This document summarizes the pathophysiology and management of chemical eye injuries. It discusses that chemical injuries can cause significant damage through alkali or acid exposure. Treatment involves immediate irrigation, debridement if needed, and aggressive medical therapy including corticosteroids, ascorbate, antibiotics and citrate to promote reepithelialization during the acute and early repair phases. More severe injuries may require surgical interventions like limbal stem cell transplantation or amniotic membrane transplantation depending on the degree of limbal involvement and prognosis.
Chemical (alkali and acid) injury of the conjunctiva and cornea is a true ocular emergency and requires immediate intervention.
Epidemiology:>-Chemical injuries to the eye represent between 11.5%-22.1% of ocular traumas.
etiology:-Chemical injuries occur as a result of acid, alkali, or neutral agents.Alkalis being responsible for 60%.
pathophysiology:-Alkali agents are lipophilic and therefore penetrate tissues more rapidly than acids.the damaged tissues then secrete proteolytic enzymes, which lead to further damage.Acids are generally less harmful than alkali .
coagulated proteins act as a barrier to prevent further penetration .
Symptoms & signs:-Pain,Lacrimation,Photophobia,Blepharospasm
Grading of severity:=1) Roper-Hall (modified Hughes) classification
2) Dua classification
MANAGEMENT:-Emergency treatment
Medical treatment
Surgical treatment
Chemical burns represent potentially blinding ocular injuries and constitute a true ocular emergency requiring immediate assessment and initiation of treatment. The majority of victims are young and exposure occurs at home, work place and in association with criminal assaults. Alkali injuries occur more frequently than acid injuries. Chemical injuries of the eye produce extensive damage to the ocular surface epithelium, cornea, anterior segment and limbal stem cells resulting in permanent unilateral or bilateral visual impairment. Emergency management if appropriate may be single most important factor in determining visual outcome.
Chemical (alkali and acid) injury of the conjunctiva and cornea is a true ocular emergency and requires immediate intervention.
Epidemiology:>-Chemical injuries to the eye represent between 11.5%-22.1% of ocular traumas.
etiology:-Chemical injuries occur as a result of acid, alkali, or neutral agents.Alkalis being responsible for 60%.
pathophysiology:-Alkali agents are lipophilic and therefore penetrate tissues more rapidly than acids.the damaged tissues then secrete proteolytic enzymes, which lead to further damage.Acids are generally less harmful than alkali .
coagulated proteins act as a barrier to prevent further penetration .
Symptoms & signs:-Pain,Lacrimation,Photophobia,Blepharospasm
Grading of severity:=1) Roper-Hall (modified Hughes) classification
2) Dua classification
MANAGEMENT:-Emergency treatment
Medical treatment
Surgical treatment
Chemical burns represent potentially blinding ocular injuries and constitute a true ocular emergency requiring immediate assessment and initiation of treatment. The majority of victims are young and exposure occurs at home, work place and in association with criminal assaults. Alkali injuries occur more frequently than acid injuries. Chemical injuries of the eye produce extensive damage to the ocular surface epithelium, cornea, anterior segment and limbal stem cells resulting in permanent unilateral or bilateral visual impairment. Emergency management if appropriate may be single most important factor in determining visual outcome.
Pseudophakic bullous keratopathy (PBK) is a post-operative condition that can occur as a complication of cataract extraction surgery and intraocular lens placement.
May be manifest in the immediate post-operative period or symptoms may not present for many years.
This presentation describes all clinical aspects of congenital glaucoma....you can watch this presentation in video form at the following link
https://www.youtube.com/watch?v=Y5YA2CYzb5c
this slide share admixed with pictures and animations will give an overall idea of immunological disorders of cornea. it covers anatomy immunology, and pharmacology as well
This presentation describes all the clinical aspects of keratoconus management
You can watch the illustrated presentation in this link :
https://www.youtube.com/watch?v=pYxwZPGm7e4&list=PLZ_mM13I_TrhWavjTmE9NjW1O5bGxkONO&index=13
Pseudophakic bullous keratopathy (PBK) is a post-operative condition that can occur as a complication of cataract extraction surgery and intraocular lens placement.
May be manifest in the immediate post-operative period or symptoms may not present for many years.
This presentation describes all clinical aspects of congenital glaucoma....you can watch this presentation in video form at the following link
https://www.youtube.com/watch?v=Y5YA2CYzb5c
this slide share admixed with pictures and animations will give an overall idea of immunological disorders of cornea. it covers anatomy immunology, and pharmacology as well
This presentation describes all the clinical aspects of keratoconus management
You can watch the illustrated presentation in this link :
https://www.youtube.com/watch?v=pYxwZPGm7e4&list=PLZ_mM13I_TrhWavjTmE9NjW1O5bGxkONO&index=13
Ophthalmologic approach to chemical burns Chimozi Tembo
Chemical burns are one of the true ophthalmologic emergencies. The ophthalmologist and general practitioner thus needs to be aware of the management of this type of eye injury.
chemical injury to eye by alkali, acids and irritants.
pathophysiology and management.
recent advances in management.
ITS A TRUE EMERGENCY IN OPHTHALMOLOGY
Dry eye disease is a common condition that occurs when your tears aren't able to provide adequate lubrication for your eyes. Tears can be inadequate and unstable for many reasons. For example, dry eyes may occur if you don't produce enough tears or if you produce poor-quality tears. This tear instability leads to inflammation and damage of the eye's surface.
Dry eyes feel uncomfortable. If you have dry eyes, your eyes may sting or burn. You may experience dry eyes in certain situations, such as on an airplane, in an air-conditioned room, while riding a bike or after looking at a computer screen for a few hours
Ocular Chemical Burns - Pathophysiology and Evidence-Based TreatmentSteven M. Christiansen
This case-based presentation describes the pathophysiology of ocular chemical burns (alkali and acid), as well as the evidence behind currently recommended medical and surgical treatment options.
Recomendações da OMS sobre cuidados maternos e neonatais para uma experiência pós-natal positiva.
Em consonância com os ODS – Objetivos do Desenvolvimento Sustentável e a Estratégia Global para a Saúde das Mulheres, Crianças e Adolescentes, e aplicando uma abordagem baseada nos direitos humanos, os esforços de cuidados pós-natais devem expandir-se para além da cobertura e da simples sobrevivência, de modo a incluir cuidados de qualidade.
Estas diretrizes visam melhorar a qualidade dos cuidados pós-natais essenciais e de rotina prestados às mulheres e aos recém-nascidos, com o objetivo final de melhorar a saúde e o bem-estar materno e neonatal.
Uma “experiência pós-natal positiva” é um resultado importante para todas as mulheres que dão à luz e para os seus recém-nascidos, estabelecendo as bases para a melhoria da saúde e do bem-estar a curto e longo prazo. Uma experiência pós-natal positiva é definida como aquela em que as mulheres, pessoas que gestam, os recém-nascidos, os casais, os pais, os cuidadores e as famílias recebem informação consistente, garantia e apoio de profissionais de saúde motivados; e onde um sistema de saúde flexível e com recursos reconheça as necessidades das mulheres e dos bebês e respeite o seu contexto cultural.
Estas diretrizes consolidadas apresentam algumas recomendações novas e já bem fundamentadas sobre cuidados pós-natais de rotina para mulheres e neonatos que recebem cuidados no pós-parto em unidades de saúde ou na comunidade, independentemente dos recursos disponíveis.
É fornecido um conjunto abrangente de recomendações para cuidados durante o período puerperal, com ênfase nos cuidados essenciais que todas as mulheres e recém-nascidos devem receber, e com a devida atenção à qualidade dos cuidados; isto é, a entrega e a experiência do cuidado recebido. Estas diretrizes atualizam e ampliam as recomendações da OMS de 2014 sobre cuidados pós-natais da mãe e do recém-nascido e complementam as atuais diretrizes da OMS sobre a gestão de complicações pós-natais.
O estabelecimento da amamentação e o manejo das principais intercorrências é contemplada.
Recomendamos muito.
Vamos discutir essas recomendações no nosso curso de pós-graduação em Aleitamento no Instituto Ciclos.
Esta publicação só está disponível em inglês até o momento.
Prof. Marcus Renato de Carvalho
www.agostodourado.com
Title: Sense of Smell
Presenter: Dr. Faiza, Assistant Professor of Physiology
Qualifications:
MBBS (Best Graduate, AIMC Lahore)
FCPS Physiology
ICMT, CHPE, DHPE (STMU)
MPH (GC University, Faisalabad)
MBA (Virtual University of Pakistan)
Learning Objectives:
Describe the primary categories of smells and the concept of odor blindness.
Explain the structure and location of the olfactory membrane and mucosa, including the types and roles of cells involved in olfaction.
Describe the pathway and mechanisms of olfactory signal transmission from the olfactory receptors to the brain.
Illustrate the biochemical cascade triggered by odorant binding to olfactory receptors, including the role of G-proteins and second messengers in generating an action potential.
Identify different types of olfactory disorders such as anosmia, hyposmia, hyperosmia, and dysosmia, including their potential causes.
Key Topics:
Olfactory Genes:
3% of the human genome accounts for olfactory genes.
400 genes for odorant receptors.
Olfactory Membrane:
Located in the superior part of the nasal cavity.
Medially: Folds downward along the superior septum.
Laterally: Folds over the superior turbinate and upper surface of the middle turbinate.
Total surface area: 5-10 square centimeters.
Olfactory Mucosa:
Olfactory Cells: Bipolar nerve cells derived from the CNS (100 million), with 4-25 olfactory cilia per cell.
Sustentacular Cells: Produce mucus and maintain ionic and molecular environment.
Basal Cells: Replace worn-out olfactory cells with an average lifespan of 1-2 months.
Bowman’s Gland: Secretes mucus.
Stimulation of Olfactory Cells:
Odorant dissolves in mucus and attaches to receptors on olfactory cilia.
Involves a cascade effect through G-proteins and second messengers, leading to depolarization and action potential generation in the olfactory nerve.
Quality of a Good Odorant:
Small (3-20 Carbon atoms), volatile, water-soluble, and lipid-soluble.
Facilitated by odorant-binding proteins in mucus.
Membrane Potential and Action Potential:
Resting membrane potential: -55mV.
Action potential frequency in the olfactory nerve increases with odorant strength.
Adaptation Towards the Sense of Smell:
Rapid adaptation within the first second, with further slow adaptation.
Psychological adaptation greater than receptor adaptation, involving feedback inhibition from the central nervous system.
Primary Sensations of Smell:
Camphoraceous, Musky, Floral, Pepperminty, Ethereal, Pungent, Putrid.
Odor Detection Threshold:
Examples: Hydrogen sulfide (0.0005 ppm), Methyl-mercaptan (0.002 ppm).
Some toxic substances are odorless at lethal concentrations.
Characteristics of Smell:
Odor blindness for single substances due to lack of appropriate receptor protein.
Behavioral and emotional influences of smell.
Transmission of Olfactory Signals:
From olfactory cells to glomeruli in the olfactory bulb, involving lateral inhibition.
Primitive, less old, and new olfactory systems with different path
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i3 Health is pleased to make the speaker slides from this activity available for use as a non-accredited self-study or teaching resource.
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Learning Objectives
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2.) Evaluate emerging data on targeted therapeutic approaches for treatment-naive and relapsed/refractory MCL and their applicability to older adults
3.) Assess mechanisms of resistance to targeted therapies for MCL and their implications for treatment selection
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2. One of the true ophthalmic emergencies.
Serious damage generally results from either strongly
basic (alkaline) compounds or acidic compounds.
3. Chemical injuries are responsible for approximately 7%
of work-related eye injuries.
> 60% -workplace accidents
30% -occur at home
10% are the result of an assault.
MORBIDITY- Severe chemical injuries result in
significant visual and cosmetic disability.
4. Chemical injuries can strike any population.
However, most injuries occur in patients aged 16-45
years.
Males are 3 times more likely to experience chemical
injuries than females.
5. Ammonia, lye,potassium hydroxide, magnesium hydroxide,
and lime.
Ammonia and lye (NaOH) tend to produce the most serious
injuries.
Magnesium hydroxide found in fireworks.
Lime(CaOH2) particularly in the form of plaster, is the most
commonly encountered alkali injury.
6. Sulfuric, sulfurous, hydrofluoric, nitrous, acetic, chromic,and
hydrochloric acids.
Sulfuric acid injury is the most commonly seen, usually after
battery explosions.
The most severe acid injuries are associated with hydrofluoric
acid.
7. The severity of the injury is related to
i. Type
ii. Volume
iii. Concentration
iv. Duration of exposure
v. Degree of penetration of the chemical .
The mechanism of injury differs slightly between acids
and alkali.
8. Acids dissociate into hydrogen ions
and anions in the cornea, e.g.:
HCl= H++Cl-
The hydrogen molecule damages
the ocular surface by altering the
pH, while the anion causes protein
denaturation, precipitation, and
coagulation .
Protein coagulation generally
prevents deeper penetration of
acids.
9. Alkaline substances dissociate into a
hydroxyl ion and a cation in the ocular
surface. eg.: NaOH= Na+ + OH-
The hydroxyl ion saponifies cell
membrane fatty acids, while the cation
interacts with stromal collagen and
glycosaminoglycans.
This interaction facilitates deeper
penetration into the cornea and into the
anterior segment.
Necrosis of conjunctival blood vessel
causing:
cornea appear as white as chalk and
opaque.
10. Necrosis of the conjunctival and corneal epithelium
Disruption and occlusion of the limbal vasculature.
Loss of limbal stem cells
Conjunctivilisation and vascularization of the
corneal surface
Persistent corneal epithelial defects with sterile
corneal ulceration
Perforation
11. IOP elevation : bimodal
Initial peak: compression of globe due to shortening of collgen
fibres.
Second peak: TM damage, TM obstruction by inflammatory
cells.
Corneal clouding: due to stromal oedema and changes in
proteoglycans.
Other long term effects include ocular surface wetting
disorders, symblepharon formation and cicatricial entropion.
Anterior chamber penetration results in iris and lens damage.
Ciliary epithelial damage impairs secretion of ascorbate which
is required for collagen production and corneal repair.
Hypotony and phthisis bulbi may ensue.
Permanent loss of corneal innervation: resulting in
neurotrophic keratitis.
12. THE EPITHELIUM
Centripetal movement of cells from the peripheral cornea, limbus, or
conjunctiva is responsible for normal and post-traumatic replacement of
corneal epithelium.
Associated with delayed re-epithelialization, superficial and deep stromal
vascularization and poor epithelium-basement membrane adhesion.
Limbal stem cells are the cells most qualified to restore the functional
competence of the corneal epithelial surface after injury.
STROMAL COLLAGEN
The maintenance and regeneration of the corneal stroma -responsibility of
the pluripotent cells- keratocyte.
Phagocytosis of collagen fibrils.
Synthesis and secretion of collagen glycosaminoglycan ground
substance, collagenase, and collagenase inhibitors.
13. Degradation of the basement membrane collagen(initiated by
MMP–9 )
Degradation of the corneal stromal matrix (by MMP–1 and
MMP–8
Collagen type 1 synthesis peak point(at 14-21 days)
Intervening period may show sterile corneal ulceration.
15. Hughes classification.
Modified Hughes classification.
Roper Hall classification.
Duas clasification.
16. Mild Erosion of corneal epithelium, faint haziness of
cornea, no ischemic necrosis of conjunctiva or
sclera.
Moderately
severe
Corneal opacity blurs iris details, mild ischemic
necrosis of conjunctiva or sclera.
Very severe Blurring of pupillary outline, significant ischemic
necrosis of conjunctiva or sclera.
17. A grade I injury involves little or no loss of limbal stem cells and
presents with little or no evidence of ischemia.
A grade II injury involves subtotal loss of limbal stem cells and
presents with ischemia of less than one-half of the limbus.
A grade III injury involves loss of>1/2 to total limbal stem cells
with preservation of the proximal conjunctival epithelium.
A grade IV injury involves total limbal stem-cell loss as well as loss
of the proximal conjunctival epithelium and presents with
extensive damage to the entire anterior segment.
18. Grade Prognosis Limbal ischemia Corneal involvement
1 Good None Epithelial damage.
2 Good <1/3 Haze but iris details are
visible.
3 Guarded 1/3-1/2 Total epithelial loss with
haze that obscures iris
details.
4 Poor >1/2 Cornea opaque with iris
pupil details obscured
19. Grade Prognosis Clinical findings
limbal involvement
Conjunctival
involvement
Analogue
scale
1 Very good 0 clock hours of
limbal involvement
0% 0/0%
2 Good 3 clock hours of
limbal involvement
30% 0.1–3/
1–29.9%
3 Good >3–6 clock hours of
limbal involvement
>30–50% 3.1–6/
31–50%
4 Good to guarded >6–9 clock hours of
limbal involvement
>50–75% 6.1–9/
51–75%
5 Guarded to poor >9–<12 clock hours
of limbal involvement
>75–<100% 9.1–11.9/
75.1–99.9%
6 Very poor Total limbus (12
clock hours) involved
Total conjunctiva
(100%) involved
12/
100%
20. The analogue scale records accurately the limbal involvement
in clock hours of affected limbus/percentage of conjunctival
involvement.
While calculating percentage of conjunctival involvement,
only involvement of bulbar conjunctiva, up to and including
the conjunctival fornices is considered.
The term “limbal involvement” is preferred over “limbal
ischaemia” because total loss of limbal epithelium (including
the stem cells) can occur despite little ischaemia but has
potentially the same consequences.
21. Three main pathophysiologic mechanisms are target for
treatment.
Regeneration of ocular surface epithelium and its state
of differentiation.
Stromal matrix remodeling including repair and
degradation.
Inflammation.
22. McCulley has divided the clinical course of chemical injuries
into four distinct pathophysiologic and clinical phases.
1.Immediate
2.Acute (days 0–7)
3.Early repair (days 7–21)
4.Late repair (day 21 to several months later) phases.
23. The extent of surface involvement can
be determined by the size of the corneal
and conjunctival epithelial defects.
The depth of corneal and intraocular
penetration can be estimated by
evaluating corneal clarity, intraocular
inflammation, intraocular pressure,and
lens clarity.
possible limbal stem-cell damage, can be
evaluated indirectly by assessment of
vascular ischemia and necrosis of limbal
and bulbar conjunctiva.
24. During the first week, important parameters that should be
monitored include evidence of reepithelialization ,intraocular
pressure, and progressive ocular inflammation.
Grade I injuries tend to heal.
Slow but progressive reepithelialization in grade II injuries.
Grade III and IV injuries show no reepithelialization.
25. During the early repair phase, epithelial migration continues
in less severe injury (grade II) but remains delayed in more
severe injuries (grades III and IV).
In severe chemical injuries, inflammatory cell infiltration
continues to progress over the next several weeks.
26. Corneal inflammation,collagen
synthesis, and collagenase activity are
peaking.
A type I healing pattern (normal
epithelial recovery)corresponds to a
grade I limbal stem-cell injury in that
restoration of an intact and
phenotypically normal corneal epithelial
surface has occurred by this stage.
A type II healing pattern (delayed
differentiation) corresponds to a grade II
limbal stem-cell injury. Sectorial corneal
epithelial defect in the quadrant
corresponding to limbal stem-cell loss.
27. A type III healing pattern
(fibrovascular pannus) corresponds
to a grade III injury:
conjunctivalization of the ocular
surface, and the ultimate outcome is
a tectonically stable but scarred and
vascularized cornea.
A type IV healing pattern (sterile
corneal ulceration) corresponds to a
grade IV injury in which there has
been complete loss of limbal stem
cells and proximal conjunctival
epithelium with ischemic necrosis.
29. Copious irrigation with any nontoxic
irrigating solution must be immediately
initiated on presentation.
Irrigation for a minimum of 30 min and
checking the pH of tears for evidence of
neutrality is recommended.
Debridement
Of necrotic corneal epithelium is necessary
to allow proper reepithelialization,
irrespective of the severity of the injury.
Paracentesis
30. The recovery of an intact and phenotypically normal corneal
epithelium is the rate-limiting determinant of prognosis of a
chemical injury.
Initially, aggressive medical therapy is indicated to facilitate
reepithelialization.
31. The use of topical Tear Substitutes
(unpreserved) may be useful in facilitating
corneal epithelial migration minimizing
conjunctival scarring and symblepharon
formation.
Administration of ointments at bed time
Topical antibiotics
Cycloplegics
32. May facilitate corneal epithelial regeneration and prevents
symblepheron formation.
Lens with greatest oxygen permeability should be preferred.
33. Ascorbate
It is a cofactor in the rate-limiting step of collagen formation.
Damage to the cilliary body epithelium by intraocular
chemical injury results in decreased secretion of ascorbate
and a reduction in its concentration in the anterior chamber.
Topical application is superior to systemic supplementation.
Topical sodium ascorbate 10% is given 2 -hourly in addition to
a systemic dose of 2g q.i.d.
34. Tetracycline derivatives are efficacious in reducing collagenase
activity.
Doxycycline 100mg bd
Tetracycline ointment QID
Acetylcysteine 10% 6 times
35. Corticosteroids:
mainstay of therapy for the reduction of tissue injury related to acute
inflammation.
Interfere with stromal repair by impairing both keratocyte migration
and collagen synthesis.
maximize the anti-inflammatory effect during the ‘window of
opportunity’ in the first 7–10 days, when there is little risk associated
with corticosteroid use.
Therapy can be modified by tapering corticosteroids & replaced by
nonsteroidal anti-inflammatory drugs (NSAIDs).
Progestational Steroids - Medroxyprogesterone 1%
36. Citrate is a calcium chelator that decreases the membrane
and intracellular levels of calcium, resulting in impaired
chemotaxis, phagocytosis, and release of lysosomal enzymes
of polymorphonuclear leukocytes.
It significantly reduces the incidence of corneal ulceration.
Topical sodium citrate 10% given 2- hourly for about 10 days.
Control of IOP
38. Acute Phase
1. Topical corticosteroids every 1–2 h.
2. Topical sodium ascorbate 10% every 2 h.
3. Topical sodium citrate 10% every 2 h.
4. Topical tetracycline 1% ointment four times a day.
5. Topical cycloplegics as needed.
6. Topical antiglaucoma medications as needed.
7. Systemic sodium ascorbate 2 g orally four times a day.
8. Systemic doxycycline 100 mg orally twice a day.
9. Consider amniotic membrane transplantation. (grade II
and III)
10. Consider conjunctival and Tenon’s advancement.
(grade IV)
39. Early Repair Phase
1. Discontinue or taper (with close observation) topical
corticosteroids.
2. Begin progestational steroids (Provera 1%), NSAIDs, or both,
topically every 1-2 hr.
3.Continue topical and systemic sodium ascorbate.
4. Continue topical sodium citrate.
5. Continue topical tetracycline and systemic doxycycline.
40. Late Repair Phase
1. Taper medical therapy after reepithelialization is
complete(grade I or II).
2. Limbal stem-cell transplantation +/– amniotic membrane
transplantation (for grade III or IV injuries).
3. Tectonic procedures (tissue adhesive, small- or largediameter
keratoplasty), if necessary.