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By covering one failure is due to the same named muscle for the right eye on eye it can be shown which eye this image belongs to. First decide whether the diplopia is horizontal or vertical image is that of the right eye, and green in front of the left from the history of the patient and by testing with red eye. However, by this method, fne details regarding tilting and green goggles, red in front of the right eye. If horizontal: diplopia chart should be plotted with either eye fxing, if l Find the position of gaze where the separation of the possible. It will be observed that there is a greater separa images is maximal—right or left by moving a light tion of images when the affected eye is fxing on the target in the horizontal plane. If vertical: occurs in the horizontal line to the right in paralysis of l Find the position of gaze where the separation of the the right lateral or left medial rectus, to the left for the left images is maximal, moving the light vertically in lateral or right medial rectus. If the separation is greatest above For vertical movements the action of four muscles must there is an elevator palsy, if greatest below there is be analysed. In view of the obliquity of their course the recti are l Find out if the separation is maximal to the right most effective as vertical rotators as the eyes are ab (above or below) or to the left (above or below). Chapter | 27 Incomitant Strabismus 439 l the diagnosis can be further confirmed by perform l Step 3: Tilt the patient’s head towards each shoul ing the 3-step test and the head tilt test. Remembering that on tilting the head Tests to Help Identify the Affected Muscle towards one shoulder the eye on the same side intorts Tests to help identify the affected muscle in a patient with and the other eye extorts, the ipsilateral synergist of paralysis of one of the vertically active extraocular muscles: the paralysed muscle will try to intort or extort the I. Park 3-step test globe as the case may be, and since the muscle also l Step 1: Identify the hypertropic eye in the primary has a vertical action, that vertical effect will be more (straight ahead) position. Remembering that the deviation increases in oblique palsy, for example, the right hypertropia will the direction of action of the paralysed muscle, iden become more prominent when the head is tilted to tify which two of the four muscles are likely to be the right shoulder and will disappear when the head affected (Fig. To measure the degree of deviation, especially if torsional, and particularly to measure any progressive increase or de crease, the Hess screen test (Fig. It consists of a tangent screen marked in red lines on a black cloth with red spots at the intersection of the l5° and 30° lines with themselves and with the horizontal and vertical lines; over it three green threads are suspended in such a way that they can be moved over the screen in any direction by a pointer. The patient, wear ing red-and-green glasses, is asked to place the junction of the three threads over the red spots in turn. Through the red glass A he can only see the red markers and through the green, the green threads, so that he indicates the point at which one eye is looking when the other fxes a spot. The position on which the indicator appears to coincide with the spot gives a permanent record of the primary and secondary deviation. In a comitant squint the felds of each eye, although relatively displaced, are equal in area and undistorted; in paretic squint the area on the affected side is diminished away from the affected muscle and in spastic squint it is increased towards the affected muscle. Another test based on a similar haploscopic principle of sepa rating the felds of view of both eyes is the Lees screen test, B where a mirror is used with an illuminated screen (Fig. Affection of several muscles simultane ously is usually due to paralysis of the third nerve. All the extrinsic and intrinsic muscles of one or both eyes may be paralysed—total ophthalmoplegia. If only the extrinsic mus cles are affected the condition is called external ophthalmople gia; if only the intrinsic muscles (sphincter pupillae and ciliary muscle) are affected it is termed as internal ophthalmoplegia.
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These superficial, nonhealing corneal ulcers are characterized by the presence of chronic (>1 week) ulceration with redundant, loose epithelial borders and no evidence of stromal involvement, infectious agents, or in flammatory cellular infiltrate7,13–15 (Fig. Note the poorly defined ulcer margins and the underrunning of fluorescein beyond the edge of the ulcer, indicating poorly adhered epithelium. Ophthalmologic Disorders in Aged Horses 251 affect horses of any age but they seem to be more common in middle-aged to aged patients. Keratocyte density seems to be higher in younger individuals than in adults16 and there is also thickening of the epithelial basement membrane with age,8 which may contribute to the delayed healing. Perhaps more importantly there is a decrease in the nerve density at the level of the sub-basal plexus, below the epithelium. Studies assessing the corneal touch threshold with a Cochet Bonnet esthesiometer showed a significant decrease in corneal sensitivity between young (<10 years) and old (>15 years) horses, and this decrease was more marked if the older horses were showing clinical signs of pituitary pars intermedia dysfunction. Animals are born with a fixed number of corneal endothelial cells, and this number decreases gradually with age. Because these cells do not divide, cell loss induced by age or disease cannot be reversed. In addition, this accumulation of fluid can induce the separation of the corneal epithelium from the underlying stroma in the form of small blisters known as bullae8 that may also affect ulcer healing. Primary corneal endothe lial dystrophy has been reported as a cause of age-related corneal edema in horses, frequently presenting clinically as a central vertical band17 (Fig. This condition should be differentiated from other potential causes of corneal edema, such as glau coma, uveitis, or traumatic injury. Central, vertical band of corneal edema in an otherwise normal eye of a 19-year-old warmblood gelding. Serial measurements of the intraocular pressure have always remained within normal limits. Posterior uveitis can be more difficult to diagnose and is characterized by vitritis with liquefaction of the vitreous, vitreal floaters, and retinal changes. Because of the recurrent nature of the disease, changes associated with previous episodes are sometimes noted in an otherwise quiescent eye; these include corneal scarring, iris depigmentation, synechiae, granula iridica degeneration, cataracts, glaucoma, phthisis bulbi, and fundic changes10,21 (Fig. Secondary complications such as cataracts and glaucoma are frequent (see elsewhere in the text) and vision can be significantly affected. Frequently in these cases treatment is directed to avoid further deterioration and control the painful epi sodes. An 18-year-old Welsh section D gelding showing signs of chronic intraocular inflam mation in his right eye. Note the abnormal superior limbal margin, ruptured granula iridica, abnormal pupillary margin with numerous synechiae and dense cataract. Ophthalmologic Disorders in Aged Horses 253 are 2 routes by which the aqueous humor exits the eye: the conventional and the un conventional pathways. With age, the trabecular meshwork changes histologically: the trabecular endothelial cellularity is reduced and the outflow spaces are decreased, which may account for an increase in intraocular pressure observed in older horses.
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The patient should immediately have an eye to cause chorioretinal adhesions and prevent future retinal shield applied and be thoroughly examined under general detachments. Evaluation for repair should be done at the same Occasionally in a corneal wound caused by a dirty im time. The gravity of such injuries is due to the immediate plement or vegetable matter, pyogenic organisms are carried damage to the eye, post-traumatic iridocyclitis (a common into the eye, multiply there and cause rapid necrosis of sequel to a perforating wound), the introduction of infection the entire cornea. In these cases a ring of deep infltration and sympathetic ophthalmitis, one of the most dreaded com appears 2 or 3 mm internal to and concentric with the plications of perforating wounds. If the organism is Pseudomonas aeruginosa (an anaerobic Gram negative rod), there is extensive chemosis of the conjunctiva, Wounds of the Conjunctiva sometimes with a greenish discharge. Enzymes released Wounds of the conjunctiva are common and should be by the organism cause liquefaction of the cornea. The institution of intensive treatment with appropriate local and systemic antibiotics and a thera Wounds of the Cornea and Sclera peutic keratoplasty may occasionally save such eyes. The margins swell up If it fnds access into the anterior chamber, pyogenic soon after the accident and become cloudy due to accumu infection leads to a purulent iridocyclitis with hypopyon, lation of fuid, thus facilitating closure of the wound and endophthalmitis and usually panophthalmitis. If small and limited to the centre, corneal wounds heal well unless they become Wounds of the Lens infected, in which case treatment is like that of a perforating ulcer (Fig. Such wounds cause traumatic cataract and are always a If the wound is large, an adhesion of the iris or its serious complication. In small recent injuries, the entry of aqueous causes a localized cloudiness in its the prolapsed iris should be replaced with the help of intra vicinity and, irrespective of the site of the wound, opacities ocular miochol or pilocarpine and the wound repaired with in the form of feathery lines appear in the posterior cortex, 10-0 nylon sutures. If the iris appears non-viable, it must which later develop into a rosette-shaped cataract resem be abscised and the edges of the wound sutured directly re bling that of early concussion cataract (Fig. Occa placing fxed anatomical landmarks such as the limbus into sionally the wound in the capsule becomes sealed, particu continuity frst and then suturing anteriorly and posteriorly as larly if a posterior synechia develops, in which case these required. However, they usually progress limbus are sutured completely after a thorough exploration. The integrity of the They are also treated with surrounding cryoapplications posterior lens capsule must be assessed pre-operatively so that appropriate surgery is planned. If the lens is damaged, it rapidly opacifes and focculent grey masses protrude through the opening in the capsule, sometimes flling the whole chamber. A traumatic cataract of this type is liable to lead to serious complications if not aspirated at once. The swelling of the lens keeps the iris in contact with the cornea and a secondary glaucoma may ensue. The treatment of traumatic cataract in association with penetrating wounds, especially if complicated by vitreous loss, is by the use of a vitrectomy instrument. The aim of surgery is to remove the cataract, perform an adequate vitrectomy, suture the globe as a primary procedure, and insert an intraocular lens in suitable cases.
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It is defined as a lateral curvature of the spine more than 10 degrees with vertebral rotation (Reamy & Slakey, 2001; Roach, 1999; Smith et al. Males and females are affected equally but evolution of the curve is more frequent in females than males (Miller, 1999). It can be classified as neuromuscular, congenital, or idiopathic which is the most common form of scoliosis (Reamy & Slakey, 2001; Smith, Sciubba, & Samdani, 2008). Idiopathic scoliosis can be categorized as infantile (0 to 3 years), juvenile (4 to 9 years), and adolescent (≥ 10 years); the most common form of idiopathic scoliosis is adolescent idiopathic sclerosis (Reamy & Slakey, 2001; Roach, 1999; Smith et al. Scoliosis requires frequent radiographic examination to assess the curve, identify underlying etiology, and help in treatment decision (Yvert et al. Nevertheless, there is growing concern on radiation-based harm on the long-term among children who undergo repeated x-rays (Bone & Hsieh, 2000; Doody et al. Back to Top Date Sent: 3/24/2020 382 these criteria do not imply or guarantee approval. It is a bi-planar technology that is based on two perpendicular fan beams of X-rays and proprietary detectors that travel vertically while scanning the patient. Micro dose option for pediatric follow up exams provides lesser radiation exposure. It is believed that the quality of image is high and therefore improves diagnostics. These diseases include scoliosis (Gummerson & Millner, 2010), the main indication, sagittal deformities (kyphosis), and lower limbs deformities. Main limitations: Results were limited to patients with moderate scoliosis (mean Cobb angle was 18. Inter-reader reproducibility and reliability of every single vertebra rotation was good but limited for the axial rotation. The authors reported great intra and interobserver reliability in sagittal curvatures, pelvic variables and global sagittal balance. The authors reported that intraoperator © 2018 Kaiser Foundation Health Plan of Washington. Back to Top Date Sent: 3/24/2020 383 these criteria do not imply or guarantee approval. Criteria | Codes | Revision History repeatability was better than inter-operator reproducibility for all clinical measurements. Primary outcome was patient health outcomes; and secondary outcomes were radiation dose and quality of image. Study characteristics included: sample size varied from 49 to 140 patients; patients were children and adolescents undergoing follow-up for scoliosis or required spine radiographs for the diagnosis of scoliosis or for follow-up; mean age was 14. Quality assessment: the overall risk of bias was high; due to study design, risk of bias, and precision issues, the quality of evidence from the systematic review was considered low.
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Crocodile tears, or lacrimation when salivating, due to reinnervation following a lower motor neurone facial nerve palsy, may also fall under this rubric, although there is no movement per se (autonomic synkinesis), likewise gustatory sweating. Abnormal synkinesis may be useful in assessing whether weakness is organic or functional (cf. Synkinesis may also refer to the aggravation of limb rigidity detected when performing movements in the opposite limb. Cross References Crocodile tears; Ewart phenomenon; Froment’s sign; Gustatory sweating; Hoover’s sign; Jaw winking; Pseudo-Von Graefe’s sign; Rigidity -341 T ‘ Table Top’ Sign the ‘table top’ sign describes the inability to place the hand flat on a level surface, recognized causes of which include ulnar neuropathy (mainengriffe), Dupuytren’s contracture, diabetic cheiroarthropathy, and camptodactyly. This has been reported in patients with cerebrotendinous xanthomatosis, particularly in the 20–40-year age group. Tachyphemia Tachyphemia is repetition of a word or phrase with increasing rapidity and decreasing volume; it may be encountered as a feature of the speech disorders in parkinsonian syndromes. Cross Reference Parkinsonism Tactile Agnosia Tactile agnosia is a selective impairment of object recognition by touch despite (relatively) preserved somaesthetic perception. This is a unilateral disorder result ing from lesions of the contralateral inferior parietal cortex. Braille alexia may be a form of tactile agnosia, either associative or apperceptive. Tactile agnosia: underlying impairment and implications for normal tactile object recognition. Cross Reference Agnosia Tadpole Pupils Pupillary dilatation restricted to one segment may cause peaked elongation of the pupil, a shape likened to a tadpole’s pupil. In ataxic disorders, cerebellar (midline cerebellum, in which axial coordina tion is most affected) or sensory (loss of proprioception), the ability to tandem walk is impaired, as reflected by the tendency of such patients to compensate for their incoordination by developing a broad-based gait. Cross References Ataxia; Cerebellar syndromes; Proprioception; Rombergism, Romberg’s sign Tasikinesia Tasikinesia is forced walking as a consequence of an inner feeling of restlessness or jitteriness as encountered in akathisia. This may be the earliest indication of a developing temporal field defect, as in a bitemporal hemianopia due to a chiasmal lesion, or a monocular temporal field defect (junctional scotoma of Traquair) due to a distal ipsilateral optic nerve lesion. Cross References Hemianopia; Scotoma Temporal Pallor Pallor of the temporal portion of the optic nerve head may follow atrophy of the macular fibre bundle in the retina, since the macular fibres for central vision enter the temporal nerve head. Cross Reference Optic atrophy Terson Syndrome Terson’s syndrome refers to vitreous haemorrhage in association with any form of intracranial or subarachnoid haemorrhage. They may temporarily be voluntarily suppressed by will power (perhaps accounting for their previous designation as ‘habit spasms’) but this is usually accompanied by a growing inner tension or restlessness, only relieved by the performance of the movement. The belief that Tourette syndrome was a disorder of the basal ganglia has now been superseded by evidence of dysfunction within the cingulate and orbitofrontal cortex, perhaps related to excessive endorphin release.
