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At times, there may also be perverse incentives that compromise quality and patient safety to achieve high outputs. Increasing access to services requires renewed efforts to integrate eye care, not only into the planning of the health sector in general, and into specific health programmes in particular. For example, while there are an increasing number of examples of large scale and effective eye screening exist in the context of school health programmes (71), availability is still lacking in many low- and middle-income countries. In light of the increasing number of children and adolescents with refractive error, high-quality and cost-effective school-based eye-care linked to service provision is of the utmost importance. This requires cooperation between the ministries of health and education, coupled with a national eye-care plan that includes school eye health (71, 72). Although there are some successful examples of eye-care interventions being delivered through other health services (73), to date, progress has been slow in the eye care sector which may reflect a disconnection with the rest of the health system. In general, those not able to access eye care services as required include people living in rural areas, those with low incomes, women, older people, people with disabilities, ethnic minorities, and refugees. Consequently, they have far higher rates of vision impairment and blindness (5, 74, 75). Despite this, the consideration of equity in eye care plans is currently weak (76). It is important to note that providing equal rates of eye care services between population subgroups does not guarantee the delivery of equitable services. Most eye care delivery focuses on the provision of curative interventions at the secondary and tertiary levels of the health system and is often restricted to urban and larger regional settings. This adds to inequity in access to effective interventions for early detection and prevention, and greater costs for patients. To assist in addressing this inequity between population subgroups, there is a need for implementation and health systems research to ensure evidence-based planning of future eye care programmes and services. There is also evidence demonstrating that eliminating user fees, or reducing out-of-pocket payments at the point of delivery, impacts positively on equitable access to services (77, 78). However, eye care medicines and interventions continue to not be integrated into the health insurance schemes in many low- and middle-income countries. For example, fees for cataract surgery and the costs of spectacles and treatment for noncommunicable eye conditions. Even high-income countries can require out-of-pocket payments for refractive error assessment and correction, or for the purchase of devices, or specialized insurance for vision care. Furthermore, eye care service delivery is frequently led by charity and nongovernmental organizations that act independently from the MoH. India, Viet Nam, Rwanda, Philippines, India) have already included cataract surgery and treatment of other eye conditions in their social health insurance 84 Most eye care delivery focuses on the provision of curative interventions at the secondary and tertiary levels of the health system and is often restricted to urban and larger regional settings. However, given substantial increases in cataract surgical rates, and the associated costs to the health insurance providers, some countries have introduced limits on the total number of surgical procedures claimable per accredited surgeon (Box 4. This can be detrimental to improving cataract surgical coverage and emphasizes the importance of a thorough planning process that takes into consideration population needs, projections and workforce availability to estimate the cost and cost coverage. Subsequently, a population-based survey conducted in 1986-89 reported a modest increase in prevalence of blindness to 1. On this basis, the Government of India embarked on the World Bank assisted cataract blindness elimination programme targeting seven states (Andhra Pradesh, Madhya Pradesh, Maharashtra, Odisha, Rajasthan, Tamil Nadu and Uttar Pradesh) where there was a known high prevalence of cataract blindness. This project was highly successful in improving cataract surgery rates (from 1342 per million in 1995 to 3620 per million in 2002) and rates of intraocular lens implantation (increasing from 3% in 1993 to 75% in 2002). Under this programme, cataract surgery with intraocular implantation is provided free of charge for approximately one third of all cataract surgeries, including all surgeries performed on patients with a poverty certificate. During this period, school screening was provided to nearly 32 million children and approximately 750 000 spectacles were distributed. As a result of these concerted efforts, an overall reduction in prevalence of blindness was reported from 1. Cataract surgery is covered in the benefit package and has long been one of the highest claimed procedures. Providers are paid a fixed case payment per eye that is the same regardless of the method of cataract extraction (i. For senior citizens, the poor and other PhilHealth members whose premiums are sponsored by the government, there is no out of pocket cost to the patient for cataract surgery conducted within government facilities. However, for all other people treated in government facilities, and all of those treated in private facilities, providers can charge above the fixed case payment, with the balance paid by the patient. Significant internal controls are in place for cataract surgery under PhilHealth including pre-authorization requirements, such as verifiable patient information and surgery approval by ophthalmology unit heads. In 2015, the control systems identified unusually high numbers of cataract surgeries being sought for reimbursement. This was driven by some providers seeking to profit from the scheme by providing cataract surgeries that may not have been necessary or that were fraudulent. In response, PhilHealth restricted the number of cataract surgical procedures claimable per accredited surgeon to 50 per month (not exceeding 10 in any one day), with the exception being when surgery was undertaken as part of a recognized residency training programme. The impact of these measures on the provision of equitable access to cataract surgery needs to be investigated. A risk of strong involvement from the private sector and/or nongovernmental organizations is that it may contribute to governments not taking responsibility for the provision of eye care services as part of national insurance schemes, with negative consequences for disadvantaged groups that cannot afford the costs of private service provision. In some circumstances the challenge may be the lack of regulation of private sector services. Although the private sector makes up a significant proportion of the provider landscape in the field of eye care, the exact share is rarely understood. Uncoordinated and unregulated workforce Several factors accentuate the problems associated with the shortage of health workers in low- and middle-income countries; these include suboptimal distribution (both geographically and across income levels), issues with retention, and poor supervision and coordination of eye care services among health workers which can often result in parallel services, overlap, inefficiencies, and gaps, and poor outcomes (84). While innovative strategies have emerged which use community-based workers and other cadres, such as optometrists, to deliver eye care and vision services, their impact has been hindered by a lack of coordination, regulation and a systematic integration, resulting in persistent service gaps and inequalities and a lack of standardization of care in many low- and middle-income countries. To be successful, such strategies must occur within the context of needs-based workforce evaluation and planning, that aligns the competencies, composition and deployment and retention of the workforce with population needs and distribution. Despite significant progress being made in the promotion of training standards for optometrists, optometric technicians and optical technicians (85), the acceptance of optometry as a profession remains an issue in many countries and is an important advocacy issue going forward in many countries (86). In this context it is important to note that, in some countries, productivity may be diminished because a section of the health workforce, such as optometrists, are not accredited to carry out eye care services independently (87). Such information is needed by (i) policy-makers to identify and respond to problems with evidence-based solutions, and to allocate resources effectively; (ii) planners to design more effective services, and managers to monitor and evaluate these services; and (iii) clinicians to provide high quality and evidence-based care (88). Consequently, decision-makers at all levels of the health system may lack the information they need to identify problems and needs, to allocate resources optimally or to provide evidence-based services. This can result in a significant gap between what policy-makers, health workers and researchers know and what they need to know to improve the health of the population (89). Furthermore, the situation in eye care is further challenged through the existence of a strong private eye care sector with parallel information systems that do not communicate with public sector information systems. In addition, recent advocacy efforts have also focused on expanding eye care indicators within primary care (90). First, effective interventions are available to reduce the risk of acquiring an eye condition or vision impairment and of mitigating the impact. Secondly, as demonstrated through Vision 2020, eye care can rely on a long tradition of effective and coordinated advocacy that progresses towards common goals. Thirdly, a number of scientific and technological advances have been made with the potential to facilitate early diagnoses and accelerate the response. Eye care services also contribute to other targets, such as those on neglected tropical disease (target 3. Global causes of blindness and distance vision impairment 1990-2020: a systematic review and meta-analysis. Accuracy of diabetic retinopathy screening by trained non-physician graders using non-mydriatic fundus camera. Use of a tablet attachment in teleophthalmology for real-time video transmission from rural vision centers in a three-tier eye care network in India: eyeSmart cyclops. Development and validation of a smartphone-based visual acuity test (peek acuity) for clinical practice and community-based fieldwork.

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All animals appeared normal throughout the study, and there were no gross lesions at necropsy on the seventh day. Three deaths resulted from administration of the higher dose and none from the lower dose. Doses greater than 165 mg/kg temporarily induced exhaustion, ataxia, and respiratory distress. The acute lethal subcutaneous dose was greater than 333 mg/kg, since no animals died from this dose. Injection sites in the majority of animals developed small, ill-defined soft cysts and small ulcerations that later healed. The only effect was a sharp but brief fall in blood pressure and a corresponding rise in the jugular venous pressure. Injections were administered to groups of four albino male rabbits; 3 days later, the animals were killed and the spinal cords dissected and examined grossly as well as microscopically. Although mechanical trauma caused by the injection procedure resulted in morphologic changes in the spinal cords, no abnormalities could be attributed to Methylparaben. The authors concluded that this material produces no neurotoxic effects, even when administered at 10 times the concentration commonly used in parenteral preparations. During the test, no significant differences in general appearance, behavior, food consumption, mortality, or survival times were observed between experimental and control groups. Values for erythrocyte numbers, hemoglobin, hematocrit and white blood cell counts were normal in all animals throughout the study. No macroscopic or microscopic abnormalities were observed(195) Ethylparaben was administered by gastric intubation to three groups of four female rats at doses of 2, 20, and 200 mg/kg for 6 consecutive days. In this study, no animals died, body weight increased, and no abnormalities were observed upon necropsy. The test material was prepared as a 2 percent and 10 percent dispersion in corn oil and administered daily in dose volumes of 2 ml/kg. The one high-dose male rat that died had pneumonia, presumably caused by test material accidentally placed in the trachea. Slight changes in hematologic and blood chemistry values and organ weights were not biologically significant. Body weight gain, food consumption, and hematologic values were similar for treated and control animals. Slight changes in blood chemistry and organ weights were considered toxicologically insignificant. A treatment group of five male and five female albino rabbits received daily topical doses of 5. The presence of glucose and blood in the urine of some untreated and treated rabbits was considered clinically unimportant. Histopathologic examination of tissues of all animals was negative for treatment-related changes other than mild inflammation at the application site (222) A 3-month dermal toxicity study similar to that described above was conducted on another product formulation containing 0. The formulation was administered to groups of five male and five female rabbits at doses of 6. The product caused persistent well-defined to moderate erythema, slight edema, and intermittent slight desquamation. Two untreated control animals died during the study; all treated animals survived. Body weight gain, food consumption, hematologic, blood chemistries and urinalysis values, and organ weights were negative for toxicologically significant changes. No treatment-related changes other than mild inflammation at the application site were found. Each group contained six or eight animals, with an equal distribution of males and females. The formulation was administered at doses of 2 mg/cm2/10 percent body surface area and 6 mg/cmYlO percent body surface area. The product caused persistent moderate erythema, slight edema, and mild desquamation. Ultraviolet light exposure had no apparent effect on the severity of the irritation. Body weight gain, food consumption and hematologic, blood chemistries, and urinalysis values were negative for toxicologically significant findings. Mild to severe dermal inflammation and hyperkeratosis with acanthosis were found at microscopic examination of the skin. All applications were made to the anterior dorsal shaved skin, which represented 10 to 15 percent of the total body surface area. Significant depression in body weight gain was noted for males of both test groups. Slight changes in hematologic and blood chemistry parameters and organ weights were considered toxicologically insignificant. Significant gross and histopathologic changes were limited to the treated skin site. The investigators concluded that there were no cumulative systemic toxic effects from these products. At 2 and 4 months, 10 rats each were killed for necropsy and collection of tissues for histopathologic examination. At the highest dose tested, a significant decrease in body weight gain was observd from months 4 to 8. Ethylparaben and Butylparaben were fed to the same numbers of rats at concentrations of 2 or 8 percent in the diet for 12 weeks. Rats, especially the males, fed the 8 percent Methylparaben or Propylparaben diets had decreased weight gain in the early part of the study. At 8 percent dietary concentration, Ethylparaben reduced growth rate, decreased motor activity, and, in some cases, caused death within the first week. Rats killed at the conclusion of the feeding test had no treatment related abnormalities. At this time, some animals were killed; others were observed for an additional 6 months and then killed for necropsy. Toxicity was determined by survival time, weight changes, and drug-related organ changes. When compared to controls, Paraben-treated rats had no significant differences in mortality, weight gain or lesions. Animals were then killed and their kidneys removed for analysis of Paraben metabolites. There was no relation between the concentration of Methylparaben and degree of irritation. At the highest concentration tested, Methylparaben induced slight, transient conjunctival hyperemia. The ingredient produced slight transient irritation with an eye irritation score of l/l 10 on Day 1. The undiluted ingredient was slightly irritating, with a maximum eye irritation score of 21110 on Day 1. Twenty-four hours after each application and the skin sites were examined and scored for prior to the next application, erythema and edema according to the Draize scale. The test material initially produced slight irritation, which increased to mild to moderate by the end of the first week and remained moderate throughout the remainder of the study. Two weeks following the last induction injection, a challenge injection was administered into an adjacent site and observed for 48 hours. Two weeks after the final induction injection, a challenge injection was administered into an adjacent site and observed 24 hours later. Two weeks after the last induction application, a challenge was administered; reactions to challenge and induction phases were compared. Results indicated that the frequency as well as the intensity of positive skin reactions decreased slightly with repeated exposures, suggesting a desensitizing effect. Twelve days after the last induction patch was removed, the test material was applied as a challenge patch for 48 hours to a previously untested site. One, 7, 24, and 48 hours after removal of the patch, the sites were scored and the skin examined microscopically for evidence of sensitization. Six of the 20 animals reacted to the challenge patch containing 5 percent Butylparaben in olive oil.

Diseases

  • Nijmegen breakage syndrome
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  • Combarros Calleja Leno syndrome
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Torticollis: A stiff neck caused by spasms of the neck muscles drawing the head to one side with the chin pointed to the other side. Trophic: Concerning nourishment; applied to a type of nerve believed to control the growth and nourishment of the parts they innervate (supply). Ventricle: A cavity such as those normally present in the brain that are filled with cerebrospinal fluid. Ventriculo-peritoneal Shunt: A shunt or tube inserted into the ventricles of the brain attached to tubing that is placed into the abdominal (peritoneal) cavity to drain excess spinal fluid from the brain. Ventriculostomy: Establishment of an opening performed in the third ventricle to relieve hydrocephalus. Vermis: the normal midline portion of the cerebellum lying between the two cerebellar hemispheres. Visceral: Pertaining to one of the organs found in the skull, chest, abdomen or pelvis (brain, lung, liver, etc. Weakness of the hands may result in difficulty grasping objects; weakness of the legs may result in difficulty walking; weakness of certain muscles in the pharynx may cause difficulty swallowing. Chiari & Syringomyelia Patient Education Foundation the Foundation works to improve the lives of Chiari and syringomyelia patients through education, awareness, and research. Their Conquer Chiari website is a comprehensive source of information about Chiari Malformation, syringomyelia, and related topics. Christopher and Dana Reeve Foundation the Foundation is dedicated to curing spinal cord injury by funding research, and improving quality of life for people living with paralysis through grants, information and advocacy. The latter is important as there is often residual refractive error after cataract surgery, whether from astigmatism or inaccurate biometry. Patients and their carers need reassurance and advice and must know what to do when they return home. Patients must know how to look after their operated eye and be empowered to take immediate action if they notice any symptoms or signs that might indicate a complication. In this edition, we cover many aspects of postoperative care, tailored for different settings. Patients may be treated as day cases or may be in-patients who live far from the hospital. The timing of postoperative refraction will vary, but the important point is that it is done. Patients also have different home circumstances, and the postoperative advice given to them must be adjusted accordingly. For postoperative care to be consistently successful, systems need to be in place to support the eye team in this important work. This can include having a checklist to ensure that every patient has been given the care and information they need before leaving the hospital, having written information ready to hand out to patients, and undertaking regular monitoring. A beautifully completed cataract operation should only be counted a success when the patient is back home, enjoying seeing again, with appropriate correction of any refractive error. To use a sporting analogy, the end of the operation signals half-time, but the game can still be lost if attention is not paid to the postoperative period and refraction (the second half). Illustrators and photographers retain copyright for images published in the journal. Although every effort is made to ensure accuracy, the School does not warrant that the information contained in this publication is complete and correct and shall not be liable for any damages incurred as a result of its use. The School does not endorse or recommend products or services for which you may view advertisements in this Journal. This issue offers practical advice and emphasises the importance of involving patients and family members in postoperative care. Good postoperative care starts even before surgery and involves patients and the community by means of counselling to allay fears and manage expectations (see the article on page 23). If this is done well, and the outcomes are good, others in the community will have confidence in the eye team and be more likely to present themselves for surgery when their time comes. Lily A Nyamai Tutorial Fellow: Department of Ophthalmology, University of Nairobi, Nairobi, Kenya. Unfortunately, for some patients, the result does not live up to their expectations. Good outcomes in cataract surgery, in those brave enough to undergo the procedure, are therefore essential to encourage other people with poor vision from the community to come forward for examination and treatment. They must have confidence in the eye service and in the people providing it, so that they will be willing to attend follow-up visits and to come back immediately if they notice anything wrong after the operation. We must also take time to address any fears, doubts and myths about cataract surgery. It is important to ensure that patients and their families have realistic expectations about their vision after surgery. They must understand the risks and benefits, including the potential effect of different complications on their eyesight. Our patients also have a role to play in alerting the eye team to potential complications at an early stage. Before surgery, explain to patients how their eyes will look and feel after a successful operation, including what level of discomfort is normal at the different stages of recovery. Encourage them to speak with an eye team member if they experience anything that concerns them. Discussion groups for patients, based on their gender and initial visual outcome, offer an opportunity to talk about coping with the challenges of self-care and follow-up appointments, which may be different for each individual. Giving patients an opportunity to attend such groups may help to allay fears and can give them an opportunity to ask questions if they are uncertain about anything. This visit is important, as it is also the time to conduct postoperative refraction. Actively encourage patients to attend, for example by including the visit in the price of the cataract operation. Transport may be a barrier for some Continues overleaf After surgery After the operation, patients should be given clear instructions about how to look after their operated eye when they are back at home (see panel on page 24). Give specific information about follow-up visits (where to go, when, and at what time) and ensure patients know how to get in touch with the eye clinic or their surgeon if they have any signs or symptoms that can indicate a complication (worsening sight, increasing pain, Before surgery Patients and their families must be given advice and counselling about the operation, including what happens before, during and after. Instructions for patients Even though you may feel well after surgery, you have had a big operation. Postoperative refraction Postoperative refraction and provision of spectacles (if needed) are essential to ensure the best possible visual outcome for a patient. This is important because satisfied patients will encourage others in the community to undergo cataract surgery. If there is no intraocular lens, carefully check the back vertex distance and centring of the spectacles. Reference 1 Blindness and visual impairment due to age-related cataract in sub-Saharan Africa: a systematic review of recent population-based studies.

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Leptothrix and other fungi may cause follicular conjunctivitis associated with preauricular lymphadenopathy. Topical fluconazole or miconazole 1% and natamycin are used in the treatment of fungal conjunctivitis. Rhinosporidiosis of the Conjunctiva Rhinosporidiosis of the conjunctiva is not a rare fungal affection of the conjunctiva. The characteristic conjunctival lesions are pedunculated or sessile fleshy growths with irregular surface dotted with white spots. Etiology the disease is mainly caused by Bartonella henselae (cat-scratch disease); other causes include tularemia, tuberculosis, syphilis, sarcoidosis and fungal infections. The condition is common in summer months and the lesion consists of yellowish-gray translucent raised nodule on the bulbar conjunctiva. The nodule is formed as a result of lymphocytic and giant cells infiltration around the hair. Acute or Subacute Allergic Conjunctivitis Acute or subacute catarrhal inflammation of conjunctiva is often associated with allergic rhinitis. Etiology the condition is caused by exogenous allergens such as pollen, grass, animal dander, etc. Occasionally, cosmetics, chemicals and drugs applied topically can induce a violent follicular or nonfollicular reaction in the conjunctiva. The conjunctivitis is often seen in the Western countries as a part of typical hay fever, hence, known as hay fever conjunctivitis. Clinical features Itching, watering and redness of the eye are common complaints of the patient. Treatment the disease can be prevented by the elimination of allergens from the surroundings or the patient may be moved to a pollen-free area. Desensitization against specific allergen may be helpful but is a cumbersome process. Symptomatic relief is quickly obtained by cold compresses and instillation of corticosteroid drops. Pemphigus or pemphigoid reaction in the conjunctiva is rare and also included in the oculocutaneous syndrome. Numerous vesicles appear on the conjunctival surface, they rupture and undergo progressive cicatrization causing essential shrinkage of the conjunctiva often associated with corneal complications and xerophthalmia. However, artificial tears and grafting of amniotic membrane and stem cells transplantation by means of conjunctival autograting may be helpful. Allergic Conjunctivitis Allergic or hypersensitivity reactions of the conjunctiva are not uncommon. They may be immediate (humoral) as seen in hay fever, acute or subacute conjunctivitis and vernal conjunctivitis, or delayed (cellular) as found in phlyctenular conjunctivitis. The disease has the onset in summer months, hence, it is also known as spring catarrh, which is a misnomer may be seen round the year in tropical climate. The disease is less common in temperate zones and almost non-existent in cold climate. Clinical features Vernal conjunctivitis frequently affects children between 4 and 15 years, often boys more than girls. However, it is a self-limiting disease and the frequency of attacks and severity of the symptoms eventually subside as the patient ages. The disease is usually seen in two clinical forms, the palpebral and the limbal, both may coexist in a patient. The palpebral form is relatively more common, the upper palpebral conjunctiva is hypertrophic and shows the presence of small to giant papillae. Each papilla is polygonal with a flat top and contains tufts of capillaries and dense fibrous tissue. The polygonal raised areas of palpebral conjunctival hypertrophy are seen mimicking cobblestones. A stringy conjunctival discharge or a fibrinous pseudomembrane (Maxwell-Lyons sign) may sometimes be found. The limbal or bulbar form is less characteristic and frequently seen in black races. The striking lesion is at the limbus where a wall of gelatinous thickening appears. As the disease progresses, the thickening becomes irregular and a few discrete, white, superficial. The corneal lesions of vernal conjunctivitis (vernal keratopathy) include superficial punctate keratitis, epithelial erosions, noninfectious oval ulcer (shield ulcer), subepithelial scarring and pseudogerontoxon with a classical cupid-bow outline. Pathology Smears of conjunctiva show the presence of eosinophilic granules in great numbers. Histopathology of vernal conjunctivitis reveals: (i) excessive epithelial hyperplasia, (ii) extensive infiltration by eosinophils, plasma cells, lymphocytes and monocytes in the adenoid layer, and (iii) spectacular increase in the fibrous layer which later on undergoes hyaline degeneration. To avoid corticosteroid-related complications, intermittent (pulse) therapy is indicated. Soluble corticosteroid drops are used 2-4 hourly for 5-7 days and then rapidly tapered. An alternative to topical steroid therapy is an injection of triamcinolone acetonide (40 mg per ml) injected in the supratarsal conjunctiva. An immunosuppressive agent, cyclosporin A, that inhibits chemotaxis, can be used as 1-2% drops in these cases. Giant papillae are treated either by application of -radiation (600-1500 rad) or by cryo application. Giant Papillary Conjunctivitis A giant papillary reaction in the conjunctiva occurs in contact lens (hydrophilic lenses) wearers, patients with ocular prosthesis and patients in whom corneal sutures, particularly of keratoplasty, are not removed. Local corticosteroid drops or cromolyn sodium drops may relieve the symptoms of foreign body sensation, itching and photophobia transiently. Cleaning of the deposits on the contact lens, discontinuation of lens or prosthesis wear and removal of corneal sutures are effective measures to manage the papillae. Phlyctenular Conjunctivitis Phlyctenular conjunctivitis is an endogenous allergic conjunctivitis marked by photophobia, mucopurulent discharge and presence of a single or multiple gray-white raised nodules at the limbus surrounded by an area of conjunctival congestion. The disease is common in malnourished and debilitated children between 5 and 12 years of age. Pathology the histopathology of a phlycten shows a characteristic subepithelial mononuclear infiltration in a triangular area, the apex of the triangle being towards the deeper layers of the cornea. When secondary infection supervenes, additional polymorphonuclear cells appear and the overlying epithelium undergoes necrosis. Differential diagnosis Besides phlycten, a nodule at the limbus may be seen in episcleritis, inflamed pinguecula, filtering bleb following glaucoma surgery, suture cyst, dermoid and foreign body granuloma. The distinguishing features of phlyctenular conjunctivitis, inflamed pinguecula and episcleritis are listed in Table 11. Treatment the treatment of phlyctenular conjunctivitis is aimed to improve the general health of the child and management of local condition. Infected tonsils and adenoids should be properly treated and attempts should be made to desensitize the patient against tubercular or Staphylococcal allergens. A calorie-rich diet supplemented with vitamins A, C and D and calcium should be given. Clinical features Phlyctenular conjunctivitis is usually unilateral, but the other eye may get involved in a few months. The disease in a pure form does not give many symptoms except mild discomfort and irritation with reflex lacrimation. However, as the disease is usually complicated by mucopurulent conjunctivitis, photophobia and mucopurulent discharge become prominent symptoms. The characteristic lesion of the conjunctivitis is a phlycten or phlyctens (blebs). Single or multiple, small, round white or gray nodules raised above the surface are found at or near the limbus. The phlycten ulcerates and forms a triangular fascicular ulcer with prominent vascularization. Multiple phlyctens may surround the cornea and their subsequent necrosis leads to the formation of a ring ulcer. Color Discharge Ulceration Tenderness Regional lymph glands Complications Phlyctenular conjunctivitis Below 15 years (Children) Both sexes Usually at limbus Small raised round nodule White Mucopurulent Common Seldom Enlarged Keratitis and nodular degeneration Inflamed pinguecula Above 50 years (Elderly) Male Away from limbus and usually nasally Flat and triangular Dull-pink, fleshy No discharge Does not occur May be present Not enlarged May lead to pterygium formation Episcleritis 16-40 years (Young) Female Away from limbus and usually temporally Relatively bigger flat round nodule Dull purple Watery Does not occur Usually present Enlarged Rarely scleritis Hot compresses and irrigation with saline reduce mucopurulent discharge. Instillation of antibiotic and corticosteroid eye drop several times in a day has a dramatic effect on the secondary infection as well as on the phlycten. Follicles are most predominantly seen on the inferior tarsal conjunctiva and fornix.

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A contingency plan will be developed to ensure that all laboratories capable of performing testing in the Americas have an adequate supply of reagents and protocols. Symptomatictreatmentis recommended after excluding more serious conditions like malaria, dengue, and bacterial infections. Patientsshouldbeadvisedtodrinkplentyof fluidstoreplenishfluidlostfrom sweating, vomiting, and other insensible losses. Although an older study suggested that chloroquine phosphate offered some benefit,45 a recent double-blind, placebo-controlled randomized trial found it to be of no real value treating joint symptoms. In patients with refractory joint symptoms, alternative therapies such as methotrexate can be evaluated. In addition to pharmacotherapy, cases that have prolonged arthralgia and joint stiffness may benefit from a program of graduated physiotherapy. Movement and mild exercise tend to improve morning stiffness and pain, but heavy exercise may exacerbate symptoms. However, other modes of transmission, such as through respiratory droplets or particles, have not been documented. Health Care and Hospital Surge Capacity Atthepeakof onerecentoutbreak,47,000suspectedcaseswereidentifiedina single week among a population of 766,000. With that potential volume of cases per week, huge demands are likely to be placed on the health care system during outbreaks of the disease. Triage systems should beconsideredatvariouslevelsof healthcaretofacilitatetheflowof patients during an outbreak. Regardless of the level of medical care available at the triage location, a key measure that needs to be considered at all levels of health care is the institution of appropriate mosquito control measures in the immediate area. During a previous outbreak, up to one-third of health care workers became infected, further taxing already overburdened and stretched resources. If present, administer supportive care in a unit that can monitor vital signs on an hourly basis during the critical phase. Autopsies should be considered on all deceased patients, with involvement of pathologists. There are documented cases that include infection of laboratory personnel handling infected blood and of a health care worker drawing blood from an infected patient. This will require a preexisting platform and regulatory clearance, and is unlikely to be available in most areas. Similar measures should be considered for organ and tissue (grafts) transplantations. Early detection will allow for proper responseandcharacterizationof theoutbreakandidentificationof the viral strains circulating. A percentage of patients presenting with fever and arthralgia or fever and arthritis with no known etiology. To ensure adequate laboratory testing and surveillance capacity, laboratories should be aware of the laboratory network set up for testing and eventual distribution of supplies. Active, passive, and laboratory surveillance should be used to calculate and monitor indicators such as: incidence, rate of spread, rate of hospitalization (per infections), proportion of severe disease, mortality ratios, and disability rates. Any changes in surveillance at the national level should be readily communicated to other surveillance and prevention partners, such as vector control specialists, to ensure the quality and uniformity of the data collected. During an epidemic, all patients need not be subjected to confirmatory tests as above. In addition, other key partners, such as vector control management teams,shouldbenotified. Suspect case Laboratory Notification Alert vector control Negative Positive Local Health Officer National Health Office Exclusive and consider other etiologies Confirmed cases Confirmoutbreak investigate and control 6E. Epidemiologic Reports Ideally, epidemiologic reporting should be established at the national level, with thesupportof localandregionalpublichealthofficials. Thetypesandnumber of epidemiologic reports will likely evolve during the course of the outbreak to reflectthetypesof surveillancethatareperformedinanarea. Reporting should be coordinated at the national level by establishing a web-based line list, if possible, that contains a few required variables and additional variables as needed. A standardized case report form, including demographic, epidemiologic and laboratory information, should be developed quickly and shared with key partners to help facilitate the collection of information (See Appendix D for anexample). In addition to case count by location and timing, reporting on disease severity (hospitalization, mortality), number of hospital beds occupied per day, and trends in cases based on syndromic surveillance can be considered as ways to present the data. The national level data should be communicated back to the collecting districts, as well as to the press and other public health and partner agencies that participate in the control efforts (see Section 8, "Risk and Outbreak Communication" formoredetail). The event would also be unusual for the Americas, since it would signal the appearance of a previously absentpathogenandasignificantriskof internationalspreadgiventheamount of travel between countries in the Region. Some jurisdictions outside the Americas have instituted mosquito abatement activities at international airports and spraying adulticides in the passenger cabinsof arrivinginternationalflightsaspartof effortsaimedatpreventing dengue importation. However, virus-infected mosquitoes arriving in passenger aircraftarenotconsideredassignificantsourcesof mostarboviralimportations. For arboviruses with a human-mosquito-human transmission cycle, the most important source of viral importation is the viremic traveler. The exception would be if cases were being detected close to an international airport or seaport, or if suspected cases worked in or around these ports of entry. Therefore, vector control planning efforts should focus on suppression of both Ae. These species have distinct morphological features,andtheidentificationof specimenscollectedduringsurveillanceand control programs in the Americas can be readily accomplished. Successful control programs require well trained professional and technical staff andsufficientfunding. The program must have the ability to systematically collect surveillance data on relative densities of Ae. Infants and others sleeping or resting during the day should use bednets to avoid infection from Ae. Household Prevention the use of intact screens on windows and doors will reduce entry of vectors into thehome,andmosquitoproofingwaterstoragevesselswillreduceoviposition sites and local production. The number of adult mosquitoes in a home may be reduced by using commercially available pyrethroid-based aerosol sprays and other products designed for the home, such as mosquito coils and electronic mat vaporizers. Aerosol sprays may be applied throughout the home, but areas where adult mosquitoes rest (dark, cooler areas) must be targeted, including bedrooms, closets, clothing hampers, etc. Care should be taken to emphasize proper use of these products exposure to pesticides. The program should be managed by experienced professional vector control biologists to assure that the program uses current pesticide recommendations, incorporates new methods of vector control, and includes resistance testing. Prevention programs should utilize the methods of vector control found in Appendix F, as appropriate. Vectorcontrolproceduresmustbeintensifiedtoeffectively reduce the abundance of infected vectors in order to halt transmission in the areas of the case(s). Initial efforts should focus on containing virus transmission and preventing expansion (Appendix G). If virus containment fails, or if cases are not detected until the outbreak has spread over a large geographic area, intensive vector control efforts will need to be expanded to a larger scale program. Risk Communication Strategies by Phase and Target Audience Appendix H gives an example of a model risk communication plan with strategies organized by preparedness, response, and recovery phases of an emergency. Risk communication should be organized across multiple agencies and should target the media, the public health community, community-based organizations, the private sector, and civil society institutions. All groups should meet regularly ensure that they are in agreement on key data points, including number of cases, geographic factors, and messages. Lack of coordination on these points will help create confusion and undermine confidenceinthemanagementof theresponse.

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Association between renal failure and foot ulcer or lower-extremity amputation in patients with diabetes. Predictors of poor outcome in female patients undergoing endovascular intervention. Renal insufficiency and use of revascularization among a national cohort of men with advanced lower extremity peripheral arterial disease. Metformin in patients with type 2 diabetes mellitus: reconsideration of traditional contraindications. Risk of fatal and nonfatal lactic acidosis with metformin use in type 2 diabetes mellitus. Handling of drugs in children with abnormal renal function, in Pediatric Nephrology, eds. Chapter 64: Drug Use and Dosage in Renal Failure, in Comprehensive Pediatric Nephrology, eds. Contrast-induced acute kidney injury: specialty-specific protocols for interventional radiology, diagnostic computed tomography radiology, and interventional cardiology. Nephrotoxicity of iso-osmolar iodixanol compared with nonionic low-osmolar contrast media: metaanalysis of randomized controlled trials. Gadolinium-based contrast agents and nephrogenic systemic fibrosis: a systematic review and metaanalysis. Gadolinium in pediatric cardiovascular magnetic resonance: what we know and how we practice. Adverse renal and metabolic effects associated with oral sodium phosphate bowel preparation. Association between oral sodium phosphate bowel preparations and kidney injury: a systematic review and meta-analysis. A randomized, multicenter study comparing the safety and efficacy of sodium phosphate tablets with 2 L polyethylene glycol solution plus bisacodyl tablets for colon cleansing. Mortality caused by sepsis in patients with endstage renal disease compared with the general population. Opportunities for improving the care of patients with chronic renal insufficiency: current practice patterns. Infectious morbidity and defects of phagocytic function in end-stage renal disease: a review. General medical care among patients with chronic kidney disease: opportunities for improving outcomes. Stage of chronic kidney disease predicts seroconversion after hepatitis B immunization: earlier is better. Hepatitis B vaccination in predialysis chronic renal failure patients a comparison of two vaccination schedules. Persistence of antibodies to pneumococcal vaccine in patients with chronic renal failure. Use of a Staphylococcus aureus conjugate vaccine in patients receiving hemodialysis. Relative risk and economic consequences of inpatient care among patients with renal failure. Predictors of hospitalization and death among predialysis patients: a retrospective cohort study. Cardiovascular disease and mortality in a community-based cohort with mild renal insufficiency. Controlling the epidemic of cardiovascular disease in chronic renal disease: report from the National Kidney Foundation Task Force on cardiovascular disease. Criteria for referring patients with renal disease for nephrology consultation: a review of the literature. Referral patterns of primary care physicians for chronic kidney disease in general population and geriatric patients. Referral to nephrologists for chronic kidney disease care: is non-diabetic kidney disease ignored? Outcomes in patients with chronic kidney disease referred late to nephrologists: a meta-analysis. Outcomes of early versus late nephrology referral in chronic kidney disease: a systematic review. An economic evaluation of early versus late referral of patients with progressive renal insufficiency. Presentation of the child with renal disease and guidelines for referral to the pediatric nephrologist. Causes and outcome of late referral of children who develop end-stage kidney disease. Late referral to paediatric renal failure service impairs access to pre-emptive kidney transplantation in children. The effect of a multidisciplinary care clinic on the outcomes in pediatric chronic kidney disease. Effectiveness of a multidisciplinary clinic in managing children with chronic kidney disease. Early initiation of dialysis fails to prolong survival in patients with end-stage renal failure. Association between estimated glomerular filtration rate at initiation of dialysis and mortality. Impact of the clinical conditions at dialysis initiation on mortality in incident haemodialysis patients: a national cohort study in Taiwan. Effect of comorbidity on the increased mortality associated with early initiation of dialysis. Age and comorbidity may explain the paradoxical association of an early dialysis start with poor survival. Survival and dialysis initiation: comparing British Columbia and Scotland registries. Early initiation of dialysis and late implantation of catheters adversely affect outcomes of patients on chronic peritoneal dialysis. Characteristics and survival of young adults who started renal replacement therapy during childhood. Cross-sectional validity of a modified Edmonton symptom assessment system in dialysis patients: a simple assessment of symptom burden. Understanding symptoms in patients with advanced chronic kidney disease managed without dialysis: use of a short patient-completed assessment tool. Symptom management in patients with established renal failure managed without dialysis. Symptoms in advanced renal disease: a cross-sectional survey of symptom prevalence in stage 5 chronic kidney disease managed without dialysis. Comparative pilot study of symptoms and quality of life in cancer patients and patients with end stage renal disease. End-of-life care preferences and needs: perceptions of patients with chronic kidney disease. Methodological considerations for end-of-life research in patients with chronic kidney disease. Prolonged conservative treatment for frail elderly patients with end-stage renal disease: the Verona experience. In contrast, this guidance was developed by consensus of an expert panel and provides guidance statements based on formal review and analysis of published literature on the topics. The quality (level) of the evidence and the strength of each guidance statement are not rated. As with clinical practice guidelines, it provides general guidance to optimize the care of the majority of patients and should not replace clinical judgment for a unique patient. The funding for the development of this Practice Guidance was provided by the American Association for the Study of Liver Diseases.

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Bagolini after image test is employed for testing retinal correspondence and suppression. The fixation can be tested either by a visuoscope or fixation star of an ophthalmoscope. In eccentric fixation the image may fall on any of the following areas: parafoveal, juxtafoveal, extrafoveal or temporal area, or may remain erratic. Synoptophore Examination In addition to the measurement of the angle of strabismus, synoptophore is used to estimate the grades of binocular vision and detection of the normal and the abnormal retinal correspondence. Good cosmetic correction with normal visual acuity is obtained when the therapy is started at six months of age. The ideal objective of treatment is to attain the 382 Textbook of Ophthalmology Surgery Surgical correction of strabismus should be undertaken after obtaining the maximal improvement in visual acuity following patching or penalization. In penalization atropine 1% is used in the normal eye to stimulate the fellow amblyopic eye. Surgical intervention merely provides a cosmetic correction, it does not correct the underlying cause of ocular deviation. However, good results are achieved in those operated between 4 and 6 years of age. There are essentially two surgical approaches for the correction of strabismus, strengthening of a weak muscle (resection) or weakening of an overacting muscle (recession). Free tenotomy or guarded tenotomy is recommended in certain conditions as weakening procedures. Two or more operations may sometimes be required in large angle deviations to straighten the eyes. The type of surgery chosen depends, to a large extent, upon the type of strabismus. Most surgeons prefer to operate upon the deviating eye only in cases of monocular squint except when very large deviation is present. In alternating convergent strabismus, recession of both medial rectus muscles is generally preferred. Correction of Refractive Error In all squinting children, a preliminary refraction under full cycloplegia should always be carried out to estimate the error of refraction. Occlusion When the vision is poor in the squinting eye due to disuse, occlusion of the sound eye is advised for 6 weeks. Occlusion (patching) should be absolute otherwise the desired improvement is seldom achieved. It carries a good prognosis and indicates that the vision in the squinting eye was not that poor initially. Later when central fixation is restored, conventional occlusion of the sound eye may be done to manage the amblyopia. Specially devised exercises on synoptophore are helpful in the development of binocular vision. Orthoptic treatment is a valuable adjunct to the operative management especially in cases with large angle of deviation. Disorders of Ocular Motility: Strabismus Optokinetic nystagmus occurs while seeing objects from a moving train or on seeing the alternate black and white strips of a spinning drum (catford drum). End-point nystagmus can be elicited by asking a person to look in extreme dextroversion or levoversion. Vestibular nystagmus is seen on stimulation of the tympanic membrane by water (caloric test). The movements appear like jerktype nystagmus and are pronounced on abduction of the eye. Congenital nystagmus occurs in severely malformed eyes, congenital leukoma and cataract, congenital toxoplasmosis, macular hypoplasia and albinism. Acquired nystagmus occurs in diseases of midbrain, cerebellum and vestibular tract and semicircular canals. Cerebellar lesions give coarse nystagmus towards the side of the lesion and fine nystagmus on the opposite side. It is characterized by very rapid rotatory ocular movements associated with headache, giddiness and tremors of the head. The incidence of nystagmus is high in workers of poorly illuminated mines suggesting a fixation difficulty as the causative factor. Labyrinthine nystagmus occurs in diseases of internal ear involving semicircular canals. It is characterized by elevation and intorsion of one eye while the other eye moves down and extorts. Convergence-retraction nystagmus is found in Parinaud syndrome (Sylvian aqueduct syndrome) which occurs due to the involvement of aqueduct of Sylvius in midbrain glioma or pinealoma. It consists of retraction of eyeball, vertical nystagmus, defective convergence, pupillary abnormality and lid retraction. Gaze-paretic nystagmus, associated with conjugate gaze weakness, is seen in brainstem lesions at the pontine level. Down-beat nystagmus occurs due to lesions of the posterior fossa at the foramen magnum level. Besides rhythmic ocular movements, the patient may complain of headache, giddiness, photophobia, moving of stationary objects and occasional diplopia. Differential Diagnosis A few ocular motility disorders of childhood like ocular bobbling, flutter-like ocular oscillations, ocular dysmetria and opsoclonus resemble nystagmus. Ocular bobbling is characterized by sudden downward and less commonly upward deviation of eyes; after some time, the eyes slowly come to the primary position. Vision often remains poor in congenital and infantile nystagmus in spite of correction of the error. Prism therapy: Prisms are used to correct the head position and shifting the image into the null point area. Nystagmus surgery: the surgery improves the visual acuity and broadens the null zone. Flutter-like oscillations of eyes and ocular dysmetria signify inability to fixate on an object accurately while shifting the gaze. Opsoclonus is marked by wild and chaotic movements of the eyes associated with myoclonic movements of face and extremities. Treatment Attempts should be made to improve the vision by correction of refractive error of the patient. Prism therapy and large recession of both medial rectus muscles are recommended to transfer the null point (where nystagmus is least) from the eccentric position to straight-ahead position. The margins of upper and lower lids meet at the medial and the lateral angle called the canthi. There is a semilunar fold of conjunctiva called the plica semilunaris at the medial canthus. The two eyelids are separated medially by a triangular space, the lacrimal lake or lacus lacrimalis. A fleshy raised body, the lacrimal caruncle, is located in the lacus lacrimalis on the medial side of the plica. On the top of the papilla is the lacrimal punctum which leads the tears to the lacrimal canaliculus. Layers of the Eyelid Each eyelid from outer to inner aspect has following layers. A horizontal fold is present in the skin of the upper lid which becomes prominent on the upward gaze, the superior palpebral sulcus or lid crease. The anterior border of the lid margin is round, while the posterior is sharp and lies closely in contact with the eyeball. The skin is loosely attached to the underlying structures; this loose attachment permits easy accumulation of edematous fluid or blood. Layer of striated muscle is composed of fibers of palpebral part of the orbicularis oculi. The orbital part is arranged in a concentric manner around the orbital margin covering the tarsus.

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Coppen A, Bailey J: Enhancement of the antidepressant action of fluoxetine by folic acid: a randomised, placebo controlled trial. Benedetti F, Colombo C, Serretti A, Lorenzi C, Pontiggia A, Barbini B, Smeraldi E: Antidepressant effects of light therapy combined with sleep deprivation are influenced by a functional polymorphism within the promoter of the serotonin transporter gene. Benedetti F, Colombo C, Pontiggia A, Bernasconi A, Florita M, Smeraldi E: Morning light treatment hastens the antidepressant effect of citalopram: a placebo-controlled trial. Practice Guideline for the Treatment of Patients With Major Depressive Disorder, Third Edition 413. Guscott R, Grof P: the clinical meaning of refractory depression: a review for the clinician. Weisler R, Joyce M, McGill L, Lazarus A, Szamosi J, Eriksson H: Extended release quetiapine fumarate monotherapy for major depressive disorder: 121 424. Cipriani A, Smith K, Burgess S, Carney S, Goodwin G, Geddes J: Lithium versus antidepressants in the long-term treatment of unipolar affective disorder. Bauer M, Dopfmer S: Lithium augmentation in treatment-resistant depression: meta-analysis of placebo-controlled studies. Practice Guideline for the Treatment of Patients With Major Depressive Disorder, Third Edition tiapine augmentation of fluoxetine in major depressive disorder. Cephalon: Updated Safety Information: Warnings regarding serious rash, including StevensJohnson Syndrome and hypersensitivity reactions, and psychiatric symptoms, Sept 12, 2007. Cullen M, Mitchell P, Brodaty H, Boyce P, Parker G, Hickie I, Wilhelm K: Carbamazepine for treatment-resistant melancholia. Barbosa L, Berk M, Vorster M: A double-blind, randomized, placebo-controlled trial of augmentation with lamotrigine or placebo in patients concomitantly treated with fluoxetine for resistant major depressive episodes. Lader M: Combined use of tricyclic antidepressants and monoamine oxidase inhibitors. Practice Guideline for the Treatment of Patients With Major Depressive Disorder, Third Edition 499. Hansen R, Gaynes B, Thieda P, Gartlehner G, DeVeaugh-Geiss A, Krebs E, Lohr K: Meta-analysis of major depressive disorder relapse and recurrence with second-generation antidepressants. Evidence suggesting the rate of true tachyphylaxis during continuation treatment is low. Parker G, Roy K, Hadzi-Pavlovic D, Pedic F: Psychotic (delusional) depression: a meta-analysis of physical treatments. Practice Guideline for the Treatment of Patients With Major Depressive Disorder, Third Edition 550. Zimmerman M, Chelminski I, McDermut W: Major depressive disorder and Axis I diagnostic comorbidity. American Psychiatric Association: Practice Guidelines for the Treatment of Patients With Panic Disorder, Second Edition. The Clomipramine Collaborative Study Group: Clomipramine in the treatment of patients with obsessive-compulsive disorder. American Psychiatric Association: Practice Guideline for the Treatment of Patients With ObsessiveCompulsive Disorder. Practice Guideline for the Treatment of Patients With Major Depressive Disorder, Third Edition 600. Arsenault-Lapierre G, Kim C, Turecki G: Psychiatric diagnoses in 3275 suicides: a meta-analysis. American Psychiatric Association: Practice Guideline for the Treatment of Patients With Borderline Personality Disorder. Bateman A, Fonagy P: Treatment of borderline personality disorder with psychoanalytically oriented partial hospitalization: an 18-month follow-up. Giesen-Bloo J, van Dyck R, Spinhoven P, van Tilburg W, Dirksen C, van Asselt T, Kremers I, Nadort M, Arntz A: Outpatient psychotherapy for borderline personality disorder: randomized trial of schema-focused therapy vs transference-focused psychotherapy. Newton-Howes G, Tyrer P, Johnson T: Personality disorder and the outcome of depression: metaanalysis of published studies. Vieta E, Nieto E, Gasto C, Cirera E: Serious suicide attempts in affective patients. Galea S, Ahern J, Nandi A, Tracy M, Beard J, Vlahov D: Urban neighborhood poverty and the incidence of depression in a population-based cohort study. Huurre T, Eerola M, Rahkonen O, Aro H: Does social support affect the relationship between socioeconomic status and depression? Fazel M, Wheeler J, Danesh J: Prevalence of serious mental disorder in 7000 refugees resettled in western countries: a systematic review. Lewis-Fernandez R, Diaz N: the cultural formulation: a method for assessing cultural factors affecting the clinical encounter. Mojtabai R, Olfson M: Treatment seeking for depression in Canada and the United States. Mojtabai R, Olfson M: National trends in psychotherapy by office-based psychiatrists. Richardson J, Anderson T, Flaherty J, Bell C: the quality of mental health care for African Americans. Practice Guideline for the Treatment of Patients With Major Depressive Disorder, Third Edition artery disease patients after hypertension treatment. Practice Guideline for the Treatment of Patients With Major Depressive Disorder, Third Edition 747. Heikkinen T, Ekblad U, Palo P, Laine K: Pharmacokinetics of fluoxetine and norfluoxetine in pregnancy and lactation. Murray L, Fiori-Cowley A, Hooper R, Cooper P: the impact of postnatal depression and associated adversity on early mother-infant interactions and later infant outcome.

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Inha University Hospital, Incheon, Korea (the Republic of) 3138 - A0255 Macular photoreceptor atrophy defines the end stage of macular telangiectasia type 2. Audo 3123 - A0240 Vitrectomy for Idiopathic Macular Epiretinal Membrane Improves Choriocapillary Circulation and Retinal Vascular Oxygen Saturation. State Key Laboratory of Ophthalmology, Zhongshan Ophthalmic Center, Guangzhou, China 3124 - A0241 Focal Laser Therapy in Symptomatic Central Serous Chorioretinopathy. Retina, Unidad Laser Del Atlantico Eye Clinic, Barranquilla, Atlantico, Colombia 3160 - A0277 Pediatric choroidal neovascularization: Hand-held spectral domain-optical coherence tomography findings and treatment response to intravitreal bevacizumab. Ocular Pathology, McGill University, Westmount, Quebec, Canada 3181 - A0324 Nestin in uveal melanoma: a novel biomarker. Department of Molecular and Clinical Cancer Medicine, Institute of Translational Medicine, Liverpool, United Kingdom 3185 - A0328 Recruitment and activation of hepatic stellate cells by uveal melanoma cells in a xenograft mouse model. Ophthalmology, Rigshospitalet, Copenhagen, 2100, Denmark; 3 Clinical Genetics, Rigshospiatalet, Copenhagen, 2100, Denmark 3190 - B0190 the central retinal venous pressure at a fixed airway pressure of 40mmHg. Opthalmology, Nagoya university, Nagoya, Japan 3195 - B0195 Changes in retinochoroidal blood flow and morphology on the macula and around optic nerve head after vitrectomy for epi-retinal membrane. Experimental Eye Research Institute, Ruhr-University Bochum, Bochum, Germany 3203 - B0203 Evaluation of a new pharmacologic strategy for Nrf2 activation for retinal ischemia-reperfusion injury. Waheed and Deeba Husain 3207 - B0306 How are fluorescence lifetimes of chorioretinal tissue in human donor eyes affected by fixation? Ophthalmology, Fukushima Medical University, Fukushima city, Fukushima pref, Japan 3239 - B0338 Optical Coherence Tomography Angiographic Changes before Development of Exudative Age-related Macular Degeneration in Eyes with Non-exudative Neovascularization. University College London, London, United Kingdom 3260 - B0359 Rapid-aging Xpg-/- mice model age-related retinal inflammation. Eye Institute & Affiliated Xiamen Eye Center of Xiamen University, Xiamen, Fujian, China 3301 - C0095 Effect of diabetes mellitus on corneal crystallins. School of Optometry and Vision Science, University of New South Wales, Sydney, New South Wales, Australia 3320 - C0162 Morphological changes to murine corneal dendritic cells after local and systemic inflammation. Biomedical Optics Laboratory at Postech, Korea, Pohang, Korea (the Republic of) 3323 - C0165 Immunomodulatory Activity of Tear Protein Lacritin. Ophthalmology, Wakayama Medical University, Wakayama, Wakayama, Japan 3338 - C0180 Suppression of corneal neovascularization by sphingosine-1-phosphate receptor 3 gene deletion in mice. Eye Institute of Xiamen University, Xiamen, China 3340 - C0182 Plasmacytoid Dendritic Cells and Their Role in Vascular Endothelial Cell Proliferation and Differentiation In Vitro. Ghate 3343 - C0225 Therapeutic effects of Idebenone in Japanese patients with Leber hereditary optic neuropathy: A multicenter prospective study. Ophthalmology, Chinese Plagh, Beijing, Beijing, China f 3359 - C0241 Histopathological, structural and visual functional changes in a rat model of neuromyelitis optica spectrum disease related optic neuritis. Congdon and Cathleen Fedtke 3368 - C0292 Predominance of hyperopia in patients with molecularly confirmed Best disease. Preventative Ophthalmology, Shanghai Eye Disease Prevention and Treatment Center, Shanghai, China 3375 - C0299 Refraction and Ocular Biometry of Preschool Children in Shanghai, China. University of Technology Sydney, Cherrybrook, New South Wales, Australia 3377 - C0301 Foveal electrophysiological input has a stronger contribution to early juvenile myopia development than peripheral defocus. School of Optometry, the Hong Kong Polytechnic University, Hong Kong, Hong Kong 3378 - C0302 Prevalence of refractive errors in children of rural zone of Londrina City, Brazil. School of Optometry, Aston University, Birmingham, United Kingdom 3384 - C0308 Change in myopia prevalence over 24 months in a school population from 6 to 13 years of age in Portugal. Physics - Optometry and Vision Science, University of Minho, Braga, Portugal 3385 - C0309 Peripheral optical anisotropy is associated with axial length to corneal curvature ratio. Aston University, Birmingham, United Kingdom 3392 - C0316 Childhood age, time outdoors, and the risk of juvenile-onset myopia. Centre for Myopia Research, School of Optometry, the Hong Kong Polytechnic University, Kowloon, Hong Kong 3401 - C0325 Investigation of Time Duration Spent on Near Work and Outdoor Activities in Children: Perception versus Real-time Measurements. Singapore National Eye Center, Singapore, Singapore 3405 - C0329 Low concentration of atropine for the treatment of children myopia: the efficacy of 0. Ophthalmology, Kaohsiung Chang Gung Memorial Hospital, Taiwan, Kaohsiung, Taiwan f 3406 - C0330 A study on the system of selfevaluation of the visual acuity based on WeChat platform. E, Barcelos, Portugal 3412 - C0336 Association Between Task Performance and Structure-Function in Glaucoma. Ophthalmology, Keio University School of Medicine, Shinjuku, Tokyo, Japan 3419 - C0343 Do scotomas in glaucoma affect eye movements? Lucia Hospital, Bologna, Italy 3423 - C0347 Dark Adaptation Symptoms Survey as a Predictive Tool for Primary Open Angle Glaucoma Severity. The panel will discuss the topic and the potential use of new technologies to overcome the present limitations Moderator: Quan Dong Nguyen Organizer. Pharma Research and Early Development, Ophthalmology Discovery and Biomarkers, Roche Innovation Center Basel, F. Institute of Experimental Medicine, Buenos Aires, Buenos Aires, Argentina Age-related loss of tolerance- lacrimal gland and ocular surface manifestations. This forum discusses technological approaches, disease applications, and clinical interpretation. Ophthalmology, Beijing Tongren Eye Center, Beijing, China Genome editing as an approach to glaucoma treatment. Securing early funding is one of the most critical steps for translating innovations into commercially viable products. This workshop will feature leading ophthalmic entrepreneurs with broad experience in academics, private practice, and industry. Drawing from their diverse backgrounds and experiences, these speakers will discuss bootstrapping to bridge the funding gap that must be overcome in order to get an idea off the ground and into a clinical trial. Next-generation sequencing technologies are helping to reveal genetic variants underlying both simple and complex traits and some gene-based therapies are achieving clinical success. This session covers topics that demonstrate the many ways in which genetic knowledge is changing management of hereditary eye diseases. Successful gene identification and application of screening tests are informing diagnoses. Increasing therapeutic opportunities are available through gene therapy and perhaps before long, personalized risk assessments may be possible for some complex disease, with tailored treatments possible through application of pharmacogenomics. This session also highlights the challenges of genomic medicine and how we may overcome them in the future to bring the full promise of genetics to fruition. Vithana, Zi-Bing Jin and Yutao Liu - 1:30 Introductions and Remarks - 1:32 Gene discovery for genetic eye diseases: from unknown to known. Department of Ophthalmology, Flinders University, Walkerville, South Australia, Australia - 2:06 Genome surgery and genetic medicine trials. Ctr for Eye Res-Australia, University of Melbourne, East Melbourne, Victoria, Australia - 2:40 Predictive testing for genetic eye diseases - where are we now? Chao and Eszter Szalai - 1:30 Introductions and Remarks - 1:31 the role of clinician-scientists in vision research. A few collaborative programs have been successful in bringing international colleagues to make significant contributions to vision research. However, a wider participation of researchers is needed to advance the high-quality science in many areas of vision research. A coordinated strategy for basic science and health services research will help in reducing the global burden of eye diseases and implementation of research findings. Moderator: Gyan Prakash - 1:30 Ebola Virus related Ocular Complications and International Research Collaboration in a "crisis situation". Dept of Path/Molec Med, McMaster University, Hamilton, Ontario, Canada - 2:20 Zika Virus related Ocular complications and Global Health.

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Cysteine is ordinarily synthesized from methionine and provides a substrate for taurine. However, this may be considered an essential amino acid for preterm infants due to low activity of the enzyme hepatic cystathionase, which converts methionine to cysteine. However, the lower pH also enhances the solubility of calcium and phosphorus and allows for improved mineral intake. Glutamine is an important fuel for intestinal epithelial cells and lymphocytes; however, due to its instability, it is presently not a component of crystalline amino acid solutions. Its use must be weighed against the risk of wide swings in blood glucose levels, as well as the concerns surrounding the overall effects of the increased uptake of glucose. When hyperglycemia is severe or persistent, an insulin infusion may be useful (see Chap. Vitamin A is important for normal growth and differentiation of epithelial tissue, particularly the development and maintenance of pulmonary epithelial tissue. Withholding enteral feeding after birth places the infant at risk for all the complications associated with luminal starvation, including mucosal thinning, flattening of the villi, and bacterial translocation. Minimal enteral nutrition (also referred to as "gut priming" or "trophic feedings") may be described as the nonnutritive use of very small volumes of human milk or formula for the intended purpose of preservation of gut maturation rather than nutrient delivery. Definitive conclusions cannot be drawn as to what constitutes the optimal volume for minimal enteral nutrition. Infants who are undergoing medical treatment for patent ductus arteriosus may receive gut priming, pending the discretion of the care term. Although there is no such gold standard for preterm infants, the use of human milk offers many nutritional and nonnutritional advantages for the premature infant. Therefore, the use of fortified human milk is considered the preferred feeding for preterm infants. Preterm human milk contains higher amounts of protein, sodium, chloride, and magnesium than term milk. However, the levels of these nutrients Fluid Electrolytes Nutrition, Gastrointestinal, and Renal Issues 249 remain below preterm recommendations, the differences only persist for approximately the first 21 days of lactation, and composition is known to vary. However, as vitamin content of the feeding is not appreciably increased with the use of this product, a multivitamin and iron supplement is typically administered daily. Small, frequent bolus feedings may result in improved nutrient delivery and absorption compared with continuous feedings. Our protocols for the collection and storage of human milk are outlined in Chapter 22. Whey-predominant, taurine-supplemented protein source, which is better tolerated and produces a more normal plasma amino acid profile than caseinpredominant protein b. Once feeding volume has reached approximately 80 mL/kg/day, infants weighing 1,250 g should be considered for feeding intervals of every 2 hours or every 3 hours, as opposed to every 4 hours. Once feeding volume has reached approximately 100 mL/kg/day, consider advancing to 22 kcal/oz or 24 kcal/oz for all infants weighing 1,500 g. Consider advancing feeding volume more rapidly than the prescribed guidelines once tolerance of 100 mL/kg/day is established, but do not exceed increments of 15 mL/kg every 12 hours in most infants weighing 1,500 g. When attempting to determine how best to advance a preterm infant to full enteral nutrition, there is very limited data to support any one method as optimal. Use full-strength, 20 kcal/oz human milk or preterm formula and advance feeding volume according to the guidelines in Table 21. Volume, at the new caloric density, is typically maintained for approximately 24 hours before the advancement schedule is resumed. In instances where high and low Fe formulations are available, the iron fortified value appears. Additional product information and nutrient composition data may be found at the following websites: Specialized formulas have been designed for a variety of congenital and neonatal disorders, including milk protein allergy, malabsorption syndromes, and several inborn errors of metabolism. Indications for the most commonly used of these specialized formulas are briefly reviewed in Table 21. However, it is important to note that these formulas were not designed to meet the special nutritional needs of preterm infants. Preterm infants who are fed these formulas require close nutritional assessment and monitoring for potential protein, mineral, and multivitamin supplementation. Many ill and preterm infants require increased energy/nutrient intakes in order to achieve optimal rates of growth. Adjustments should be made gradually with feeding tolerance assessed after each change. Powdered infant formula may be used, as there is not a sterile, liquid, nutritionally adequate supplement to retain the volume of human milk provided. However, fat mixed with the feeding is subject to adherence to the storage container over time. Formula-fed, fluid-restricted preterm infants may be switched to a 26 to 30 kcal/oz premature infant formula once they are tolerating appropriate volumes of 24 kcal/oz feedings. As with preterm infants, adjustments should be made gradually with feeding tolerance assessed after each change. For term infants receiving standard formula, the formula density may be increased as needed by the use of standard formula powder, and/or modulars, or formula concentrate diluted to a more calorically dense feeding. Growth patterns of infants receiving these supplements are monitored closely and the nutritional care plan is adjusted accordingly. These should be individualized based on gestational age, clinical condition, and feeding tolerance. Nasogastric tube feedings are utilized more frequently, as orogastric tubes tend to be more difficult to secure. Infants with impaired suck/swallow coordination due to conditions such as encephalopathy, hypotonia, and maxillofacial abnormalities. Studies may be found in support of either method and, in practice, both are utilized. If difficulties with feeding tolerance occur, the amount of time over which a feeding is given may be lengthened by delivery via a syringe pump for 30 to 120 minutes. Transpyloric feedings should be delivered continuously, as the small intestine does not have the same capacity for expansion as does the stomach. There is an increased risk of fat malabsorption, as lingual and gastric lipase secretions are bypassed. Infants with neurologic impairment and/or those who are unable to take sufficient volumes through breast/bottle feeding to maintain adequate growth/hydration status G. It has been suggested that greater than 2 mg/kg/day may be needed when adjusted for noncompensated phlebotomy losses and the number of days during which the infant does not receive iron due to feeding intolerance or illness. Vitamin E is an important antioxidant that acts to prevent fatty acid peroxidation in the cell membrane. Preterm infants are not initiated on iron supplements until they are tolerating full enteral volumes of 24 kcal/oz feedings, which provides vitamin E at the low to midrange of the recommendations. An additional vitamin E supplement would be required to meet the upper end of the recommendation. As with parenteral glutamine supplementation, there are presently no recommendations for enteral glutamine supplementation in preterm infants. Emesis can be associated during the introduction and advancement of enteral feeds in preterm infants. These episodes are most commonly related to intestinal dysmotility secondary to prematurity and will respond to modifications of the feeding regimen. Temporary reductions in the feeding volume, lengthening the duration of the feeding (sometimes to the point of using continuous feeding), removal of nutritional additives, and temporary cessation of enteral feeds are all possible strategies depending upon the clinical course of the infant. Rarely, specialized formulas are used when all other feeding modifications have been tried without improvement. In general, these formulas should only be used for short periods of time with close nutritional monitoring. Infants who have repeated episodes of symptomatic emesis that prevent achievement of full-volume enteral feeds may require evaluation for anatomic problems such as malrotation or Hirschsprung disease. In general, radiographic studies are not undertaken unless feeding problems have persisted for 2 or more weeks, or unless bilious emesis occurs (see Chap. Preterm infants on full-volume enteral feeds will have occasional episodes of symptomatic emesis. If these episodes do not compromise the respiratory status or growth of the infant, no intervention is required other than continued close monitoring of the infant.

References:

  • https://www.thelamfoundation.org/Portals/0/News/Primary%20Spontaneous%20Pneumothorax%20Article.pdf
  • http://www.allnationaljournal.com/download/101/3-2-11-723.pdf
  • https://academic.oup.com/jid/article-pdf/201/7/1016/18061036/201-7-1016.pdf