Geetha Jayaram, M.B.B.S., M.D.
- Co-Director, Short Stay Unit
- Professor of Psychiatry and Behavioral Sciences
https://www.hopkinsmedicine.org/profiles/results/directory/profile/0004486/geetha-jayaram
We are fortunate our pub lishing partners at Review of Optometry continue to support this project and we remain enthusiastic about its mission: to bring Iyou concise symptoms of breast cancer quality synthroid 200 mcg, evidence-based advice that can be clinically useful for managing all eye diseases medications not to be crushed buy synthroid cheap online, be they commonplace or rare treatment chronic bronchitis buy synthroid 100mcg mastercard. In the era when the Handbook launched symptoms throat cancer order synthroid canada, we three were early in our careers as educators. We remember creating actual slides using Kodachrome or Ektachrome for printed text with clinical images on the same medium. Once created, there would be no further editing as we do today with PowerPoint and similar programs. Today, we are able to use software to create digital presentations, which easily allow for embedding videos, audio and animations. We have encountered colleagues who told us that they kept all the old copies of the Handbook for reference and wished that they could have everything in one place. In keeping with the technological revolution, this summer we and Review of Optometry are launching the Handbook of Ocular Disease Management in new digital forms: a down loadable mobile app as well as a stand-alone website. The project will allow us to place more pictures with the text, keep a running archive of all the entities rather than just the 30 we traditionally publish in each printed version, and update the project regularly as new information becomes available. Instead of a stack of printed manuals that take up a lot of space, you literally will have everything at your fingertips. And updates will come to you once per quarter to keep the material fresh and relevant. Creating it is one way we can give back to the profession that has enriched our lives and sustained our careers. We thank our teachers who not only shared with us their knowledge but pro vided inspiration, we thank our mentors for guidance and advice that allowed us to grow and excel, and we thank the Review of Optometry staff for promoting and protecting this project. We hope you find both the print version and the new digital incarnation useful to you during practice. We strive to create a resource that answers questions, solves problems, reviews concepts and makes your clinical life easier. Sowka is a founding member of the Optometric Glaucoma Society, the Optometric Retina Society and the Neuro-ophthalmic Disorders in Optometry Special Interest Group. He is a founding member of the Optometric Retina Society and a member of the Optometric Glaucoma Society. Gurwood has lectured and published nationally and internationally on a wide range of subjects in ocular disease. He is an attending physician at the Eye Center in both the Adult Primary Care service and the Advanced Care Ocular Disease service. Kabat is a founding member of both the Optometric Dry Eye Society and the Ocular Surface Society of Optometry. The authors have no direct financial interest in any product mentioned in this publication. Most individuals with adduction, and, in some cases, a pupil that disorders acting locally at the level of congenital blepharoptosis develop adapta is dilated and unresponsive to light. Most commonly, neurogenic self-image problem combined with func blepharoptosis involves local dehiscence, ptosis implicates either the levator muscle tional limitations can have psychological stretching and disinsertion of the levator via oculomotor palsy. It may also be seen in cases acquired blepharoptosis reveals a narrowed upper eyelid. The most Distance from the corneal light reflex to common etiologies include trauma, lid Marginal Reflex Distance 4mm to 5mm the upper eyelid margin tumors, dermatochalasis and conjunctival Distance between the upper and lower scarring. The use of a prosthetic ptosis myogenic or neurogenic blepharoptosis is considered essential. These include upper crutch (also known as lid crutch) attached reserved for those cases that fail to resolve lid height, marginal reflex distance, palpebral to the spectacle frame can provide relief spontaneously or with first-line treat fissure height, levator function and margin from some of the major symptoms ment. Levator normal values for these are listed in the principle advantage of this modality is muscle resection is typically employed accompanying table. It should be noted diminished cost without the risks of surgi when the levator function is >5mm, while that age, gender and race may influence cal intervention. Blepharoptosis may be graded in contact lenses when used for this purpose) Cases of mechanical blepharoptosis severity using the upper lid height and may also be helpful as an alternative or are the easiest to remedy, in principle, marginal reflex distance as follows: adjunct treatment to surgery. Procedures such as for oculoplastic consultation and treat a patient with acquired blepharoptosis is levator resection and aponeurosis tighten ment. Blepharoptosis that is myogenic or roptosis as a separate and distinct cat Some examples of pseudoptosis include neurogenic in nature is best managed egory, but experience suggests that eyelid patients with small globes. Diagnostic evaluation is criti plete and accurate history, reviewing old Blepharoptosis of an aponeurogenic cal in such instances, and, in addition to photographs may often help to differenti nature is typically bilateral and often a comprehensive ocular examination, the ate a congenital or long-standing ptosis asymmetrical such that the patient com workup may involve neuroimaging, diag from an acquired ptosis. If the lid does not spontane an increased margin-crease distance and drome), serologic testing for autoantibod ously re-evert, then levator function is normal or increased levator function in ies, muscle biopsy or genetic testing. Eyelid movements in health will be unilateral except in those rare cases and disease. The supranuclear impairment of the palpebral rologic etiology and may implicate such involving the third nerve nucleus. Diagnosis of and most common complaint in myasthe tensilon-negative ocular myasthenia gravis by daily selfie. Advances in the diagno sleep test, the patient rests with eyes closed sis and treatment of ptosis. Relative incidence of nificantly after this, myasthenia should be blepharoptosis subtypes in an oculoplastics practice at a ter rotates inward against the ocular sur suspected. Anatomic changes in involutional laterally or bilaterally and may involve the blepharoptosis. Patients with myasthenia will blepharoptosis induced by prolonged hard contact lens wear. The long and wind Clinical features associated with entro during the course of this test. The obvious gross finding is pack is placed over the closed eye for two contact lens wearers. Not only skin or eyelashes contacting the bulbar hard contact lens wear but also soft contact lens wear ment in ptosis following this is suggestive may be associated with blepharoptosis. Surgical treatment of variable corneal pathology, ranging from blepharoptosis caused by chronic progressive external ophthal noted to have a variable ptosis. Eye may be variably affected, depending upon with attempted adduction); limitation of (Lond). Blepharoptosis Most commonly, entropion occurs as cal movements; adduction of the involved and floppy eyelid. Acquired ptosis secondary to eye on attempted elevation or depression; vernal conjunctivitis in young adults. Ophthal Plast Reconstr however, it can also represent cicatricial and absent vertical optokinetic response. Exophthal trauma, particularly those who are under nuclear pathway, a condition referred to mometric value and palpebral fissure dimension in an African 60 years of age. Clinical evaluation and management of ent as a congenital disorder, secondary to condition is characterized by inability to ptosis. Scleral contact Pathophysiology lens usage in patients with complex blepharoptosis.
In recent years medications 2 cheap synthroid 200 mcg fast delivery, considerable effort has been made to improve erosion prediction after 0 0 wildfire through the development and refinement of 0 20 40 60 80 100 120 new models (Elliot and others 1999 sewage treatment cheap 100 mcg synthroid mastercard, 2000) symptoms rheumatic fever purchase synthroid 100mcg without a prescription. However treatment 3 degree heart block cheap synthroid 125 mcg visa, no 20 statistical difference was found in the geologic parent material and the percent of burned area that was 15 water repellent. Robichaud and Hungerford (2000) also found no differences in the water repellant condi 10 tions with various soil types. Comparison of reduction in 0 infiltration rate to percentage of area that was water 0 20 40 60 80 100 120 repellent showed no statistically significant relation Design Storm Return Period (yr) ship (fig. However, Robichaud (2000) and Pierson and others (2001a) showed a 10 to 35 percent reduction Figure 10. Estimation methods for expected changes in chan nel flow due to wildfire were variable but primarily usually less than 24 hours, with the common design based on predicted change in infiltration rates. Some of the percentage of burned watersheds that have reports show a large percent increase in design flows water repellent soil conditions. Fire-induced water repellency was not significantly different by parent material (t-test, alpha = 0. As an emergency treat 20 ment, rapid vegetation establishment has been re 10 garded as the most cost-effective method to promote 0 rapid infiltration of water and keep soil on hillslopes 0 10 20 30 40 50 60 70 80 90 100 (Noble 1965, Rice and others 1965, Miles and others Water Repellant Area (%) 1989). Legumes are often added to seeding mixes for their ability to increase 100000 available nitrogen in the soil after the postfire nutri ent flush has been exhausted, aiding the growth of 10000 seeded grasses and native vegetation (Ratliff and McDonald 1987). Seed mixes were refined for particu 1000 lar areas as germination and establishment success were evaluated. Most mixes contained annual grasses 100 to provide quick cover and perennials to establish longer term protection (Klock and others 1975, Ratliff 10 and McDonald, 1987). However, nonnative species that persist can delay recovery of native flora and alter 1 local plant diversity. Native grass seed can be expen 0 20 40 60 80 100 sive and hard to acquire in large quantities or in a timely manner compared to cereal grains or pasture Infiltration Reduction (%) grasses. When native seed is used, it should come from a nearby source area to preserve local genetic integ Figure 10. In steep areas and in areas where access is limited, aerial seeding is often the only option. Ground seeding, applied from all-terrain ve hicles or by hand, assures more even seed application Hillslope treatments are intended to reduce sur than aerial seeding. Seeding is often combined with face runoff and keep postwildfire soil in place on the other treatments, such as mulching and scarifying, as hillslope and thereby prevent sediment deposition in these additional treatments help anchor the seeds and unwanted areas. Both conditions hillsides and laying them on the ground along the also reduce loss to rodents. The potential advantage of slope contour to provide mechanical barriers to water seeded grass to inhibit the growth and spread of flow, promote infiltration, and reduce sediment move noxious weeds also depends on timely application and ment. The potential the soil surface that functions like the organic forest volume of sediment stored is highly dependent on floor that is often destroyed in high and moderate slope, the layout design, the size and length of the severity burn areas. Both wet mulch (hydromulch) felled trees, and the degree to which the felled trees are and dry mulch (wheat straw, jute excelsior, rice straw, adequately staked and placed into ground contact. In and so forth) are available; however, mulches have some instances contour-felled log barriers have filled only recently been used as a postfire rehabilitation with sediment following the first several storm events treatment. Mulch is applied alone or in combination to after installation, while others have taken 1 to 2 years reduce raindrop impact and overland flow and, thereby, to fill (Robichaud 2000). It is this treatment was originally designed to provide often used in conjunction with grass seeding to provide the same function as contour trenches and furrows. It also intercepts pre the primary function of the Contour Log Basins or cipitation for subsequent infiltration. Mulch protects Contour Log Terraces was to detain and infiltrate the soil and improves moisture retention underneath runoff from a design storm. To accomplish this, logs it, benefiting seeded plants in hot areas but not always ranging generally from 6 to 12 inches (15 to 30 cm) in in cool ones. Hydromulch can be applied from the air using helicopters fitted Where: S = spacing of log courses down slope measured with hydromulch slurry tanks or buckets, which are horizontally in feet. Wind is exceeded, the structure provides some secondary either blows the mulch off site or piles it so deeply that benefit by reducing slope length, which interrupts seed germination is inhibited. Use of a of their small size, the effective life of properly in tackifier or felling small trees across the mulch may stalled treatments is only a few years at most. Hydromulches often have signed and underdesigned treatments with wide spac tackifiers that help bind the mulch in the soil. In subsequent passes, the trench is rainfall areas of the West Coast, contour log basins tipped into the slope, forming a basin. In these cases, contour logs are pass, bulldozers back out and push up baffles that placed in the same manner as above, but the exception segment the trench and allow flows to equalize into is that they will provide only secondary benefits. Where: S = spacing of trench courses down slope Shallow, rocky soils that are uneven are problem measured horizontally in feet. Contour trenches require a required and the limited capacity to detain runoff or minimum of 4 feet (1. They work best in gravelly tler slopes and finer textured soils (except clayey loams and have been applied in granitic soils and clay soils) lead to better installation and greater runoff soils with less success (Schmidt Personal Communica control efficiency. Granitic soils do not maintain a structural parent material such as granitics or glacial till, so shape well because of their coarseness and difficulty to much sediment can be mobilized that it might over get regenerated with cover. Availability of ad plastic with the addition of water, and in landslide equate numbers of straight trees must be considered prone topography, contour trenches can activate local when choosing this treatment. They are permeable barriers used to been used to break up the slope surface, to slow runoff, detain surface runoff long enough to reduce flow veloc to allow infiltration, and to trap sediment. With end sills, trenches or terraces are often used in conjunction with baffles, and on the proper design spacing, straw wattles other treatments such as seeding. Width and depth vary with design drainages or on side slopes for detaining small amounts storm, spacing, soil type, and slope. They should never be placed in main or with heavy equipment, trenches may result in consid active drainages. Straw wattles function similarly to erable soil disturbance that can create immediate contour-felled logs. In addition, erosion problems can be increased by turning 2 feet at each end of the wattle occur many years after installation when runoff cuts upslope. Shallow hand Straw wattles are relatively inexpensive, but they can trenches tend to disappear with time as they are filled be disturbed by grazing animals or decompose or catch with sediment and covered by vegetation. Although the wattle netting is photodegradable, hand, large trenches installed several decades ago are there are concerns that it persists long enough to pose still visible on the landscape. Slash is often used increase the amount of rainfall that infiltrates into the to rehabilitate firebreaks and dozer firelines. In addition, scarification can provide a seedbed used in moderately burned areas where there is more for planting that improves germination rates. Shallow material available to spread, or below an intensely soils, rock outcrops, steep slopes, incised drainages, burned slope or area of water repellent soils. To be fine-textured soils, and high tree density create sig effective, slash needs to be cut so it makes good contact nificant problems for scarification and ripping. Pannkuk and Robichaud (2003) indicate that hillslopes where they provide temporary sediment 50 percent ground cover can reduce interrill erosion by storage. Given the labor-intensive installation, they 60 to 80 percent and rill erosion 20 to 40 percent.
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