylane) are derived from bacteria.
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