A systematic approach with practical tips to diagnose and manage optic disc pallor. Disc pallor is often encountered in the routine clinical practice and remains a diagnostic enigma for most ophthalmologist. I illustrate the relevant practical points to be looked out for to deal with disc pallor.
Presenting Author: Dr. Shaikh Kalamuddin I.Resident, Dr. Vasantrao Pawar Medical College, Nashiik. Co-author: Dr. Dhiraj Balwir, Associate Professor, Dr. Vasantrao Pawar Medical College, Guide: Dr. Ajit Khune, Associate Professor, Dr. Vasantrao Pawar Medical College
Rare Case Of Right Eye Persistent Fetal Vasculature With Left Eye Optic Nerve...Dr. Jagannath Boramani
Sayli Gavaskar - Jr.Resident, V H Karambelkar - Professor, D K Sindal - Professor, and HOD , Department of Ophthalmology KRISHNA INSTITUTE OF MEDICAL SCIENCES AND DEEMED UNIVERSITY, KARAD, MAHARASHTRA.
Wolfram syndrome, otherwise known by an acronym DIDMOAD SYNDROME which comprises, Diabetes Insipidus, Diabetes Mellitus, Optic Atrophy and Deafness. We report three siblings with clinical features of Wolfram syndrome.
Approach to Disc Pallor and Automated Fields in Neuro-ophthalmology Dr. Shah Noor Hassan
Visual field assessment is important in the evaluation of lesions involving the visual pathways and should be performed at baseline and periodically in the follow-up. Standard automated perimetry has been shown to be adequate in neuro-ophthalmic practise and is now the technique of choice for a majority of practitioners.
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References-Harrison textbook of Internal medicine,Various sourcres
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These lecture slides, by Dr Sidra Arshad, offer a quick overview of the physiological basis of a normal electrocardiogram.
Learning objectives:
1. Define an electrocardiogram (ECG) and electrocardiography
2. Describe how dipoles generated by the heart produce the waveforms of the ECG
3. Describe the components of a normal electrocardiogram of a typical bipolar lead (limb II)
4. Differentiate between intervals and segments
5. Enlist some common indications for obtaining an ECG
6. Describe the flow of current around the heart during the cardiac cycle
7. Discuss the placement and polarity of the leads of electrocardiograph
8. Describe the normal electrocardiograms recorded from the limb leads and explain the physiological basis of the different records that are obtained
9. Define mean electrical vector (axis) of the heart and give the normal range
10. Define the mean QRS vector
11. Describe the axes of leads (hexagonal reference system)
12. Comprehend the vectorial analysis of the normal ECG
13. Determine the mean electrical axis of the ventricular QRS and appreciate the mean axis deviation
14. Explain the concepts of current of injury, J point, and their significance
Study Resources:
1. Chapter 11, Guyton and Hall Textbook of Medical Physiology, 14th edition
2. Chapter 9, Human Physiology - From Cells to Systems, Lauralee Sherwood, 9th edition
3. Chapter 29, Ganong’s Review of Medical Physiology, 26th edition
4. Electrocardiogram, StatPearls - https://www.ncbi.nlm.nih.gov/books/NBK549803/
5. ECG in Medical Practice by ABM Abdullah, 4th edition
6. Chapter 3, Cardiology Explained, https://www.ncbi.nlm.nih.gov/books/NBK2214/
7. ECG Basics, http://www.nataliescasebook.com/tag/e-c-g-basics
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MIP 201T & MPH 202T
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Overall life span (LS) was 1671.7±1721.6 days and cumulative 5YS reached 62.4%, 10 years – 50.4%, 20 years – 44.6%. 94 LCP lived more than 5 years without cancer (LS=2958.6±1723.6 days), 22 – more than 10 years (LS=5571±1841.8 days). 67 LCP died because of LC (LS=471.9±344 days). AT significantly improved 5YS (68% vs. 53.7%) (P=0.028 by log-rank test). Cox modeling displayed that 5YS of LCP significantly depended on: N0-N12, T3-4, blood cell circuit, cell ratio factors (ratio between cancer cells-CC and blood cells subpopulations), LC cell dynamics, recalcification time, heparin tolerance, prothrombin index, protein, AT, procedure type (P=0.000-0.031). Neural networks, genetic algorithm selection and bootstrap simulation revealed relationships between 5YS and N0-12 (rank=1), thrombocytes/CC (rank=2), segmented neutrophils/CC (3), eosinophils/CC (4), erythrocytes/CC (5), healthy cells/CC (6), lymphocytes/CC (7), stick neutrophils/CC (8), leucocytes/CC (9), monocytes/CC (10). Correct prediction of 5YS was 100% by neural networks computing (error=0.000; area under ROC curve=1.0).
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- Video recording of this lecture in English language: https://youtu.be/lK81BzxMqdo
- Video recording of this lecture in Arabic language: https://youtu.be/Ve4P0COk9OI
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2. OVERVIEW
• INTRODUCTION
• IMPORTANT POINTS IN HISTORY
• IMPORTANT POINTS IN EXAMINATION
• RELEVANT INVESTIGATIONS
• MANAGEMENT
• CASE EXAMPLE
3. • Rule out the mimics
• Clinical diagnosis
• Classify
– Pattern of optic disc appearance
– Etiology
• Investigations to confirm diagnosis
• Assess visual prognosis (progressive / static)
• Management (if needed)
4. INTRODUCTION
• End result of a number of pathologic
processes leading to loss of axonal fibres and
their replacement by glial tissue
• Normal color is salmon pink
– Vascularity
– Proportional glial and axonal elements
5. • Pale appearance due to
– Decreased vascularity
– Capillary dropout
– Gliosis
– Increased visibility of scleral laminae
6. AIM OF CLINICAL EVALUATION
• To determine the possible cause of the disc pallor
and whether this is due to
– An ongoing process which is likely to progress
• Ischemic / compressive
– Result of a previous one time insult
• Inflammatory / toxic / traumatic
• Visual prognosis
• Any intervention needed at present
7. DIFFERENTIAL DIAGNOSIS
• Optic atrophy
• Disc coloboma
• Optic pit
• Morning glory syndrome
• Medullated nerve fibres
• Myopic disc
• Optic disc drusen
• Optic disc hypoplasia
Should be kept in
mind while looking
at a pale disc
16. TEMPORAL PALLOR
• Carries papillomacular bundle
• Most active fibres with high metabolic activity
• Travel through the centre of the optic nerve
– Others report them being scattered throughout
the nerve
• Vulnerable to ischemic insult
19. FEATURE PRIMARY SECONDARY CONSECUTIVE
APPEARANCE Chalky white Dirty grey white Waxy pallor
MARGINS Well defined Ill defined Well defined
LAMINA CRIBROSA Well seen Obscured Well seen
VESSELS Normal Peripapillary
sheathing
Attenuation
SURROUNDING
RETINA
Healthy Hyaline bodies /
drusen
Pathology seen
23. MANAGEMENT
• Irreversible loss of acuity / field
• ISCHEMIC :
– Hypercholesterolemia
– Low dose aspirin
– Vascular surgery
– Pentoxifylline
– Steroids in acute stage (not recommended)
24. • INFLAMMATORY
– Immunosuppressants
– Prognosticate for MS
• COMPRESSIVE
– According to the lesion
– Thyroid
• TRAUMATIC
– Pale disc is indicator of irreversible damage
• TOXIC / NUTRITIONAL
– Avoid exposure
– Vitamin supplementation
25. CASE
• 35-year-old man with diabetes (5 yrs ; on
insulin)
• 2 months of blurred vision in his left eye with
near work
• No ocular history and never used spectacles
• No family history
• No history of trauma
• Non smoker / alcohol user
Ocular Surgery News U.S. Edition, September 15, 2007
Isabel M. Balderas, MD; Thomas R. Hedges, MD
26. • Vision (best corrected)
– Right 6/6 left 6/60
– No anisometropia
• Impaired color vision left
eye
• Anterior segment normal
• Circumpapillary
telangiectatic vessels
• No evidence of DR
27. • MRI BRAIN : normal study
• NUTRITIONAL INIDCES : normal
• Suspected LHON
• 11778 glycine to alanine mutation
DISC PALLOR IS NOT TO BE
IGNORED