1. Monocular elevation deficiency (MED), also known as double elevator palsy, is characterized by an inability to elevate one eye in all fields of gaze, resulting in hypotropia of the affected eye.
2. The condition can be congenital or acquired, with causes including superior rectus palsy, inferior rectus restriction, and supranuclear lesions.
3. Surgical management of MED depends on forced duction testing and may include inferior rectus recession, superior rectus resection, or Knapp's procedure to improve eye alignment and increase binocular vision.
1. The document discusses various causes and types of diplopia including monocular diplopia caused by refractive errors or macular disorders and binocular diplopia caused by cranial nerve palsies or muscle restrictions.
2. Evaluation of diplopia involves assessing head posture, eye movements, refractive error and neurological function through tests like the three-step test for fourth nerve palsy. Special tests like diplopia testing and cyclodeviation measurements localize the site of muscle weakness.
3. Causes of transient or intermittent diplopia include decompensated phoria, convergence insufficiency, myasthenia gravis or TIAs, while surgical procedures can also cause diplopia through restrictions
Duane retraction syndrome is a congenital eye movement disorder characterized by limited eye movement due to abnormal innervation of the lateral rectus muscle. It is classified into 3 types based on the pattern of eye movement restriction and alignment. Surgical correction may be considered to improve eye alignment and eliminate compensatory head posture, though most cases are managed without surgery by maintaining binocular vision. The goal of surgery is to centralize the field of single binocular vision without a head turn. Procedures include recession or transposition of the horizontal rectus muscles. Potential complications include under or overcorrection of eye alignment.
This document discusses Duane syndrome and Brown syndrome, which are congenital cranial dysinnervation disorders (CCDDs) characterized by abnormalities in the development of cranial nerves and muscles. Duane syndrome involves anomalous innervation of the lateral rectus muscle, causing limited eye movement and retraction. It is classified into three types based on the pattern of motility defects. Brown syndrome involves a mechanical restriction of the superior oblique tendon, limiting elevation of the eye in adduction. Both conditions are usually diagnosed based on their characteristic eye movement limitations and may require surgery if causing functional or cosmetic issues.
a detailed informative compilation on everything related to hypermetropia or hyperopia required in ophthalmic or optometric clinical practice and education
This document discusses various conditions that affect the pupil, including Adie's tonic pupil, Argyll Robertson pupils, and pituitary adenomas. Adie's tonic pupil is caused by damage to the ciliary ganglion and results in a dilated, poorly reactive pupil. Argyll Robertson pupils are caused by neurosyphilis and show a dissociation between the light and near reflexes. Pituitary adenomas are tumors of the pituitary gland that can compress the optic chiasm and cause visual field defects such as bitemporal hemianopia. MRI is useful for evaluating these conditions.
Diplopia, or double vision, can be caused by ocular misalignment or optical abnormalities. The document discusses various types of diplopia including monocular and binocular diplopia. It describes how to evaluate a patient with diplopia through history, physical exam, and tests to determine the underlying cause which may be supranuclear, nuclear, internuclear, infranuclear, restrictive or orbital issues. Key examination findings that help localize the source of diplopia are discussed.
This document discusses convergence insufficiency (CI), including its definition, causes, symptoms, diagnosis, and treatment. CI is characterized by a weak ability to maintain proper binocular eye alignment for near vision tasks. It is often associated with exophoria and reduced fusional convergence. Symptoms include eyestrain, headaches, and blurred vision when reading. Treatment involves orthoptic exercises to strengthen convergence, as well as base-in prisms or surgery in severe cases. The document provides detailed explanations of CI and outlines goals and aspects of its medical, surgical, and follow-up management.
This document provides information on examining a case of strabismus. It begins with the author's disclosure statement and then is divided into sections on history, examination, equipment, motor status, sensory status, measurement of deviation, and special tests. The history section covers items like visual acuity, eye involvement, and medical history. Examination assesses areas such as head posture, ocular deviation, eye movements, and binocular vision status. Various tests and equipment used are also outlined.
1. The document discusses various causes and types of diplopia including monocular diplopia caused by refractive errors or macular disorders and binocular diplopia caused by cranial nerve palsies or muscle restrictions.
2. Evaluation of diplopia involves assessing head posture, eye movements, refractive error and neurological function through tests like the three-step test for fourth nerve palsy. Special tests like diplopia testing and cyclodeviation measurements localize the site of muscle weakness.
3. Causes of transient or intermittent diplopia include decompensated phoria, convergence insufficiency, myasthenia gravis or TIAs, while surgical procedures can also cause diplopia through restrictions
Duane retraction syndrome is a congenital eye movement disorder characterized by limited eye movement due to abnormal innervation of the lateral rectus muscle. It is classified into 3 types based on the pattern of eye movement restriction and alignment. Surgical correction may be considered to improve eye alignment and eliminate compensatory head posture, though most cases are managed without surgery by maintaining binocular vision. The goal of surgery is to centralize the field of single binocular vision without a head turn. Procedures include recession or transposition of the horizontal rectus muscles. Potential complications include under or overcorrection of eye alignment.
This document discusses Duane syndrome and Brown syndrome, which are congenital cranial dysinnervation disorders (CCDDs) characterized by abnormalities in the development of cranial nerves and muscles. Duane syndrome involves anomalous innervation of the lateral rectus muscle, causing limited eye movement and retraction. It is classified into three types based on the pattern of motility defects. Brown syndrome involves a mechanical restriction of the superior oblique tendon, limiting elevation of the eye in adduction. Both conditions are usually diagnosed based on their characteristic eye movement limitations and may require surgery if causing functional or cosmetic issues.
a detailed informative compilation on everything related to hypermetropia or hyperopia required in ophthalmic or optometric clinical practice and education
This document discusses various conditions that affect the pupil, including Adie's tonic pupil, Argyll Robertson pupils, and pituitary adenomas. Adie's tonic pupil is caused by damage to the ciliary ganglion and results in a dilated, poorly reactive pupil. Argyll Robertson pupils are caused by neurosyphilis and show a dissociation between the light and near reflexes. Pituitary adenomas are tumors of the pituitary gland that can compress the optic chiasm and cause visual field defects such as bitemporal hemianopia. MRI is useful for evaluating these conditions.
Diplopia, or double vision, can be caused by ocular misalignment or optical abnormalities. The document discusses various types of diplopia including monocular and binocular diplopia. It describes how to evaluate a patient with diplopia through history, physical exam, and tests to determine the underlying cause which may be supranuclear, nuclear, internuclear, infranuclear, restrictive or orbital issues. Key examination findings that help localize the source of diplopia are discussed.
This document discusses convergence insufficiency (CI), including its definition, causes, symptoms, diagnosis, and treatment. CI is characterized by a weak ability to maintain proper binocular eye alignment for near vision tasks. It is often associated with exophoria and reduced fusional convergence. Symptoms include eyestrain, headaches, and blurred vision when reading. Treatment involves orthoptic exercises to strengthen convergence, as well as base-in prisms or surgery in severe cases. The document provides detailed explanations of CI and outlines goals and aspects of its medical, surgical, and follow-up management.
This document provides information on examining a case of strabismus. It begins with the author's disclosure statement and then is divided into sections on history, examination, equipment, motor status, sensory status, measurement of deviation, and special tests. The history section covers items like visual acuity, eye involvement, and medical history. Examination assesses areas such as head posture, ocular deviation, eye movements, and binocular vision status. Various tests and equipment used are also outlined.
Strabismus, also known as squint, refers to misalignment of the eyes. The document provides an overview of strabismus, including types, causes, signs and symptoms, diagnosis, and treatment approaches. Specifically, it discusses pseudo-strabismus versus real strabismus, classifications based on age of onset, fusional status, direction of deviation, and variation with gaze. Diagnosis involves assessing visual acuity, ocular movements, binocular vision, refractive error, and ruling out underlying conditions. Management may include glasses, eye exercises, prism therapy, or surgical correction depending on the type and severity of strabismus. The goal is to restore or maintain binocular vision and eye
Hypermetropia, or farsightedness, occurs when the eye is too short, causing light rays to focus behind the retina. There are several types of hypermetropia based on its cause, including axial hypermetropia due to a short eyeball, and index hypermetropia which occurs in older patients due to changes in the lens. Hypermetropia is classified by severity and can range from asymptomatic to causing blurred vision. Treatment involves prescribing convex lenses to optically shift the focal point of light rays to the retina.
Hypermetropia, also known as hyperopia or longsightedness, is a refractive error where the eye focuses images behind the retina. It has various causes including a short axial length of the eye or flattened cornea. Symptoms include blurry near vision and asthenopia. Treatment involves prescribing convex lenses to correct refractive errors or refractive surgery for more severe cases. Early treatment of hypermetropia in children is important to prevent amblyopia and strabismus.
Myopia, also known as nearsightedness, is a refractive error where light rays focus in front of the retina instead of directly on it. There are several types and grades of myopia. Simple or developmental myopia typically develops during childhood and progresses until early adulthood. Pathological myopia develops rapidly in childhood and is associated with degenerative changes to the eye. Treatment options include optical correction with glasses or contacts, low vision aids, general measures like a healthy diet, and in some cases surgery like LASIK.
This document discusses suppression, which is one of the three mechanisms of sensory adaptation that occurs in patients with strabismus. Suppression refers to the active inhibition of the image from the deviated eye to avoid diplopia. There are different types of suppression depending on factors such as etiology, retinal area involved, constancy, and the eye affected. Several tests are used to diagnose suppression including the Worth four dot test, Bagolini striated glass test, and visual acuity testing. Treatment involves refractive correction, occlusion therapy, eye alignment procedures, and anti-suppression exercises.
Lecture on Pupillary Reflexes; Common Abnormalities For 4th Year MBBS Undergr...DrHussainAhmadKhaqan
This document provides information on common abnormalities of pupillary reflexes, including Adie's (tonic) pupil, Argyll Robertson pupils, Horner's syndrome, and anisocoria. It defines each condition, describes associated signs and symptoms, potential causes, diagnostic testing, and treatment considerations. Prof. Dr. Hussain Ahmad Khaqan provides details on evaluating pupils using slit lamp examination and pharmacological testing to differentiate various conditions causing pupillary reflex abnormalities.
This document discusses strabismus, which is a misalignment of the visual axes of the eyes. It defines key terms like phoria, tropia, intermittent tropia, and provides details on the anatomical and visual axes. It describes various types of strabismus like concomitant, incomitant, horizontal, vertical, and torsional deviations. It also discusses the mechanisms, causes, adaptations, and evaluations of strabismus, including cover tests, versions, ductions, fusional amplitudes, stereopsis tests, and diplopia evaluation methods.
Orbital complications of zygomaticomaxillary complex fracture mrinalini123456789
1) The document discusses orbital complications that can arise from zygomatic fractures, including diplopia and enophthalmos. Diplopia is double vision that can result from impaired extraocular muscles due to trauma or nerve palsies. Enophthalmos is the retropositioning of the eye within the orbit.
2) Methods for evaluating diplopia include diplopia charting using a simple or electronic Hess screen to map deviations in eye position and movements. Common causes of nerve palsies like III, IV, and VI are also reviewed.
3) Enophthalmos is evaluated using exophthalmometry and is related to increased orbital volume from fractures. Surgical correction may be
This document provides an overview of ocular examination methods. It discusses abnormal head posture and its components which can indicate underlying eye muscle weakness. It describes tests to evaluate the visual axis like cover tests. It also outlines uniocular and binocular eye movements including versions, vergences, and cardinal positions. Examination of structures like the eyelids, lashes, conjunctiva and cornea are explained. Methods to evaluate ptosis, lid position and levator function are provided. The document is a comprehensive guide to evaluating the eyes.
complete information about the refractive errors due to the problem in the acomodation of eye lense , disturbed image formation in the retina, contains -types of disease condition .
Hypermetropia, also known as farsightedness or hyperopia, is a refractive error where the eye focuses light behind the retina. It occurs when the eyeball is too short or the cornea is too flat. Hypermetropia can be classified as physiological, pathological, or functional. It is commonly diagnosed using a retinoscope or autorefractor. Symptoms include blurry vision and eye strain. Treatment options include corrective lenses, refractive surgery such as LASIK, or intraocular lens implantation.
This document discusses congenital cranial dysinnervation disorders (CCDDs), which are a group of congenital neuromuscular diseases resulting from developmental errors in cranial nerve innervation. The document focuses on congenital fibrosis of the extraocular muscles (CFEOM), providing details on the classification, clinical features, genetics, and pathogenesis of different types of CFEOM. It also briefly discusses other CCDDs such as Duane syndrome and Möbius syndrome.
This document discusses ptosis, which is a drooping of the upper eyelid. It describes the functional anatomy of the levator palpebrae superioris muscle, which is responsible for eyelid elevation, as well as Muller's muscle and other muscles that can modify eyelid position. The document then covers evaluation of ptosis, including measurements of eyelid position, levator function testing, and classification of ptosis as congenital, acquired neurogenic, myogenic, aponeurotic, mechanical or pseudoptosis. Surgical management options are then briefly mentioned depending on the type and severity of ptosis.
This document provides information about infantile esotropia, including its definition, clinical features, etiology, differential diagnosis, and management. Infantile esotropia is defined as a large-angle esotropia present before 6 months of age. It is the most common form of strabismus. Clinical features include alternating or crossed fixation, apparent limitation of abduction, and associated motor abnormalities like inferior oblique overaction and dissociated vertical deviation. Treatment involves correcting refractive errors, amblyopia therapy, observation for small angles, and early surgical correction typically between 6 months to 2 years of age.
Paralytic strabismus ( third cranial nerve )PRAKRITIYAGNAM
This document provides information about paralytic strabismus caused by a third cranial nerve palsy. It discusses the anatomy and supply of the oculomotor nerve. Signs of a third nerve palsy include ptosis, divergent squint with intorsion, restricted eye movements, and diplopia. Causes can include lesions of the nerve nuclei, nerve trunk, or intraorbital muscles. Investigation involves assessing eye alignment and movements to localize the site of lesion, with diplopia charting helping to differentiate nerve or muscle involvement.
This document provides an overview of esotropia, including its types, causes, and clinical features. Esotropia is a convergent misalignment of the eyes. There are two main types - infantile esotropia, which presents in the first 6 months of life, and accommodative esotropia, which is usually caused by hyperopia. Accommodative esotropia can be fully, partially, or non-refractive. Clinical assessment of esotropia involves measuring visual acuity and the angle of deviation using tests such as cover-uncover and prism cover tests. Treatment involves correcting refractive errors with glasses and potentially strabismus surgery.
This document defines various types of hyperopia (farsightedness) and discusses their prevalence, natural history, diagnosis, and management. It defines classifications of hyperopia including simple/physiological, pathological, and functional. It also discusses evaluating and managing hyperopia in young children, older children/younger adults, and those developing presbyopia. Key points covered include the need to monitor and treat moderate-high hyperopia to prevent amblyopia and strabismus in young children, and addressing both distance and near vision with age.
Strabismus, also known as squint, refers to misalignment of the eyes. The document provides an overview of strabismus, including types, causes, signs and symptoms, diagnosis, and treatment approaches. Specifically, it discusses pseudo-strabismus versus real strabismus, classifications based on age of onset, fusional status, direction of deviation, and variation with gaze. Diagnosis involves assessing visual acuity, ocular movements, binocular vision, refractive error, and ruling out underlying conditions. Management may include glasses, eye exercises, prism therapy, or surgical correction depending on the type and severity of strabismus. The goal is to restore or maintain binocular vision and eye
Hypermetropia, or farsightedness, occurs when the eye is too short, causing light rays to focus behind the retina. There are several types of hypermetropia based on its cause, including axial hypermetropia due to a short eyeball, and index hypermetropia which occurs in older patients due to changes in the lens. Hypermetropia is classified by severity and can range from asymptomatic to causing blurred vision. Treatment involves prescribing convex lenses to optically shift the focal point of light rays to the retina.
Hypermetropia, also known as hyperopia or longsightedness, is a refractive error where the eye focuses images behind the retina. It has various causes including a short axial length of the eye or flattened cornea. Symptoms include blurry near vision and asthenopia. Treatment involves prescribing convex lenses to correct refractive errors or refractive surgery for more severe cases. Early treatment of hypermetropia in children is important to prevent amblyopia and strabismus.
Myopia, also known as nearsightedness, is a refractive error where light rays focus in front of the retina instead of directly on it. There are several types and grades of myopia. Simple or developmental myopia typically develops during childhood and progresses until early adulthood. Pathological myopia develops rapidly in childhood and is associated with degenerative changes to the eye. Treatment options include optical correction with glasses or contacts, low vision aids, general measures like a healthy diet, and in some cases surgery like LASIK.
This document discusses suppression, which is one of the three mechanisms of sensory adaptation that occurs in patients with strabismus. Suppression refers to the active inhibition of the image from the deviated eye to avoid diplopia. There are different types of suppression depending on factors such as etiology, retinal area involved, constancy, and the eye affected. Several tests are used to diagnose suppression including the Worth four dot test, Bagolini striated glass test, and visual acuity testing. Treatment involves refractive correction, occlusion therapy, eye alignment procedures, and anti-suppression exercises.
Lecture on Pupillary Reflexes; Common Abnormalities For 4th Year MBBS Undergr...DrHussainAhmadKhaqan
This document provides information on common abnormalities of pupillary reflexes, including Adie's (tonic) pupil, Argyll Robertson pupils, Horner's syndrome, and anisocoria. It defines each condition, describes associated signs and symptoms, potential causes, diagnostic testing, and treatment considerations. Prof. Dr. Hussain Ahmad Khaqan provides details on evaluating pupils using slit lamp examination and pharmacological testing to differentiate various conditions causing pupillary reflex abnormalities.
This document discusses strabismus, which is a misalignment of the visual axes of the eyes. It defines key terms like phoria, tropia, intermittent tropia, and provides details on the anatomical and visual axes. It describes various types of strabismus like concomitant, incomitant, horizontal, vertical, and torsional deviations. It also discusses the mechanisms, causes, adaptations, and evaluations of strabismus, including cover tests, versions, ductions, fusional amplitudes, stereopsis tests, and diplopia evaluation methods.
Orbital complications of zygomaticomaxillary complex fracture mrinalini123456789
1) The document discusses orbital complications that can arise from zygomatic fractures, including diplopia and enophthalmos. Diplopia is double vision that can result from impaired extraocular muscles due to trauma or nerve palsies. Enophthalmos is the retropositioning of the eye within the orbit.
2) Methods for evaluating diplopia include diplopia charting using a simple or electronic Hess screen to map deviations in eye position and movements. Common causes of nerve palsies like III, IV, and VI are also reviewed.
3) Enophthalmos is evaluated using exophthalmometry and is related to increased orbital volume from fractures. Surgical correction may be
This document provides an overview of ocular examination methods. It discusses abnormal head posture and its components which can indicate underlying eye muscle weakness. It describes tests to evaluate the visual axis like cover tests. It also outlines uniocular and binocular eye movements including versions, vergences, and cardinal positions. Examination of structures like the eyelids, lashes, conjunctiva and cornea are explained. Methods to evaluate ptosis, lid position and levator function are provided. The document is a comprehensive guide to evaluating the eyes.
complete information about the refractive errors due to the problem in the acomodation of eye lense , disturbed image formation in the retina, contains -types of disease condition .
Hypermetropia, also known as farsightedness or hyperopia, is a refractive error where the eye focuses light behind the retina. It occurs when the eyeball is too short or the cornea is too flat. Hypermetropia can be classified as physiological, pathological, or functional. It is commonly diagnosed using a retinoscope or autorefractor. Symptoms include blurry vision and eye strain. Treatment options include corrective lenses, refractive surgery such as LASIK, or intraocular lens implantation.
This document discusses congenital cranial dysinnervation disorders (CCDDs), which are a group of congenital neuromuscular diseases resulting from developmental errors in cranial nerve innervation. The document focuses on congenital fibrosis of the extraocular muscles (CFEOM), providing details on the classification, clinical features, genetics, and pathogenesis of different types of CFEOM. It also briefly discusses other CCDDs such as Duane syndrome and Möbius syndrome.
This document discusses ptosis, which is a drooping of the upper eyelid. It describes the functional anatomy of the levator palpebrae superioris muscle, which is responsible for eyelid elevation, as well as Muller's muscle and other muscles that can modify eyelid position. The document then covers evaluation of ptosis, including measurements of eyelid position, levator function testing, and classification of ptosis as congenital, acquired neurogenic, myogenic, aponeurotic, mechanical or pseudoptosis. Surgical management options are then briefly mentioned depending on the type and severity of ptosis.
This document provides information about infantile esotropia, including its definition, clinical features, etiology, differential diagnosis, and management. Infantile esotropia is defined as a large-angle esotropia present before 6 months of age. It is the most common form of strabismus. Clinical features include alternating or crossed fixation, apparent limitation of abduction, and associated motor abnormalities like inferior oblique overaction and dissociated vertical deviation. Treatment involves correcting refractive errors, amblyopia therapy, observation for small angles, and early surgical correction typically between 6 months to 2 years of age.
Paralytic strabismus ( third cranial nerve )PRAKRITIYAGNAM
This document provides information about paralytic strabismus caused by a third cranial nerve palsy. It discusses the anatomy and supply of the oculomotor nerve. Signs of a third nerve palsy include ptosis, divergent squint with intorsion, restricted eye movements, and diplopia. Causes can include lesions of the nerve nuclei, nerve trunk, or intraorbital muscles. Investigation involves assessing eye alignment and movements to localize the site of lesion, with diplopia charting helping to differentiate nerve or muscle involvement.
This document provides an overview of esotropia, including its types, causes, and clinical features. Esotropia is a convergent misalignment of the eyes. There are two main types - infantile esotropia, which presents in the first 6 months of life, and accommodative esotropia, which is usually caused by hyperopia. Accommodative esotropia can be fully, partially, or non-refractive. Clinical assessment of esotropia involves measuring visual acuity and the angle of deviation using tests such as cover-uncover and prism cover tests. Treatment involves correcting refractive errors with glasses and potentially strabismus surgery.
This document defines various types of hyperopia (farsightedness) and discusses their prevalence, natural history, diagnosis, and management. It defines classifications of hyperopia including simple/physiological, pathological, and functional. It also discusses evaluating and managing hyperopia in young children, older children/younger adults, and those developing presbyopia. Key points covered include the need to monitor and treat moderate-high hyperopia to prevent amblyopia and strabismus in young children, and addressing both distance and near vision with age.
share - Lions, tigers, AI and health misinformation, oh my!.pptxTina Purnat
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Rasamanikya is a excellent preparation in the field of Rasashastra, it is used in various Kushtha Roga, Shwasa, Vicharchika, Bhagandara, Vatarakta, and Phiranga Roga. In this article Preparation& Comparative analytical profile for both Formulationon i.e Rasamanikya prepared by Kushmanda swarasa & Churnodhaka Shodita Haratala. The study aims to provide insights into the comparative efficacy and analytical aspects of these formulations for enhanced therapeutic outcomes.
Cell Therapy Expansion and Challenges in Autoimmune DiseaseHealth Advances
There is increasing confidence that cell therapies will soon play a role in the treatment of autoimmune disorders, but the extent of this impact remains to be seen. Early readouts on autologous CAR-Ts in lupus are encouraging, but manufacturing and cost limitations are likely to restrict access to highly refractory patients. Allogeneic CAR-Ts have the potential to broaden access to earlier lines of treatment due to their inherent cost benefits, however they will need to demonstrate comparable or improved efficacy to established modalities.
In addition to infrastructure and capacity constraints, CAR-Ts face a very different risk-benefit dynamic in autoimmune compared to oncology, highlighting the need for tolerable therapies with low adverse event risk. CAR-NK and Treg-based therapies are also being developed in certain autoimmune disorders and may demonstrate favorable safety profiles. Several novel non-cell therapies such as bispecific antibodies, nanobodies, and RNAi drugs, may also offer future alternative competitive solutions with variable value propositions.
Widespread adoption of cell therapies will not only require strong efficacy and safety data, but also adapted pricing and access strategies. At oncology-based price points, CAR-Ts are unlikely to achieve broad market access in autoimmune disorders, with eligible patient populations that are potentially orders of magnitude greater than the number of currently addressable cancer patients. Developers have made strides towards reducing cell therapy COGS while improving manufacturing efficiency, but payors will inevitably restrict access until more sustainable pricing is achieved.
Despite these headwinds, industry leaders and investors remain confident that cell therapies are poised to address significant unmet need in patients suffering from autoimmune disorders. However, the extent of this impact on the treatment landscape remains to be seen, as the industry rapidly approaches an inflection point.
TEST BANK For An Introduction to Brain and Behavior, 7th Edition by Bryan Kol...rightmanforbloodline
TEST BANK For An Introduction to Brain and Behavior, 7th Edition by Bryan Kolb, Ian Q. Whishaw, Verified Chapters 1 - 16, Complete Newest Versio
TEST BANK For An Introduction to Brain and Behavior, 7th Edition by Bryan Kolb, Ian Q. Whishaw, Verified Chapters 1 - 16, Complete Newest Version
TEST BANK For An Introduction to Brain and Behavior, 7th Edition by Bryan Kolb, Ian Q. Whishaw, Verified Chapters 1 - 16, Complete Newest Version
Integrating Ayurveda into Parkinson’s Management: A Holistic ApproachAyurveda ForAll
Explore the benefits of combining Ayurveda with conventional Parkinson's treatments. Learn how a holistic approach can manage symptoms, enhance well-being, and balance body energies. Discover the steps to safely integrate Ayurvedic practices into your Parkinson’s care plan, including expert guidance on diet, herbal remedies, and lifestyle modifications.
Promoting Wellbeing - Applied Social Psychology - Psychology SuperNotesPsychoTech Services
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Dive into an in-depth exploration of the histological structure of female reproductive system with this comprehensive lecture. Presented by Dr. Ayesha Irfan, Assistant Professor of Anatomy, this presentation covers the Gross anatomy and functional histology of the female reproductive organs. Ideal for students, educators, and anyone interested in medical science, this lecture provides clear explanations, detailed diagrams, and valuable insights into female reproductive system. Enhance your knowledge and understanding of this essential aspect of human biology.
Here is the updated list of Top Best Ayurvedic medicine for Gas and Indigestion and those are Gas-O-Go Syp for Dyspepsia | Lavizyme Syrup for Acidity | Yumzyme Hepatoprotective Capsules etc
Osteoporosis - Definition , Evaluation and Management .pdfJim Jacob Roy
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Osteoporosis - Definition , Evaluation and Management .pdf
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1. DOUBLE ELEVATOR PALSY
(MED: MONOCULAR ELEVATION DEFICIENCY SYNDROME)
Dr. VINIT KUMAR
SCEH, LAHAN, NEPAL
PEDIATRIC OPHTHALMOLOGY
2. Monocular Elevation Deficiency, also known by the older term
Double Elevator Palsy, is an inability to elevate one eye in all fields of gaze, usually
resulting in one eye that is pointed downward relative to the other eye (hypotropia)
3.
4. Disease
• Monocular Elevation Deficiency (MED) is the limitation of elevation of the affected
eye from any position of gaze with normal ductions in all other gazes.
• MED is a frequent cause of hypotropia & can be associated with
ptosis/pseudoptosis.
• Superior rectus palsy, inferior rectus restriction & supranuclear lesions have been
found to be contributory to MED.
6. Etiology : congenital (mostly sporadic) & acquired
• Congenital causes of MED include, supranuclear palsy, primary superior rectus
(SR) paresis & primary inferior rectus(IR) restriction as in cases of congenital
fibrosis of inferior rectus.
• Acquired MED is usually caused by trauma, cerebrovascular diseases like
hypertension, thromboembolism, sarcoidosis, syphilis & midbrain tumors like
pineocytomas, acoustic neuromas & metastatic tumors affecting supranuclear
pathways
7. Pathology : Ziffer classification
• Type 1 includes patients with primary IR restriction or fibrosis
• Forced duction test (FDT) demonstrates a tight IR. The upward saccades are usually
normal until stopped by tight IR , preventing further upgaze. Bells phenomenon is
usually poor.
• In Type 2 MED, cases of primary SR palsy are included. FDT is free & upward saccades
are slow both below & above midline.
• Bell’s phenomenon is usually absent.
8. • Type 3 MED is supranuclear type & is usually congenital.
• It is characterized by intact or mildly reduced vertical saccadic velocity below
midline but abnormal or absent velocity above midline & FDT is free.
9. Pathophysiology
• It has been established that superior rectus is the main muscle responsible for
elevation of the eye, be it in abduction, adduction or primary position.
• Thus, the defective elevation can be explained by presence of a superior rectus palsy
alone, inferior rectus restriction can also be considered as a cause of MED in
presence of a normal superior rectus.
10. Pathophysiology :
• Efferent tracts for upgaze leave the rostral interstitial nucleus of the medial longitudinal
fasciculus (riMLF), cross the midline in the posterior commissure, course through the
pretectum & enter the superior rectus (SR) subnucleus of the oculomotor nucleus,
leaving the subnucleus, upgaze fibres to the SR immediately cross the midline again.
• As a result of double decussation of upgaze fibers, the SR receives innervation from
ipsilateral riMLF as well as contralateral pretectum & SR subnucleus. In cases of MED, it
is presumed that supranuclear input from riMLF into third cranial nerve nucleus is
interrupted. Supranuclear deficiency affects upgaze, therefore causes monocular
elevation deficiency.
11. Clinical
feature
• Age: Average age of presentation is 14 years as reported in previous studies.
• Gender: No gender predisposition
• Vertical deviation , head posture , diplopia & ptosis
• BINOCULAR FIXATION : patient keep their head tipped backward & maintain binocular
fusion , visual acuity is normal in this patients . The posture adopted by these patients
Dolls head phenomenon
to move the eyes by means of in to the field of action of the
depressors of the globe.
12. Clinical features :
• However when these patients hold their head erect in primary position their may
occure : hypotropia of the affected eye & vertical diplopia .
• Fixation with uninvolved eye : shows hypotropia in involved eye . Pseudoptosis (
that is ptosis disappears when the patient fixates with the paretic eye ) . True ptosis
due to associated LPS weakness may be present in 50% of cases . True ptosis does
not resolve when patient fixates with paretic eye .
• Amblyopia of the affected eye with visual acuity of 6/60 or less
• Diplopia is absent .
13. Chief Complaints
• Vertical misalignment of the eyes
• Diplopia
• Abnormal head posture
• Inability to elevate the affected eye
• Drooping of eyelid
• Decrease vision
• Fixation with involved eye : shows following features : hypertropia of normal eye
which is greater due to secondary deviation , visual acuity in the normal eye may be
reduced , & true ptosis due to associated weakness of LPS may be present .
14. CLINICAL FEATURES :
• Limitation of elevation ( in adduction as well as abduction, both on version & ductions )
beyond midline is main characteristic of this condition .
• Other clinical characteristics :
• An extra or deep lower lid fold on the affected side may be seen in patients with IR
muscle restriction.
Bells phenomenon
• : is poor / absent with IR muscle restriction .
• Positional tonometry : with applanation tonometer shows a rise in IOP of more than 3mm Hg in 15
degree upward gaze as compared to that in primary gaze in patient with restrictive limitations . But no
such significant increase in IOP occurs in paretic weakness
15. Signs
• Ptosis/Pseudoptosis: Ptosis can be associated with hypotropia because of fascial
attachments between levator palpebrae superioris & superior rectus muscle..
Pseudoptosis & true ptosis both the components can be present in the patient.
• In these cases when the patient is made to fix with the affected eye, ptosis partly
recovers. True ptosis when present is usually complex type & is associated with
Marcus Gunn Jaw Winking phenomenon (MGJWP).
Amblyopia
• may be present if there is a constant deviation of affected eye or
associated ptosis, or anisometropia .
16. • Abnormal Head Posture : Most commonly patient has a chin elevation if
binocular fusion is present. Abnormal head posture may not be present if the
affected eye is amblyopic.
• Upward Saccades: Upward saccades are slow/floating in cases of SR palsy, absent
above the midline in supranuclear palsy & intact (coming to an abrupt halt) in
cases associated with IR restriction .
17. • Bell’s phenomenon is usually absent in cases of IR restriction & SR palsy as they
limit the upward rotation of globe, but Bell's is usually present in cases of MED
resulting from supranuclear defects.
• Deviation: There is hypotropia of the affected eye when the normal eye is fixing , but as the
affected eye takes up fixation there is hypertropia of the normal eye. MED cases may also have
co-existent horizontal deviations.
18. Diagnostic procedures
• Forced duction test
• Forced duction test is a clinical test which should be done pre-operatively to reveal
any restriction.
• The test is typically performed under topical anaesthesia, conjunctiva is held at
limbus with Pierce Hoskin forceps or globe holding forceps, & patient is asked to look
in opposite direction of testing muscle to relax the concerned muscle. A positive
Forced Duction Test (FDT) is seen in patients of IR restriction.
19. • Active Force Generation Test
• Active force generation test is done under topical anaesthesia by asking the
patient to look in the direction of muscle being tested, presence of a tug is
suggestive of residual SR action.
20. • Diplopia Charting
• Red & green glasses over right & left eyes respectively, dissociate the two images
& would be seen double.
• Test can be done both for distance & near, with the help of illuminated slit target.
The slit is used vertically for charting horizontal deviations & horizontally for
charting vertical deviations. The seperation between two images is recorded & is
useful in diagnosis & follow-up.
21. Hess Screen & Lees Screen
• Hess Screen & Lees Screen is used to document relative incomitance & underactions
& is based on haploscopic principle. Two test objects are shown to the patient which
is seen as one localisation.
• Hess Screen consist of a three and a half feet black cloth marked with a series of red
lines forming a square of 5 degree each. From the central zero point three squares
15 degree marks the inner square and outer square has excursion of 30 degree.
22. • The outer square is used for mild incomitances not detected on inner square
charting. Patient wears a red green glass, with red glass in front of right eye and
green glass in front of left eye, patient is given a green pointer which he aligns on
the red dots and the observer records the points.
• Lees Screen is also similar but does not require red green glass instead uses a
mirror septa to cause dissociation of two eye.
23. Differential diagnosis
• Brown’s Syndrome is characterised by limitation of elevation in adduction, with
divergence in upgaze caused by slippage of globe resulting in characterstic Y pattern .
• Vertical Duane Syndrome can be diagnosed by the presence of globe retraction in
downgaze along with limitation of elevation in upgaze.
• Congenital fibrosis of extra ocular muscles initially affecting inferior recti can be
misdiagnosed as MED.
• …….Bilateral presentation involvement of other extraocular muscles are features that
help distinguish it.
24. • Partial third nerve palsy involving the superior division of oculomotor nerve may
simulate the findings of MED.
• Progressive external ophthalmoplegia involves multiple extra ocular muscles.
• Orbital inflammatory disease and orbital cellulitis present with a tender inflamed
globe.
26. Management
• Management of MED includes both non-surgical & surgical components.
• Non-surgical management
• The correction of underlying refractive error is to be done & amblyopia therapy is
given if needed, followed by surgery whenever indicated.
27. Indications of surgery ?? ??
• Which include …….
• Significant vertical deviation in primary gaze
• Significant abnormal head posture/ AHP
• Deviation-induced amblyopia
• Diplopia in primary gaze, & restricted binocular fields.
28. GOAL OF SURGERY …
• The goal of surgery is to improve the position of
the affected eye in primary gaze & to increase
binocular field of vision.
• The surgery of choice in the management of
monocular elevation deficit depends on results of
forced duction test. FDT
• In patients with positive forced duction test, inferior
rectus recession is the first choice of management.
29. • In patients with negative forced duction test
but a positive active force generation test,
superior rectus resection can be done.
negative
• In patients with FDT /forced duction
test & a negative active force generation test
/ATGT Knapp's procedure is preferred.
30.
31. • Knapp's procedure
• Knapp’s procedure is commonly practiced & is now a well-established treatment
for MED syndrome . In the Knapp’s procedure, the tendons of the medial & lateral
rectus muscles are transposed to the insertion of the superior rectus muscle.
• Knapp’s in his work studied 15 patients over a period of eight years. The
procedure showed marked variability correcting 21-55 PD (average 38 PD)
hypotropia .
32. • Modifications of Knapp's procedure
• For management of MED cases with associated horizontal deviation partial
tendon Knapp’s (Modifed Knapp’s) procedure has been described, in which the
superior part of equally divided horizontal muscles is placed near the superior
rectus muscle insertion, allowing the correction of horizontal deviation with the
untouched inferior half.
33. • Augmented Knapp's procedure, Knapp's procedure can be combined with
posterior fixation sutures on the horizontal recti, known as Augmented Knapp's.
• Following the surgical correction of hypotropia & improvement in Bell’s
phenomenon, associated ptosis and/or Marcus Gunn phenomenon be addressed.
34. • Contralateral superior rectus recession
• Contralateral superior rectus recession can be an option of management in the
patients with residual hypotropia after inferior rectus recession.
35. • Modified Nishida's for monocular elevation deficit / MED syndrome
• No split no tenotomy technique by Nishida et al has originally been described for
abducen nerve palsy, the procedure has been found to be useful in the
management of monocular elevation deficit by Murthy et al and can help in
correction of upto 30 pd of vertical deviation with low risk of anterior segment
ischemia
36. Management of Acquired MED
• As there are wide variety of causes of acquired MED, thorough investigations
(general, ophthalmologic, neurologic, neuro-ophthalmologic & orthoptic (ocular
motility work up) should be undertaken, & management varies according to the
underlying cause.
37. Complications
• Ptosis can lead to refractive error & amblyopia, also if ptosis surgery is done before the strabismus
surgery it can lead to exposure keratopathy as most of the patients have
phenomenon.
poor Bell's
• Surgical complications :
• Anterior segment ischemia : presenting with corneal edema, thinning, non
pigmented keratin precipitates, iris atrophy & anterior chamber flare.
• Anterior segment ischemia can result if three or more adjacent recti surgery has
been done in one eye, adults with atherosclerosis, previous radiation therapy &
retinal detachment surgery are more vulnerable.
38. • The complication can be avoided if two vertical recti along with one horizontal
recti are not operated in the same sitting.
• Management includes, systemic & local corticosteroid .
• Overcorrections & undercorrections.
• Tenon's prolapse & conjunctival cyst can result due to improper apposition of the
conjunctiva which allows Tenon's to prolapse & interferes with healing process.
39. • Corneal dellen formation can occur due to disruption of tear film & local
dehydration.
• Other intraoperative complications like surgery on wrong eye, wrong muscle,
hemorrhages, scleral perforation,slipped muscle, bradycardia, infections may also
occur in patients undergoing surgery.
41. Points to remember
• Recession of IR muscle : useful for presence of inferior restriction for a vertical deviation up to
18-20 D
• Recession of the IR muscle plus resection of SR is indicated when in the presence of inferior
restriction & the deviation is more than 18 to 20 D
• KNAPPS procedure usually corrects 20 to 35 PD of hypotropia in primary position. Knapp after
IR recession usually has greater effect
• Augmented transposition using posterior fixation suture should be done for large hypotropia >
35 PD with no IR restriction
• Modified Knapp’s : if horizontal deviation is present then recess- resect & also transpose the
MR & LR muscles .