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The menstrual cycle of the uterus includes the following: (1) the menstrual phase (days 1–4) symptoms throat cancer order compazine 5 mg with amex, which is characterized by the necrosis and shedding of the functional layer of the endometrium medicine 3605 v cheap compazine 5 mg free shipping. Primordial germ cells (46 symptoms nausea 5mg compazine amex,2N) from the wall of the yolk sac arrive in the testes at week 4 of embryonic development and remain dormant until puberty symptoms anemia cheap compazine 5 mg online. At puberty, primordial germ cells differentiate into type A spermatogonia (46,2N). Type A spermatogonia undergo mitosis to provide a continuous supply of stem cells throughout the reproductive life of the male (called spermatocytogenesis). Primary spermatocytes complete meiosis I to form two secondary spermatocytes (23,2N). Spermatids undergo a postmeiotic series of morphological changes (called spermiogenesis) to form sperm (23,1N). Newly ejaculated sperm are incapable of fertilization until they undergo capacitation, which occurs in the female reproductive tract and involves the unmasking of sperm glycosyltransferases and removal of proteins coating the surface of the sperm. Prolonged dormancy of primary oocytes may be the reason for the high incidence of chromosomal abnormalities in offspring of older women. Since all primary oocytes are formed by month 5 of fetal life, a female infant is born with her entire supply of gametes. Primary oocytes remain dormant until ovulation; those ovulated late in the woman’s reproductive life may have been dormant for as long as 40 years. The incidence of trisomy 21 (Down syndrome) increases with advanced age of the mother. Clinical findings include severe mental retardation, epicanthal folds, Brushfield spots, simian creases, and association with a decrease in fetoprotein. Normally up to 10% of sperm in an ejaculate may be grossly deformed (two heads or two tails), but these sperm probably do not fertilize an oocyte owing to their lack of motility. Clomiphene citrate competes with estrogen for binding sites in the adenohypophysis, thereby suppressing the normal negative feedback loop of estrogen on the adenohypophysis. Figure 2-1 summarizes the events that occur during week 1, following fertilization. Penetration of the zona pellucida elicits the cortical reaction, rendering the secondary oocyte impermeable to other sperm. The sperm and secondary oocyte cell membranes fuse, and the contents of the sperm enter the cytoplasm of the oocyte. The zygote cytoplasm is successively cleaved to form a blastula consisting of increasingly smaller blastomeres. At the 16to 32-cell stage, the blastomeres form a morula consisting of an inner cell mass and outer cell mass. The outer cell mass, which becomes part of the placenta, is now called the trophoblast. The blastocyst implants within the functional layer of the endometrium during the secretory phase of the menstrual cycle. The rectouterine pouch (pouch of Douglas) is a common site for an ectopic abdominal pregnancy. Result from the fertilization of two different secondary oocytes by two different sperm; the resulting two zygotes form two blastocysts, which implant separately into the endometrium of the uterus. Hence, the twins are no more genetically alike than are siblings born at different times. Dizygotic twins and 35% of monozygotic twins have two placentas, two amniotic sacs, and two chorions. The resulting zygote forms a blastocyst in which the inner cell mass (embryoblast) splits into two. In 65% of the cases, monozygotic twins have one placenta, two amniotic sacs, and one chorion. Form exactly like monozygotic twins, except that the inner cell mass (embryoblast) does not completely split. Hence, two embryos form, but they are joined by tissue bridges at various regions of the body. She noted that she and her husband were trying to have a baby and that she had her last period about 5 weeks ago. She said that after talking with her girlfriends about her symptoms she was a little afraid of what it could be, so she decided to see a physician. Diagnosis • Ectopic pregnancy Chapter 3 Week 2 (Days 8–14) I Embryoblast (Figure 3-1) A. The embryoblast differentiates into two distinct cell layers: the dorsal epiblast and the ventral hypoblast. The epiblast and hypoblast together form a fiat, ovoid-shaped disk known as the bilaminar embryonic disk. Within the epiblast, clefts develop and eventually coalesce to form the amniotic cavity. Hypoblast cells migrate and line the inner surface of the cytotrophoblast and eventually delimit a space called the definitive yolk sac. The epiblast and hypoblast fuse to form the prochordal plate, which marks the future site of the mouth. The syncytiotrophoblast continues its growth into the endometrium to make contact with endometrial blood vessels and glands. The cytotrophoblast does divide mitotically, adding to the growth of the syncytiotrophoblast. Primary chorionic villi formed by the cytotrophoblast protrude into the syncytiotrophoblast. Extraembryonic somatic mesoderm (somatopleuric mesoderm) lines the cytotrophoblast, forms the connecting stalk, and covers the amnion (see Figure 3-1). The wall of the chorionic cavity is called the chorion and consists of three components: extraembryonic somatic mesoderm, cytotrophoblast, and syncytiotrophoblast. This is clinically significant because progesterone produced by the corpus luteum is essential for the maintenance of pregnancy until week 8. Will initiate menstruation when taken within 8–10 weeks of the start of the last menstrual period. If implantation of a conceptus has occurred, the conceptus will be sloughed along with the endometrium. A hydatidiform mole (complete or partial) represents an abnormal placenta characterized by marked enlargement of chorionic villi. A complete mole (no embryo present) is distinguished from a partial mole (embryo present) by the amount of chorionic villous involvement. The hallmarks of a complete mole include gross, generalized edema of chorionic villi forming grape-like, transparent vesicles, hyperplastic proliferation of surrounding trophoblastic cells, and absence of an embryo/fetus. Follow-up visits after a mole are essential because 3%–5% of moles develop into gestational trophoblastic neoplasia. This is due to the rapid proliferation of trophoblastic cells combined with marked propensity to invade blood vessels. The central portion of the lesion is hemorrhagic and necrotic with only a thin rim of trophoblastic cells at the periphery. She tells you that she had a miscarriage about 2 months ago and “all of a sudden these other problems come up. She said that she was supposed to come back in but she didn’t because she “felt depressed about losing the baby. Malnutrition and loss of appetite were excluded because she mentioned that she was eating a lot of food. All major organ systems begin to develop during the embryonic period, causing a craniocaudal and lateral body folding of the embryo. By the end of the embryonic period (week 8), the embryo has a distinct human appearance. During the embryonic period, the basic segmentation of the human embryo in a craniocaudal direction is controlled by the Hox (homeobox) complex of genes. Is a process that establishes the three primary germ layers (ectoderm, mesoderm, and endoderm), thereby forming a trilaminar embryonic disk. This process is first indicated by the formation of the primitive streak within the epiblast. Mesoderm gives further rise to paraxial mesoderm (somitomeres and 35 pairs of somites), intermediate mesoderm, and lateral mesoderm.

The disease may progress very rapidly medicine - compazine 5 mg, so a high index of suspicion needs to treatment of chlamydia compazine 5 mg lowest price be maintained if the diagnosis is to treatment esophageal cancer purchase compazine 5mg visa be made pathophySioloGy early enough for treatment to symptoms food poisoning discount compazine 5 mg visa be efective. The classical feature of the Development of the disease involves: disease is a petechial or purpuric rash (purple rash, which does not • Colonisation of the nasopharynx fade on pressure), but up to 20% of cases may have no rash or an atypical maculopapular rash. Symptoms of meningitis include: Both innate and acquired immune mechanisms are responsible for • Headache host protection. The resultant disease process may be focal infection (normally meningitis), septicaemia or both. About 60% of cases in • Fever Europe have evidence of meningitis and septicaemia, while about • Vomiting 20% have meningitis only and 20% septicaemia only. Endotoxin and other bacterial factors cause a host response that results in • Photophobia much of the damage. In infants, particularly, • Raised intracranial pressure the features can be very non-specifc; they frequently present with only: • Recent or prolonged seizures • Irritability • Cardiorespiratory compromise • Refusal to eat • Coagulopathy • Drowsiness • Infection at the site. If a positive microbiological diagnosis can be made from a skin Death is usually caused by refractory raised intracranial pressure. Unless contra-indication exists, patients with suspected meningitis Typically the rash spreads rapidly and can lead to widespread necrosis should have a lumbar puncture, but it should be done promptly and and gangrene of skin and underlying tissues. The rash is a visible should not delay giving the antibiotics by more than thirty minutes. It should only be used to exclude other diaGnoSiS causes for focal neurological signs or to investigate complications of Because of the need for immediate treatment once the disease meningitis. They may also ofer false reassurance since in fulminant treatment infections the white cell count, C-reactive protein and lumbar puncture may all be normal early in the disease. The initial initial assessment and resuscitation diagnosis is based on clinical history and examination. In hospital, assessment and cultures are more likely to be positive if taken before antibiotics are resuscitation of vital functions should occur together, with given. Priorities are: Tere have been a number of reports suggesting that major morbidity 1. Some experts believe that too few lumbar punctures • All patients should receive a high concentration of inspired are done and this remains a controversial area. Treat • Shock is recognised by the presence of an increased heart rate and shock aggressively if present. The patient should be immediately) and a decreased level of consciousness examined for the typical rash but this may not always be present. As soon as intravenous access is obtained, take blood for culture, biochemical (including • Activity against meningococci that are less sensitive to penicillin glucose) and haematological tests, and give antibiotics (see (due to a diferent penicillin binding protein) or resistant to later). Determine whether major neurological compromise exists: even if the cause for them is not immediately obvious. Other complications that may need treatment include: Patients with meningitis rather than septicaemia may develop raised intracranial pressure. This is particularly common, causes major morbidity if unrecognised, and is easy to treat. Determine the • Fluctuating or decreasing level of consciousness blood glucose when intravenous access is frst obtained • Unequal, dilated or poorly reacting pupils • Hypokalaemia • Focal neurological signs • Hypomagnesaemia • Abnormal posturing • Seizures • Hypocalcaema • Hypertension accompanied by tachycardia or bradycardia • Anaemia • Papilloedema is sometimes seen. As a result, many paediatric intensivists give a femoral line may be inserted as it is associated with less morbidity hydrocortisone in a replacement dose (1mg. The use of inotropes/vasopressors should be guided by clinical coagulopathy assessment and markers of ‘global metabolic status’: Deranged clotting is commonly seen as part of the septic process and blood products are often required to correct this. Long-term problems related to renal or myocardial function are less Choice of vasoactive drug should be guided by the clinical picture common. The haemodynamic picture Patients remain infectious for 24 hours after receiving a cephalosporin can change frequently during the frst 48 hours and high doses and should be isolated during this period. Widespread thrombosis and haemorrhagic necrosis of the skin and underlying tissues is called • If infection is due to serogroup A, W-135 or Y, contacts should “purpura fulminans”. When the thrombosis involves large vessels, also receive the quadrivalent conjugate vaccine. The combination of Further information on meningitis and meningococcal disease is ischaemia, necrosis and oedema can cause compartment syndrome. It has been suggested that fasciotomies are only indicated in the frst 24 hours after reFerenceS onset of purpura fulminans and only for compartment syndrome Law R. Update in Anaesthesia of the lower limb and where there is no major bleeding diathesis. Arch Dis Child 2002; 87: 181-3 possible; amputation should be an elective procedure. Deaxamethasone as adjunctive therapy in bacterial Tere is now evidence from randomised controlled trials of adults meningtis: A meta-analysis of randomised clinical trials since 1998. Eric Vreede, Anamaria Bulatovic, Peter Rosseel and Xavier Lassalle Correspondence Email: rachelhomer@doctors. In recent years it has regained popularity in both adult and paediatric resuscitation. Skin disinfectant ways to establish access for the rapid infusion of fuids, measure drugs and blood products in emergency situations as Indicated in life2. In many countries, where threatening situations children are the victims of war trauma, road trafc 3. Intraosseous infusion needle or Jamshidi bone aspect of the tibia to obtain and alternatives such as central venous access marrow needle. The 14 and 16G are usually used avoid the epiphyseal for children older than 18 months. Use an aseptic technique circulation and can therefore be used to infuse fuids It is possible but not ideal to use a 16 – 20G butterfy Crystalloids, colloids, and drugs, and to take blood samples for crossmatch, needle, spinal needle or even hypodermic needle. The procedure must be performed under chance that the needle gets blocked with bone marrow drugs can be infused sterile conditions to avoid causing osteomyelitis. It is however, is much increased when not using a needle Remove as soon as the also recommended to limit the duration of the use of with a trochar. In experienced hands intraosseous access can The best site to use is the fat anteromedial aspect of the be established within 1 minute. The anterior aspect of the femur and the superior the authors are members of the international medical aid iliac crest can also be used. Avoid bones with the intraosseous route are similar to those given osteomyelitis or fractures and do not use the tibia if Eric Vreede, Consultant intravenously. Use sterile gloves and an aseptic technique and a Anaesthesiologist in Breda fail (three attempts or 90 seconds) or in cases where it sterile needle. Inject a small amount of local anaesthetic in the skin and continue complicationS to infltrate down to the periostium. When the child is unconscious Important complications are tibial fracture especially in neonates, it is not necessary to use local infltration. Hold the limb frmly above the site of insertion, usually at the level be a clinical problem. Avoid putting your hand behind the site of insertion Provided the correct technique is employed there does not seem to be to avoid accidentally injuring your own hand. Fluid can be infused under gentle pressure, manually by using a 50ml syringe or by infating a blood-pressure cuf around the infusion bag. The intraosseous route should be replaced as soon as a normal vein can be cannulated and certainly within a few hours. Editors’ note Since this article was frst published, battery-powered insertion devices for intraosseous needles became available. Tese new devices are more expensive; some fnd them easier to insert and hence more reliable. Insertion of intraosseous needle in the right tibia reFerenceS Vreede E, Bulatovic A, Rosseel P, Lassalle X. Advance the needle using a drilling motion until a ‘give’ is felt – Update in Anaesthesia (2000)12:38-40. Check that the limb does not swell up and that there is no increase in resistance.

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This case study provides a perfect example of additional signs/symptoms contributing to medications migraine headaches buy 5 mg compazine amex a feeding disorder independent of the known primary medical diagnosis treatment lupus compazine 5mg fast delivery. The clinician forms a hypothesis regarding the location and severity of dysphagia medicine 3 sixes generic compazine 5 mg on-line, dependent on the clinical history of symptom onset and based on when signs and symptoms occur in relation to treatment 4s syndrome compazine 5mg free shipping the mealtime (Arvedson and Lefton-Greif, 1998). For example, if the child demonstrated marked post-swallow oral residue and required multiple swallows to clear the material, it would be reasonable to suspect a problem with the oral phase of the swallow, whereas marked pulmonary congestion and altered post-feed vocal quality might indicate potential pharyngeal phase difficulties, or aspiration. Clinical signs and symptoms can therefore help guide the clinician in determining areas for further investigation in their initial evaluation. Common clinical signs and symptoms of dysphagia associated with various aetiologies are reported throughout the body of this chapter. The reader is referred to the following papers for commonly reported clinical signs and symptoms of paediatric dysphagia associated with various aetiologies: Loughlin, 1989; Rogers et al. Common clinical signs noted in children with oral-motor impairment are: • lack of energy or endurance for oral feeding; • significant amount of oral residue remaining in mouth post-swallow; • excessive drooling/sialorrhea; • drooling in addition to speech/language delays; • prolonged mealtimes (30 minutes on average); • excessive gagging on oral secretions during feeds; • lip retraction/limited upper lip movement; • poor labial seal for sucking/removing food from spoon/preventing anterior spillage; • jaw thrust/jaw clenching/jaw retraction/jaw instability/tonic or phasic bite refiex; • tongue thrust, retraction, hypotonia, deviation, limited movement; • reduced buccal tone/reduced buccal sensory awareness; • reduced bolus formation and transport; • delayed or difficult initiation of swallow; • multiple swallows required to clear oral cavity. In order to assess oral-motor function adequately, the clinician must understand normal oral-motor development. These changes are intricately linked to neurological maturation, changes to oral structure, and postural development in the young infant. As one might expect, different skills are acquired in parallel with the introduction of new types of foods/fiuids in conjunction with new methods of presentation. For example, young infants are heavily dependent upon the breast or bottle delivering fiuids, and they must have adequate sucking skills to allow efficient stripping of fiuid into the oropharynx for swallowing in order to achieve adequate oral intake for growth. As solid foods are introduced via a spoon, alongside fiuids delivered via a cup, the child must develop more mature patterns of lip, tongue and jaw movement in order to again achieve efficient and successful oral intake for nutrition and survival. The present review details three primary stages of oral-motor development: sucking skills in infants less than six months of age, the transitional feeding period from six months up to three years, and the continued maturation of juvenile oral-motor skills to approximate adult oral-motor patterns. Initially, the infant’s movement patterns are bound largely by refiexes, which gradually develop from automatic into more refined voluntary feeding patterns (Stevenson and Allaire, 1991). Adequate structure and movement of the tongue, lips, cheek, jaw and palate is required in order for an infant to attain an optimal suck, and therefore to achieve efficient feeding and adequate oral intake. Any disruption in the structure or movement of these areas may result in disruption to the sucking mechanism, and typically in inefficient and reduced oral intake, see Tables 13. Suckle feeding Suckling involves the rhythmical compression of the lower jaw and tongue against the upper jaw and palate, and the lips forming an anterior seal with the nipple, resulting in the generation of negative intraoral pressure and thus suction (Herbst, 1983; Morris, 1989; Tuchman, 1989; Gisel et al. Tongue movement is partly limited due to the decreased size of the oral cavity, where it is bound laterally by the fatty buccal pads, posteriorly by the high position of the larynx, and anteriorly by the relatively small mandible (Stevenson and Allaire, 1991). A true suck is achieved later as greater lip pressure is developed to seal off the oral cavity, and the tongue moves up and down synchronously with the jaw achieving greater intraoral pressure and a more efficient sucking pattern (Morris, 1989; Stevenson and Allaire, 1991). Sucking should be rhythmical and there should be good coordination of sucking, swallowing and breathing, with approximately one cycle per second (Wolff, 1968). Problems with sucking the relative contribution and integration of the tongue, lips, jaw, buccal cavity and palate as documented in this review highlights how a disruption in either the anatomical structure, or the physiological movement may result in oral-motor dysfunction. Oral-motor impairment is likely to lead to inefficient sucking, and potentially poor oral intake, weight loss or an inability to gain weight, and failure to thrive. Premature infants and infants with congenital heart disease are particularly at risk for developing sucking difficulties, and these are also discussed. Organization/arrhythmicity One common problem noted with sucking is disorganization or arrhythmicity of the sucking pattern. This difficulty may occur due to general neurological disorganization, mild respiratory problems, or a nipple fiow rate that is incompatible with the infant’s sucking characteristic (Wolf and Glass, 1992). Morris (1989) noted that disorganization and arrhythmicity were characteristic of the majority of neurologically impaired infants. This is not surprising given that very premature infants who do not yet have the neurological maturity for sucking tend to demonstrate disorganized sucking patterns, which take longer to mature into the coordinated sucking patterns typically seen at around 35 weeks postmenstrual age (Gewolb, Bosma et al. Ineffective tongue movement or protrusion may interfere with the child’s sucking or compression mechanism. Whilst impairment of any oral structure may affect the coordination of sucking, swallowing and breathing, poorly graded or poorly controlled jaw movement significantly disrupts the rhythmical movements of the lips, cheeks and tongue due to the close anatomical attachment of these structures (Morris, 1989). Children with respiratory problems may also demonstrate lack of coordination of the sucking mechanism due to disruption to the rhythm and timing of breathing. Disorganized or arrhythmic sucking may be characterized by irregular bursts of sucking, random pauses, and possibly coughing or choking depending on the level of disorganization. Weak suck or reduced endurance A weak suck is characterized by limited generation of intraoral pressure and hence poor suction, and also by poor compression, leading to reduced liquid fiow. A weak suck of muscular origin typically occurs due to generalized muscle weakness or immature muscle development. Other medical conditions may result in a weak suck, where the child may be too ill or fatigued to generate adequate sucking pressure and compression. Children may begin with a strong suck initially which becomes weak over the duration of the feed (Wolf and Glass, 1992). Poor initiation of sucking Some children may not initiate feeding easily, being sleepy and hard to arouse, or showing limited appetite. The child with congenital heart problems or respiratory problems may commonly display this pattern of feeding behaviour. Other children may have excessive rooting to the stimulus of the nipple and be unable to inhibit the refiex in order to attach and begin sucking (Wolf and Glass, 1992). Neurologically impaired infants may be unable to attach properly due to extreme problems of oral and postural tone and aversive oral refiexes preventing mouth closure over the nipple. Other factors infiuencing sucking Postural stability, mobility, and sensorimotor development all infiuence oral-motor development. Sensorimotor development in particular is closely related to oralmotor development in the child from birth to approximately 8 months of age (Macie and Arvedson, 1993). Stability of the head, neck and shoulder girdle is required for adequate oral-motor function (Gisel et al. The sucking pads, small intraoral space, and larynx high in the neck provide adequate stability for oral movement in newborns who have not yet developed postural stability. Postural stability begins around the temperomandibular joint, and facilitates improved jaw control, which is required for further refinement of oral mobility and precision (Morris, 1982). Dysfunction or instability of the temperomandibular join has been documented to result in oral-motor problems in children (Bonjardim et al. Children with impairment of muscle tone affecting the body present with specific deficits in oral movement that refiect their dominant tonal patterns (Sheckman-Alper and Manno, 1996). Either fiexion or extension can lead to poor oral-motor movement and thus compromise oral intake. For example, hyperextension of the neck reduces jaw stability clinically associated with wider movements of the jaw, and jaw thrusting, whereas fiexion of shoulder girdle is associated with jaw clenching (Morris, 1989). The transitional stage encompasses the development of chewing skills, and the initiation of spoonfeeding and cup drinking. Development of chewing skills Tongue and jaw movement begin with movements in straight planes of extension and fiexion in the infant, in and out and up and down (Morris and Klein, 1987). At around 5 to 6 months, tongue movements increase in range to include lateral excursion and the tongue begins to move independently of the jaw (Bosma, 1985; Stolovitz and Gisel, 1991). In parallel with this oral-motor development, children are able to eat food with tiny lumps from approximately 7 to 10 months of age (Carruth and Skinner, 2002). Rotary jaw movement begins at around 10 to 12 months and will continue to develop into the child’s second year (Alexander et al. At approximately the same time, the tongue will begin to move laterally and diagonally to bring the food to the cutting edge of the teeth if further chewing is required, and to assist in oral preparation of the bolus (Stevenson and Allaire, 1991; Alexander et al. In conjunction with this development, children are able to begin chewing and swallowing firmer foods without choking from approximately 10 to 14 months of age (Carruth and Skinner, 2002). Controlled rotary jaw movements and tongue lateralization should be noted by approximately 2 years of age (Stevenson and Allaire, 1991). Thus, the increase in tongue lateralization typically occurs when jaw stability has developed. Movement of the lips, jaw and tongue become more differentiated so that in place of the rhythmical up-and-down movement of these structures noted during sucking, the jaw is now able to perform the finer graded movements required for chewing, being slightly more independent of the lips and tongue, and the lips and tongue in turn can also move independently of the jaw. A mature pattern of swallowing with tongue tip elevation is also noted at 12 months of age, and lip control develops so that the corners of the lips are actively drawn in to help in bolus transit (Stevenson and Allaire, 1991). Not surprisingly, chewing has been shown to become more efficient during this period of increased tongue mobility and jaw stability from 6 months to 2 years (Stolovitz and Gisel, 1991).

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Projector charts are not recommended for testing subnormal vision because of low contrast and insufficient letter choice at low acuities ombrello glass treatment effective 5mg compazine. Although relatively insensitive symptoms 1dp5dt effective compazine 5 mg, it can be used to 5 asa medications generic 5 mg compazine amex advantage in low vision medications given before surgery generic 5mg compazine with amex, particularly to identify the dominant eye. If the dot is seen, the patient is using either a viable macula or an eccentric viewing area. Then check the grid monocularly and again ask the patient to report seeing the center fixation dot and any distortion or scotoma. If the grid is presented in this manner, the patient understands what is expected and the test can provide helpful data. For example, if a large scotoma in the dominant eye overrides the better nondominant eye, the patient probably will require occlusion of the dominant eye. If the dominant eye is the better eye, it will override the poorer nondominant eye, and the patient can benefit from binocular correction. Tests of contrast express the functional level of retinal sensitivity more accurately than any other test, including acuity. Of the available tests for contrast sensitivity, the Mars test using letters arranged on three 14 fi 19 charts in 8 rows 999 2 of 6 letters each is rapid and accurate (Figure 24–2). Regardless of acuity, if contrast is subthreshold or in the severe loss category, the patient is less likely to respond to optical magnification. Simple color identification tests are done if the patient’s complaints include difficulty with color cues. Graded text is then presented to establish reading skills with the selected optical devices. Near-vision test charts, including the Lighthouse Continuous Text Cards for children and adults. A rule of thumb for the starting power is to calculate the reciprocal of visual acuity—for example, an acuity of 20/160 suggests a starting lens of 8 diopters (160/20). Keep in mind that visual acuity is not a particularly sensitive measure of function. Scotomas within the reading field and the contrast sensitivity of the paramacular retina have a greater influence on ability to read magnified print through an optical lens. After the dioptric range has been agreed upon, the three major categories of devices are presented in sequence in the selected power. Lenses in a spectacle mounting are presented and evaluated first, followed by hand-held magnifiers and, third, stand-mounted magnifiers. Telescopes and television or computerdesigned devices are increasingly prescribed as the population becomes more sophisticated in the use of advanced technology. Attention should be paid to daily living activities, which can be complemented by low-vision lenses but may also require referral to an agency for the visually impaired. The patient uses the various devices under the supervision of an instructor until proficiency is achieved. The patient is allowed ample time to learn correct techniques in one or more sessions and possibly provided a loaner lens for home or job trial. Older patients usually need more adaptation time and reinforcement than younger or congenitally impaired persons. Practitioners and staff benefit from training programs to learn how to manage a low-vision patient in the office. Basic setups for incorporating low vision into a practice are reviewed in a number of publications. If minor problems arise within the first few days after the appointment, they can usually be resolved by telephone. C: High-power reading spectacles with prisms to reduce the requirement for convergence. A: Reading and writing guides, marking devices, pill organizer, and liquid level indicator. The main advantage of spectacle (Figure 24–4A) and spectacle-mounted magnifiers (Figure 24–4B) is that both hands remain free to hold the reading material. They require the reading material to be held at the focal distance of the lens, for example, 10 cm for a 10-diopter lens. Increasing lens strength shortens the reading distance and increases the tendency to obstruct light. Patients with binocular function may use 4to 14-diopter spectacles with base-in prisms to reduce the requirement for convergence (Figure 24–4C). Dome magnifiers (Figure 24–4D and E), which are placed directly on the reading material, also allow both hands to be free, always provide a focused image, and maximize illumination, but the amount of magnification is limited, and there may be problems with distortion and light reflection. Hand magnifiers (Figure 24–4F–L) that can have colored illumination are convenient for shopping, reading dials and labels, identifying money, etc. They are often used by older people in conjunction with their reading glasses to enlarge print. The advantage is a greater working space between the eye and lens, but holding a lens may be a disadvantage for a trembling hand or stiff joints. Stand magnifiers 1009 (Figure 24–4M) are convex lenses mounted on a rigid base whose height is related to the power of the lens, for example, a 10-diopter lens is just under 10 cm from the page, writing on the material being read being possible with the lower magnification devices. Because the lens mounting may block light, a battery-powered light may be helpful. All telescopes share the disadvantage of a small field diameter and shallow depth of field. The simplest device is the hand-held monocular telescope (Figure 24–5A) used for short-term viewing, particularly of signs. For close tasks and vocational or hobby interests, telescopes mounted in (Figure 24–5B–D) or clipped on (Figure 24–5E) a spectacle frame are practical but difficult to use above 6fi. They are traditionally called “nonoptical devices,” although “adaptive aids” is probably a better term. In daily life, difficulty in reading is not the only frustrating experience for the low-vision person. Cooking, setting thermostats and stove dials, measuring, reading a scale, putting on makeup, selecting the correct illumination, identifying banknotes, and playing cards are only a few things that sighted people take for granted. Many devices are available for the visually impaired to assist in performing these tasks. The field is expanding rapidly, and it is important to keep up to date with available aids and resources. Light or medium gray lenses are prescribed to reduce light intensity, and amber or yellow lenses improve contrast and reduce the effect of short-wave light rays (Figure 24–7). Devices designed specifically for low-vision patients offer nonchangeable filters and photochromic (variable intensity tint) lenses. An additional antireflective coating should be considered for glare-sensitive patients. Trial lenses are advisable because each patient responds differently to the various available tints and to the degree of light transmission that the lens provides. Adequate task and ambient lighting is essential for persons who depend principally on the macula for vision, enhancing contrast, reducing glare, and simulating natural lighting. Light that is too bright may cause strain, glare, and photophobia, which may be relieved by introducing amber to yellow filters that block ultraviolet and visible blue light below 527 nm. Patients with early cataracts, macular changes, and corneal dystrophies may have difficulty reading with their current lighting. Light that does not scatter and is aimed directly on the print or task is preferred. Such systems encourage a natural reading posture and are a good choice for school children to help them see their class work and view graphs, diagrams, or photos. Portable video magnifiers (Figure 24–9) allow the visually impaired to read medication labels, mail, price tags, and menus, or view videos. The devices have built-in illumination and allow for contrast enhancement, color display, and 1011 variable magnification. Some have a built-in distance camera to allow viewing of signs, arrival and departure boards at airports, and classroom lectures. Electronic portable reading devices can download printed material such as books and newspapers, which can be read or listened to using text to speech options. The rapid development of devices for the general population has benefited visually impaired patients by increasing choice and reducing cost, allowing them to regain their independence more easily.

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