The document provides an overview of the pupillary pathway, including its anatomy, physiology, and clinical aspects. It describes:
- The afferent and efferent pathways that control the pupillary light reflex and near response.
- Clinical tests to evaluate the pupillary light reflex, including for anisocoria, RAPD, and other defects.
- Causes and features of different types of pupillary defects affecting the afferent pathway (e.g. optic nerve lesions) or efferent pathway (e.g. Horner's syndrome, Adie's tonic pupil).
visual field- its assessment, defects, diseases associated. Types of visual field defects. visual field defects in glaucoma in detail. Humphrey's visual field analyser chart.
visual field- its assessment, defects, diseases associated. Types of visual field defects. visual field defects in glaucoma in detail. Humphrey's visual field analyser chart.
This presentation gives a brief idea about angle of anterior chamber along with its structures and diagnostic methods to grade and visualize the structures.
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anatomy of optic nerve and its blood supply and clinical corelation
Presentation Layout: optic nerve anatomy
Embryology of optic nerve
Introduction
Parts of optic nerve
Blood supply
Clinical significance
For Further Reading
Wolff’s Anatomy of the eye and orbit by Bron, Tripathi and Tripathi
Anatomy and Physiology of eye by A.K. Khurana 2nd edition
Comprehensive Ophthalmology by A.K. Khurana 5th edition
AAO- Fundamentals & Principles of Ophthalmology : sec 2
Walsh and Hoyt’s Clinical Ophthalmology
Internet
This presentation gives a brief idea about angle of anterior chamber along with its structures and diagnostic methods to grade and visualize the structures.
Direct Download Link ❤❤https://healthkura.com/eye-ppt/28/❤❤
Dear viewers Check Out my other piece of works at ❤❤❤ https://healthkura.com/eye-ppt/❤❤❤
anatomy of optic nerve and its blood supply and clinical corelation
Presentation Layout: optic nerve anatomy
Embryology of optic nerve
Introduction
Parts of optic nerve
Blood supply
Clinical significance
For Further Reading
Wolff’s Anatomy of the eye and orbit by Bron, Tripathi and Tripathi
Anatomy and Physiology of eye by A.K. Khurana 2nd edition
Comprehensive Ophthalmology by A.K. Khurana 5th edition
AAO- Fundamentals & Principles of Ophthalmology : sec 2
Walsh and Hoyt’s Clinical Ophthalmology
Internet
importance of pupil in clinical applications.examination of pupil can highlight underlying afferent and efferent pathway defects.eg Argyl robertson pupil
Antibiotic Stewardship by Anushri Srivastava.pptxAnushriSrivastav
Stewardship is the act of taking good care of something.
Antimicrobial stewardship is a coordinated program that promotes the appropriate use of antimicrobials (including antibiotics), improves patient outcomes, reduces microbial resistance, and decreases the spread of infections caused by multidrug-resistant organisms.
WHO launched the Global Antimicrobial Resistance and Use Surveillance System (GLASS) in 2015 to fill knowledge gaps and inform strategies at all levels.
ACCORDING TO apic.org,
Antimicrobial stewardship is a coordinated program that promotes the appropriate use of antimicrobials (including antibiotics), improves patient outcomes, reduces microbial resistance, and decreases the spread of infections caused by multidrug-resistant organisms.
ACCORDING TO pewtrusts.org,
Antibiotic stewardship refers to efforts in doctors’ offices, hospitals, long term care facilities, and other health care settings to ensure that antibiotics are used only when necessary and appropriate
According to WHO,
Antimicrobial stewardship is a systematic approach to educate and support health care professionals to follow evidence-based guidelines for prescribing and administering antimicrobials
In 1996, John McGowan and Dale Gerding first applied the term antimicrobial stewardship, where they suggested a causal association between antimicrobial agent use and resistance. They also focused on the urgency of large-scale controlled trials of antimicrobial-use regulation employing sophisticated epidemiologic methods, molecular typing, and precise resistance mechanism analysis.
Antimicrobial Stewardship(AMS) refers to the optimal selection, dosing, and duration of antimicrobial treatment resulting in the best clinical outcome with minimal side effects to the patients and minimal impact on subsequent resistance.
According to the 2019 report, in the US, more than 2.8 million antibiotic-resistant infections occur each year, and more than 35000 people die. In addition to this, it also mentioned that 223,900 cases of Clostridoides difficile occurred in 2017, of which 12800 people died. The report did not include viruses or parasites
VISION
Being proactive
Supporting optimal animal and human health
Exploring ways to reduce overall use of antimicrobials
Using the drugs that prevent and treat disease by killing microscopic organisms in a responsible way
GOAL
to prevent the generation and spread of antimicrobial resistance (AMR). Doing so will preserve the effectiveness of these drugs in animals and humans for years to come.
being to preserve human and animal health and the effectiveness of antimicrobial medications.
to implement a multidisciplinary approach in assembling a stewardship team to include an infectious disease physician, a clinical pharmacist with infectious diseases training, infection preventionist, and a close collaboration with the staff in the clinical microbiology laboratory
to prevent antimicrobial overuse, misuse and abuse.
to minimize the developme
Defecation
Normal defecation begins with movement in the left colon, moving stool toward the anus. When stool reaches the rectum, the distention causes relaxation of the internal sphincter and an awareness of the need to defecate. At the time of defecation, the external sphincter relaxes, and abdominal muscles contract, increasing intrarectal pressure and forcing the stool out
The Valsalva maneuver exerts pressure to expel faeces through a voluntary contraction of the abdominal muscles while maintaining forced expiration against a closed airway. Patients with cardiovascular disease, glaucoma, increased intracranial pressure, or a new surgical wound are at greater risk for cardiac dysrhythmias and elevated blood pressure with the Valsalva maneuver and need to avoid straining to pass the stool.
Normal defecation is painless, resulting in passage of soft, formed stool
CONSTIPATION
Constipation is a symptom, not a disease. Improper diet, reduced fluid intake, lack of exercise, and certain medications can cause constipation. For example, patients receiving opiates for pain after surgery often require a stool softener or laxative to prevent constipation. The signs of constipation include infrequent bowel movements (less than every 3 days), difficulty passing stools, excessive straining, inability to defecate at will, and hard feaces
IMPACTION
Fecal impaction results from unrelieved constipation. It is a collection of hardened feces wedged in the rectum that a person cannot expel. In cases of severe impaction the mass extends up into the sigmoid colon.
DIARRHEA
Diarrhea is an increase in the number of stools and the passage of liquid, unformed feces. It is associated with disorders affecting digestion, absorption, and secretion in the GI tract. Intestinal contents pass through the small and large intestine too quickly to allow for the usual absorption of fluid and nutrients. Irritation within the colon results in increased mucus secretion. As a result, feces become watery, and the patient is unable to control the urge to defecate. Normally an anal bag is safe and effective in long-term treatment of patients with fecal incontinence at home, in hospice, or in the hospital. Fecal incontinence is expensive and a potentially dangerous condition in terms of contamination and risk of skin ulceration
HEMORRHOIDS
Hemorrhoids are dilated, engorged veins in the lining of the rectum. They are either external or internal.
FLATULENCE
As gas accumulates in the lumen of the intestines, the bowel wall stretches and distends (flatulence). It is a common cause of abdominal fullness, pain, and cramping. Normally intestinal gas escapes through the mouth (belching) or the anus (passing of flatus)
FECAL INCONTINENCE
Fecal incontinence is the inability to control passage of feces and gas from the anus. Incontinence harms a patient’s body image
PREPARATION AND GIVING OF LAXATIVESACCORDING TO POTTER AND PERRY,
An enema is the instillation of a solution into the rectum and sig
How many patients does case series should have In comparison to case reports.pdfpubrica101
Pubrica’s team of researchers and writers create scientific and medical research articles, which may be important resources for authors and practitioners. Pubrica medical writers assist you in creating and revising the introduction by alerting the reader to gaps in the chosen study subject. Our professionals understand the order in which the hypothesis topic is followed by the broad subject, the issue, and the backdrop.
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This conference will delve into the intricate intersections between mental health, legal frameworks, and the prison system in Bolivia. It aims to provide a comprehensive overview of the current challenges faced by mental health professionals working within the legislative and correctional landscapes. Topics of discussion will include the prevalence and impact of mental health issues among the incarcerated population, the effectiveness of existing mental health policies and legislation, and potential reforms to enhance the mental health support system within prisons.
3. The Afferent Pathway
Optic tract
Nasal Fibers decussate in optic chiasm
Travels centrally along the optic nerve
Ganglion cells
Rods and cones AND
Melanopsin Retinal Ganglion cells
4. The Afferent Pathway(contd.)
The Accessory motar nuclei of
EW nucleus
New relay fibers partially cross
over
Pretectal Nucleus
Midbrain from Lateral side of
Superior colliculus
5. The Efferent Pathway
Located inferiorly as it enters the
orbit
Passes laterally to petroclinod
ligament and dorsum sellae
Lie on the superficial dorsomedial
aspect as it leave the brain stem
The axons of the EW nucleus extend
into the III n.
8. Pathway of Convergence Reflex
Fibers form Medial Rectus m.
via III n.
Mesencephalic n. of V n.
Convergence Center in Tectal
or Pre Tectal Region
EW Nucleus
Efferent fibers travel along III
n.
Relay in Accessory Ganglion
Sphincter Pupillae
9. Pathway of Accommodation Reflex
Retina
Via Optic nerve,
Chaisma Optic Tract
Lateral Geniculate
Body
Striate Cortex
From the Para
Striate Cortex
Via
Occipitomesencephalic
Tract and Pontine center
EW Nucleus
Via III n. to
Sphincter Pupillae
10. Function of the Pupil
Functions:
Control in retinal Illumination
Reduction in optical aberration
Depth of Focus
Clinical Importance
Objective indicator of Light Input
Anisocoria
Pharmacological Indicator
Indicated level of wakefulness
11. The Light Reflex
The light reflex consist of simultaneous and equal
constriction of pupils in response to stimulation of
one eye by light
Pupil constriction is elicited with extremely low
intensities and is proportional within limits to both
intensities and duration of stimulus.
13. Near Reflex
Two components:
1. Convergence Reflex: Convergence of visual axis and
associated constriction of pupil
2. Accommodation Reflex: Increased accomodation and
associated constriction of pupil
Near Reflex Traid consists of:
- Increased Accommodation
- Convergence of Visual Axis
- Constriction of pupils
Both neurons in the EW nucleus stimulated from
SUPRANUCLEAR level
15. Method of Examination
Confirm that the pupils
respond to light
Compare the pupillary
diameters to one another.
The swinging flashlight test.
Normal responses Pathological findings
Anisocoria with normal responses
RAPD
Monocular or bilateral deficit
16. Near Reflex Test
Instruct the patient to look at the distant target
The examiner holds up a target containing fine detail
approximately 25cm from the patient
Ask the patient to fixate the near target and look for
pupil constriction
Note the speed of the constriction and the roundness
of each pupil
17. Afferent pupillary defects
Assessment of afferent input from the retina, optic nerve, and chiasm, optic
tract and midbrain till LGB
Damage anywhere along this portion of the visual pathway reduces the
amplitude of pupil movement in response to a light stimulus
The pupillary light reflex summates the entire area of the visual field, with
some increased weight given to the central 10°, is roughly proportional to the
amount of working visual field.
18. •Other objective tests of visual function, such as the electroretinogram
and visual evoked potential may be inadequate
Similarly, peripheral visual field defects caused by glaucoma or
anterior ischemic optic neuropathy may yield a normal visual
evoked potential, or false-negative result, but the pupillary light
reflex is reduced
19. Total Afferent Pathway Defect
Absence of Direct light reflex on affected side and
absence of consensual light reflex on normal side
When the normal is stimulated both pupils react
normally
Diffuse illumination both pupils are equal in size
Near reflex is normal in both eyes
20. RAPD (Relative Afferent Pupillary Defect)
RAPD cause a reduction in pupil contraction when one eye is
stimulated by light compared with when the opposite eye is
stimulated by light.
RAPD may be associated with visual field or electroretinographic
asymmetries between the two eyes.
Asymmetrical differences in retinal appearance or optic nerve
appearance may occur.
21. Grading Scale: RAPD
Grade 1+: A weak initial pupillary constriction followed by greater
redilation
Grade 2+: An initial pupillary stall followed by greater redilation
Grade 3+: An immediate pupillary dilation
Grade 4+: Immediate pupillary dilation following 6 sec illumination
Grade 5+: Immediate pupillary dilation with no constriction at all
However, most subjective grading of RAPDs has serious limitations,
such as some large-scale errors that arise from age variations in pupil
size and pupil mobility
22. Neutral Density Filters
Estimation of the amount of RAPD in log units provides an objective data.
Accurate quantification of RAPDs is accomplished by determination of the
log unit difference needed to “balance” the pupil reaction between the two
eyes
24. Wernicke’s Hemianopic Pupil
This phenomenon is caused by division of the optic tract that results
in a contralateral homonymous hemianopia.
The pupils fail to react when a narrow pencil of light is shone onto the
non-seeing part of the retina, but they do react if it falls onto the
seeing retinal areas.
It is also characterized by ptosis on the same side as the hemianopia
and anisocoria with the larger pupil also on the same side as the
hemianopia.
The macular area is often involved and optic atrophy may follow.
Wernicke's Hemianopic pupil occurs as a result of a lesion in the
optic tract in an area that precedes the splitting of the two types of
fibers.
25. Anisocoria
Anisocoria is defined by a difference in the size of the two pupils of 0.4
mm or greater.
Roughly one fifth of the normal population has an anisocoria, but the
difference in size is not more than 1mm.
Anisocoria or a difference in pupil size may be normal but may be a
sign of ocular or neurologic disease.
It should be considered a neurosurgical emergency if a patient has
anisocoria with acute onset of third-nerve palsy and associated with
headache or trauma.
26. Evaluation of anisocoria
To evaluate anisocoria, the examiner must determine
which pupil is abnormal by noting pupil size under light
and dark illumination.
If the difference in pupil size in both light and dark
illumination is constant, then it is called Physiologic or
Essential anisocoria
Helps differentiate and localize a lesion to one of the PS or
Sympathetic Pathway
27. But does not localize the lesion’s location within
those pathways.
Afferent pathways not affected
A lesion in the midbrain produces a subtle and
transient anisocoria.
However, most neurologic causes of anisocoria
involve lesions in the parasympathetic (efferent) and
sympathetic pupillary pathways.
28. If the Larger pupil is abnormal (poor constriction), the
anisocoria is greatest in Bright illumination, as the normal
pupil becomes small.
This is caused from the disruption of the
Parasympathetic (efferent) pupillary pathway. [BPL]
If the Smaller pupil is abnormal (poor dilation), the
anisocoria is greatest in Dark illumination, as the normal
pupil becomes large.
It is caused from the disruption of the Sympathetic
pupillary pathway.
32. Iris Trauma
An abnormal dilated pupil could be alarming to an examiner because
you must rule out third-nerve palsy from pharmacologic pupil dilation
and traumatic dilated pupil.
A traumatic dilated pupil could be ruled out clinically by careful
history and biomicroscopic examination.
A patient with traumatic iris sphincter damage will present with torn
pupillary margin or iris illumination defects seen on biomicroscopic
examination.
33. Adie’s Tonic Pupil
Adie’s tonic pupil refers to an idiopathetic tonic pupil
Adie’s syndrome is applied when both tonic pupil and associated
hyporeflexia are present
Causes:
Idiopathic/ Trauma
Local Disorders: Tumor, Inflammation, Surgery, Infection
within the orbit affecting ciliary ganglion
Systemic Neuropathies: DM, GB syndrome, Ross’s syndrome,
Riley Day syndrome
Unilateral in 80% to 90% of cases and may become bilateral at a rate
of 4% per year.
34. Adie’s Tonic Pupil (contd.)
Due to damage to the ciliary ganglion or postganglion fibers of the
short posterior ciliary nerves.
This subsequently leads to dilated pupil and anisocoria (light > dark).
It has minimal or no reaction to light but slow reaction to
accommodative response due to damage to the parasympathetic
innervation to the eye.
35. Intact near pupillary reflex due to the ratio of fibers that control
the near pupillary reflex is much greater as compared to those
that control the light pupillary reflex.
Preservation of the pupil constriction in accommodation may be
result of accommodative fiber aberrant regeneration
Some accommodative fibers formerly destined for the ciliary
body now travel to the pupil becoming misdirected and supply
the iris sphincter.
36. Features:
Symptoms:
Difference in the size of the pupils
Unilateral blurred vision
May be asymptomatic
Critical Signs:
Anisocoria (Light > Dark)
Slow pupillary constriction to near response and slow redilation
Iris sphincter sector palsy
Segmental pupil response – “vermiform” pupil response
movement.
Other Characteristics:
Decreased amplitude of accommodation
Diminished deep tendon reflexes of the knee and ankle – Holmes-
Adie syndrome.
37. Oculomotor Nerve (CN III) Palsy with or
without Pupil Involvement
Neuro Surgical Emergency
Presentation:
Complete or Partial Palsy with or without pupil involvement
Complete or Partial Ptosis which may mask the diplopia
Its clinical presentation depends on the location of the dysfunction
along the pathway between the oculomotor nucleus in the midbrain
and its branches of the oculomotor nerve
38. DDx: ischemia, aneurysm, tumor, trauma, infection, inflammation or
congenital anomalies.
Diagnosis is critical if pupil in involved
Sparing of the pupil is an important diagnostic sign for ruling out a
more serious etiology such as aneurysm or tumor.
Most pupil sparing cases are microvascular in origin such as diabetes
or hypertension.
39. As a rule of thumb, a patient with sudden onset of painful third-nerve
palsy with pupil involvement and no history of trauma or vascular
disease should assume an intracranial aneurysm until proven
otherwise.
The most common site of an intracranial aneurysm causing third-
nerve palsy is :
The posterior communicating artery
Internal carotid artery and basilar artery
Life-threatening emergency : Potential of rupturing and leading to
subarachnoid hemorrhage (within hours or days)
40. Sympathetic Pupillary Defects
Disruption along the sympathetic pupillary fibers from hypothalamus to iris
dilator.
Causes of Miotic Pupils:
Horner's Syndrome (Oculosympathetic paralysis)
Argyll Robertson Pupils
Long-Standing Adie's Pupil
Pharmacologic Agents:
Unilateral use of miotic drops:
Pilocarpine
Drugs causing miosis : Narcotics, Barbiturates, Chloral hydrate, Morphine,
Propoxyphene,Tamsulosin
Uveitis, pseudoexofoliation syndrome and recent eye surgery
42. First Order Second Order Third Order
Arnold-Chiari malformation Pancoast tumor Internal carotid artery dissection
Basal meningitis (e.g., syphilis) Birth trauma with injury to lower
brachial plexus
Carotid cavernous fistula
Basal skull tumors
Pitutary Tumor
Aneurysm/dissection of aorta
Subclavian or common carotid
artery
Raeder syndrome (paratrigeminal
syndrome) - Oculosympathetic
paresis and ipsilateral facial pain
with variable involvement of the
trigeminal and oculomotor nerves
Cerebral vascular accident
(CVA)/Wallenberg syndrome
(lateral medullary syndrome)
Lymphadenopathy (Hodgkin
disease, leukemia, tuberculosis,
mediastinal tumors)
Herpes zoster
Demyelinating disease (e.g.,
multiple sclerosis
Central venous catheterization
Intrapontine hemorrhage Mandibular tooth abscess
Lesions of the middle ear (e.g.,
acute otitis media)
Neck trauma Neuroblastoma
43. Features
Symptoms:
Difference in the size of the pupils
Droopy eyelid
Often asymptomatic
Critical Signs:
Anisocoria (dark illumination > light illumination)
Miotic pupil with intact light and near reactions
Mild ptosis (less than 2 mm due to Muller’s muscle)
. Reverse ptosis (lower lid elevation on same side)
Anhidrosis (first and second-order neuron) lesions
Apparent enophthalmos
Other Characteristics:
Iris heterochromia (lighter iris color in congenital cases)
Increased amplitude of accommodation
Ocular hypotony
44. Pharmacologic Testing:
Negative 4% or 10% cocaine testing (no pupillary dilation)
1% hydroxyamphetamine: Localizing the lesion
First and secod-order neuron lesions (preganglionic) show
pupillary dilation
Third-order neuron lesions (postganglionic) show NO pupillary
dilation
The dilation of Horner’s pupil is due to the denervation
hypersensitivity of the postsynaptic alpha-1 receptor in the pupil
dilator muscles.
45. Pupillary Light-Near Dissociation
LND refers to any situation where the light reaction is absent and
pupillary near reaction is present
The near reflex fibers are more ventrally located than the light reflex
fibers, thus the near reflex fibers are spared even with afferent light
reflex fiber lesions.
IF unilateral or bilateral and it’s associated ocular manifestations such
as extra-ocular muscle abnormalities and nystagmus (Parinaud’s
syndrome).
47. Argyll Robertson Pupils
Argyll Robertson pupils are miotic pupils with irregular in shape.
It is usually bilateral, but asymmetric.
The light reflex is absent or very sluggish, but the near reflex is normal
(light-near dissociation).
Rule out Tertiary Syphillis
48. Features of ARP
Involvement is usually Bilateral but Asymmetrical
The retinae are sensitive to light
The pupils are small in size and irregular in shape
The light reflex is absent but near reflex is present
Dilate poorly with mydriatics like Atropine
Physiostigmine may cause further constriction
Editor's Notes
Melanopsin Retinal Ganglion cells act via the input received from the rods and cones but also a direct transduction of light invokes a light reflex.
Fibers pass into the midbrain from the lateral side of superior colliculus
Reach the Pretectal nucleus where they terminate.
New relay fibers partially cross the posterior commisurae ,go ventrally from the aqueduct
They reach the Accessory motar nuclei of EW nucleus on both Ipsilateral and contra lateral side
From the inferior division of the III n. by the way of its branch to Inf Oblique m .
A short and a thick nerve trunk reaches the ciliary ganglion.
Myelinated PG PS terminate in synapses with ganglionic neurons.
The PG fibers innervate the sphincter pupillae.through the short ciliary
Affeerent fibers from MR via III n.
To Mesencephalic nuclei of 5th n
To convergence center in Tectal or Pre Tectal region
From convergence center to EW nucleus
Efferent fibers travel along the III n.
Relay in accessory ganglion
Reaches the sphincter pupillae
From Retina to Para striate cortex
Via ON,chiasma,OT, LGB,optic radiation and Striate cortex
Relay the impulses from para striate cortex to EW nucleus of both sides
Via the occipito mesencephalic tract and the pontine center
Efferent fibers travel along the III n.
Relay in accessory ganglion
Reaches the sphincter pupillae
Left tonic pupil: greater anisocoria in light illumination (above) than dark illumination (below).
Right tonic pupil (light-near dissociation from aberrant degeneration): the dilated right pupil (above) constricts slowly and progressively until it becomes slightly smaller (below) than the simultaneously constricted left pupil.
Neurosurgical emergency if a patient has anisocoria with acute onset of third-nerve palsy and associated with headache or trauma.