Jennifer M. Gierisch, PhD

• Associate Professor in Population Health Sciences
• Associate Professor in Medicine
• Member in the Duke Clinical Research Institute
• Member of the Duke Cancer Institute

https://medicine.duke.edu/faculty/jennifer-m-gierisch-phd

Slit Lamp Examination Although most young children who cannot cooperate with a slit lamp examination can be adequately evaluated with a muscle light medications reactions purchase retrovir 100 mg on line, at times more detailed examination is mandatory symptoms enlarged spleen order retrovir 300mg line. There are several handheld slit lamps symptoms 6dpiui buy cheap retrovir online, which have the advantage of being portable and useful in examining supine patients symptoms low blood sugar generic 100 mg retrovir mastercard. They are not very good for assessing mild intraocular infiammation or subtle corneal abnormalities symptoms lymphoma cheap retrovir 100mg amex, but they are the best alterna tive treatment knee pain discount retrovir amex. There are several other more readily available magnifiers such as the direct and indirect ophthalmoscope, both of which can be focused on the anterior segment. Often a child of 1 or 2 years will allow a quick look at the standard slit lamp; the key is to keep the light as dim as possible, have in mind what you most want to see, and look at that first. Intraocular Pressure Measurements Certain children are more prone to develop elevated intraocular pressure, and these patients must have accurate measurements. Such patients include aphakes, those with any anterior segment anomaly, those with orbital vascular lesions, or those on steroids. Most children under 3 years will not cooperate with routine applanation tonometry and they must be supine (sedated or restrained). The original Schiotz tonometer is easy to use and read but often is too large for the infant eye. It has the advantage of being less sensitive to pressures induced by lids or extraocular muscles but is more affected by ocular rigidity, which tends to be lower in infants. The Perkins tonometer is an applanation device using fiuorescein and a split prism to assess the pressure. It is highly accurate at all ranges of pressure but requires some experience on the part of the examiner to read and is unreliable with an abnormal corneal surface. The Tonopen is easier to use and can obtain approximate readings off the sclera or an irregular cornea, but it is not accurate at high or low pressures, and it is difficult to hear the tones that signal endpoint when the child is crying. Struggling and crying both cause swings in the intraocular pressure, which must be taken into account, and pressures taken with a calm child are more accurate. Chloral hydrate has the advantage of not lowering the pres sure, whereas inhalation anesthetics and Propofol can. Several conditions predispose to corneal astigmatism, which may be amblyogenic or require contact lens correction. Children with limbal dermoids or corneal scars may have poor retinoscopy refiexes, which make accurate assessment of astig matism difficult. The refiected image can be used to assess the axis of astigmatism and corneal regu larity. It is handheld and nonthreatening to most children but only gives a rough qualitative assessment. More accurate mea surements must be obtained with a keratometer; this may require a sleeping or sedated infant to get accurate readings, and the standard keratometer can be mounted on a special bar to use with supine infants. Alcon Corporation has produced a handheld ker atometer that has been very helpful in the pediatric age group. Dilatation and Cycloplegia Cycloplegia is essential to eliminate uncontrolled accommoda tion and adequately assess the refractive error in children. Several agents are available, but the adequacy of cycloplegia, not 18 handbook of pediatric strabismus and amblyopia the maximal pupil dilatation, is most important. Tropicamide is not a strong enough cycloplegic for young children; instead, cyclopentolate, homatropine, or atropine should be used. Cyclopentolate has the most rapid onset and shortest duration and thus lends itself to clinic use. For most children, one drop each of cyclopentolate 1% in combination with phenylephrine 2. For children less than 6 months old, it is safer to use diluted drops such as Cyclomidril (cyclopentolate 0. Homatropine 5% is another choice used for clinic dilation, especially in darkly pigmented patients, but this drop lasts up to 3 days. Both cyclopentolate and homat ropine produce maximal cycloplegia within 30min to 1h, but the former recovers within 1 day. If cycloplegia seems inadequate, based on either pupil size or changing retinoscopy streak, it is best to use atropine; this is usually given to the parents to take home and administer. To avoid toxicity of frequently administered atropine, the drops are given twice a day for 3 days prior to the visit. Atropine should not be given to children with possible heart defects or reactive airways. Punctal occlusion can be performed for 1min after the drops to decrease systemic absorption. Parents should be alerted to discontinue the drops if signs of toxicity or allergy develop (fiushing, tachy cardia, fever, delirium, lid edema, redness of the eyes). Most cases of toxicity respond to discontinuation of the drops, but more severe cases can require treatment with subcutaneous physostigmine (Eserine), 0. The phenylephrine drops will occa sionally cause blanching of the periocular skin, especially where the drop contacts the skin either by tears or a tissue; this is seen most often in infants and does not require treatment or discon tinuation of the drops. For examination of premature babies, dilate with cyclomidril (combination of cyclopentolate and phenylephrine) and tropicamide 0. Care must be taken to control the working distance and the chapter 1: pediatric eye examination 19 20 handbook of pediatric strabismus and amblyopia visual axis, or inaccurate readings will be taken. Expertise with loose trial lenses or a skiascopy rack is important as the phoropter is useless in small children. If the endpoint is unclear, it is best to get a second or even third reading, either by repeat refraction on another visit or by a second refractionist. There are several handheld autorefractors on the market now that show promise in pediatric application (Nikon Retinomax, Welch Allyn Suresight). Fundus Examination An adequate fundus examination is imperative for all children who present to the ophthalmologist. The extent of the fundus exam necessary will vary widely depending on the patient. For most patients visualization of the posterior pole (optic nerve and macula) is adequate; this is done quickly and easily in most chil dren by keeping the indirect light low and not touching the child. A brief look may be all that is obtainable by this tech nique, but this is often adequate. The optic nerve can be exam ined in more detail with the direct ophthalmoscope if the examiner is unhurried and stays several inches away from the child. By staying focused on the retinal vessels, the observer can see the nerve as it wanders into view while the child is busy watching a distant target (moving targets, especially videos, work best for this). For more detailed fundus examination or examination of the periphery, sedation or restraints are usually needed because most children will not tolerate the examining light for extended periods of time. As fundus examination comes at the end of the clinic visit, the child may be sleeping, espe cially if they have taken a bottle after the eyedrops, and this makes the examination much easier. Children less than 2 years old can usually be restrained adequately to allow a thorough fundus examination, even to the periphery, whereas older chil dren require examination under anesthesia if uncooperative. Use of high dose chloral hydrate for ophthalmic exams in children: a retrospective review of 302 cases. Visual acuity in human infants: a review and comparison of behavioral and electrophysiologic studies. Neuro-ophthalmologic examination: general con siderations and special techniques. The threshold contrast sensitivity function in strabismic amblyopia: evidence for a two type classification. Chloral hydrate sedation as a sub stitute for examination under anesthesia in pediatric ophthalmology. Peda tric photoscreening for strabismus and refractive errors and a high risk population. Evoked potential and preferential looking estimates of visual acuity in pedatric patients. A study of separation difficulty: its relation ship to visual acuity in normal and amblyopic eyes. Intramuscular meperidine, promethazine, and chlorpromazine: analysis of use and complica tions in 487 pediatric emergency department patients. Intraocular pressure changes following laryngeal mask airway insertion: a com parative study. Use in connection with any form of information storage and retrieval, electronic adaptation, computer software, or by similar or dissimilar methodology now known or hereafter developed is forbidden. While the advice and information in this book are believed to be true and accurate at the date of going to press, neither the authors nor the editors nor the publisher can accept any legal responsibility for any errors or omissions that may be made. There is no doubt that some features of the history can strike one with the force of a physical sign. Thankfully, the clinical examination still has some supporters (not merely apologists), and neurological signs feature prominently amongst the core competencies. Abdominal refiexes are said to be lost early in multiple sclerosis, but late in motor neurone disease, an observation of possible clinical use, particularly when differentiating the progressive lateral sclerosis variant of motor neurone disease from multiple sclerosis. Isolated weakness of the lateral rectus muscle may also occur in myasthe nia gravis. Abductor sign: a reliable new sign to detect unilateral non-organic paresis of the lower limb. Cross Reference Functional weakness and sensory disturbance Absence An absence, or absence attack, is a brief interruption of awareness of epileptic origin. Ethosuximide and/or sodium valproate are the treatments of choice for idiopathic generalized absence epilepsy, whereas carbamazepine, sodium val proate, or lamotrigine are first-line agents for localization-related complex partial seizures. The behavioural and motor consequences of focal lesions of the basal ganglia in man. Cross References Akinetic mutism; Apathy; Bradyphrenia; Catatonia; Frontal lobe syndromes; Psychomotor retardation Acalculia Acalculia, or dyscalculia, is difficulty or inability in performing simple mental arithmetic. The latter, though convenient and quick, is probably the least sensitive method, since absence of an observed muscle contraction does not mean that the refiex is absent; the latter methods are more sensitive. Cross References Age-related signs; Neuropathy; Refiexes Achromatopsia Achromatopsia, or dyschromatopsia, is an inability or impaired ability to per ceive colours. Optic neuri this typically impairs colour vision (red-green > blue-yellow) and this defect may persist whilst other features of the acute infiammation (impaired visual acuity, central scotoma) remit. The differential diagnosis of achromatopsia encompasses colour agnosia, a loss of colour knowledge despite intact perception; and colour anomia, an inability to name colours despite intact perception. There does seem to be an age-related loss of distal sensory axons and of spinal cord ventral horn motor neurones accounting for sensory loss, loss of muscle bulk and strength, and refiex diminution. Indeed, many complaints of loss of taste are in fact due to anosmia, since olfactory sense is responsible for the discrimination of many fiavours. Central processes run in the solitary tract in the brainstem and terminate in its nucleus (nucleus tractus solitarius), the rostral part of which is sometimes called the gustatory nucleus. Intact perception is sometimes used as a sine qua non for the diagnosis of agnosia, in which case it may be questioned whether apperceptive agnosia is truly agnosia. However, others retain this category, not least because the suppo sition that perception is normal in associative visual agnosia is probably not true. The difficulty with definition perhaps refiects the continuing problem of defining perception at the physiolog ical level. Cross References Agraphognosia; Alexia; Amnesia; Anosognosia; Aprosodia, Aprosody; Asomatognosia; Astereognosis; Auditory agnosia; Autotopagnosia; Dysmorphopsia; Finger agnosia; Phonagnosia; Prosopagnosia; Pure word deafness; Simultanagnosia; Tactile agnosia; Visual agnosia; Visual form agnosia Agrammatism Agrammatism is a reduction in, or loss of, the production or comprehension of the syntactic elements of language, for example articles, prepositions, conjunc tions, verb endings. From the linguistic viewpoint, two types of paragraphia may be distinguished as follows: Surface/lexical/semantic dysgraphia: misspelling of irregular words, producing phonologically plausible errors. Writing disturbance due to abnormal mechanics of writing is the most sen sitive language abnormality in delirium, possibly because of its dependence on multiple functions. Akathisia Akathisia is a feeling of inner restlessness, often associated with restless move ments of a continuous and often purposeless nature, such as rocking to and fro, repeatedly crossing and uncrossing the legs, standing up and sitting down, and pacing up and down (forced walking, tasikinesia). Treatment of akathisia by reduction or cessation of neuroleptic therapy may help, but may exacerbate coexistent psychosis. More usually in clinical practice there is a difficulty (reduction, delay), rather than com plete inability, in the initiation of voluntary movement, perhaps better termed bradykinesia, or reduced amplitude of movement or hypokinesia.

This time should be spent listening to what the client wants to achieve and for you to decide firstly whether your client is a suitable candidate for treatment (for example medicine 0829085 generic retrovir 300mg line, a lip treatment will not be suitable for darker skin tones as we will later discuss) and also whether you believe that you can successfully manage your clients expectations and that what they desire is appropriate medications blood thinners purchase generic retrovir. If there is any chance that the final outcome of the treatment is not an improvement symptoms 10 dpo cheap retrovir 100 mg fast delivery, we would never recommend carrying out the procedure medications by class buy generic retrovir on-line. A consultation will also allow for you to give the client a patch test (usually a small dot of pigment behind the ear) to ensure that when they come for their treatment medications used to treat adhd discount retrovir uk, they have no allergy to the pigment treatment enlarged prostate 300 mg retrovir mastercard. The next stage is carrying out the actual treatment which will be discussed in more depth later during this course pack, but in essence is comprised of the initial pre-drawing and then the actual cosmetic tattooing procedure. When you are still in the early stages of your Permanent Make Up career, it is important that you allow yourself enough time to carry out your treatment so that you do not feel under pressure or rushed. We generally recommend First Platform to Permanent Make Up that you block out a 2 hour interval for the initial treatment to make sure that you achieve the optimum results. As a beginner, it should certainly not take you any time shorter than 2 hours, and you may find that you require a longer period of time to produce the desired outcome. The client will be required to return after 2-12 weeks (depending on the treatment method) to complete the process, otherwise known as their retouch. The process will not necessarily be finished until the client has had this retouch, as some skins will not sufficiently retain the pigment from the initial session. Some clients may even need 2 retouches, although this is not common for experienced technicians. To keep the colour looking fresh and fabulous, we would suggest that on average, your client returns every 12 months for a yearly retouch, but if it is correctional/medical work that has been carried out, this time period may vary. The Importance of Hygienic Practices Effective use of hygiene practices are necessary in the salon to prevent cross-infection. Some germs are harmless, some are even beneficial, but others present a danger to us because they cause disease. Cross-infection occurs when microorganisms capable of causing disease and/or infection are transferred through personal contact or by contact with infected tools that have not been properly cleaned and sterilised. When you carry out your consultation it is important to check for any type of contraindication or signs of infection. Infection Infection occurs when the body becomes contaminated by micro-organisms, these usually include bacteria, fungal or viral causes. The reaction to the infection will depend on its cause and the part of the body which is infected. Secondary infection can occur if bacteria penetrate an existing injury or compromised skin that is already infected by a viral or a fungal infection. Clients with skin disorders that have caused the skin to crack and inflame should also not be treated as they are more susceptible to secondary infection. First Platform to Permanent Make Up Hygiene practices must always be strictly adhered to for every service offered as sometimes people have a contraindication they are not aware of. Sanitation and Sterilisation Refers to any procedure undertaken in the salon to remove contamination and reduce the risk of infection. Specific methods are required to ensure effective sanitisation of tools, equipment and implements have taken place. As a permanent make up practitioner, you have a duty of care and it is absolutely imperative that you provide a clean and sanitised environment and equipment for your client. It is very difficult to maintain sterile conditions as once the items have been exposed to the air they are no longer classed as sterile. Articles that have been cleaned, sterilised and stored hygienically are safe to use on clients. Disinfectants only reduce the number of organisms however this is usually sufficient for maintaining hygienic conditions. The object being sterilised must be turned regularly as only the surface being exposed to the light rays will be effectively treated. If there is debris or product residue on the instruments this will act as a barrier to the light penetration so effective sterilisation will be slowed down. The heat from the beads transfers to the objects effectively killing off microorganisms. It works similar to a pressure cooker using high pressure steam to cleanse the objects. Due to the higher levels of heat it is only suitable for certain objects and these should be cleansed before being placed in the autoclave. Waste disposal Disposal of waste should be in a sealed bin lined with a durable polythene bin liner. Clinical contaminated waste usually by blood and tissue fluid should be disposed of as recommended by the environment agency in accordance with the controlled waste regulations 1992. Any sharp implements that have been used to penetrate or pierce the skin should be placed in a sharps box. The local environmental health department will be able to advise you on disposal arrangements. All disposable waste matter following permanent make up First Platform to Permanent Make Up application is contaminated as it will contain blood and tissue fluid. The waste should be placed in an orange sack which indicates its level of risk and should be kept separate from all other general waste. Yellow bags are now provided to medical establishments as they are classed as clinical waste and are hazardous. Orange bags are generally provided to salons as they are classed as a potential hazard. Your local environmental health office can give up to date guidance on disposal of such waste. Pigment caps and all contaminated usable items, including the barrier film wrapping should be disposed of in the yellow waste bags 6. First Aid It is imperative that as a semi-permanent make up practitioner, you know basic first aid techniques acquired through a relevant course (such as those run by St. You should know how to deal with fainting and blackouts, panic attacks, heart palpitations and anaphylaxis, as well as cuts, burns and sprains. You should remove your gloves and squeeze the injured area hard so that it bleeds, and then run the area under cold water. You should apply a disinfectant such as neat Dettol and put a plaster on the broken skin. You may wish to carry out a risk-assessment on your client and visit the doctor if you feel you need. All practitioners should have had a Tetanus and Hepatitis B vaccination prior to entering the industry. Preliminary Consultation the preliminary consultation is used to understand what your client wants to achieve and to determine whether they are a suitable candidate for Micropigmentation. Their colourings will be assessed as well as any contraindications they may have that will prohibit them from having the treatment. It is during this consultation that you should be able to answer any questions that your client has and they should be given a patch test. Either at this point, or at the beginning of their procedure the client should be given a consent form to sign, giving you permission to carry out the treatment. Patch Test A patch test should be given to the client at least 24 hours prior to them having their treatment to help determine whether they have an allergy to either the pigment or anaesthetic. If the client comes to the clinic, a small dot of pigment and anaesthetic should be applied to an inconspicuous part of their body, for example behind the ear. If you are posting their patch test to them, you may wish to send a cotton bud that has some of the pigment and anaesthetic on it which they can rehydrate and apply to themselves. Contraindications As has previously been mentioned, a contraindication to micropigmentation is a condition that serves as a purpose for a person not undergoing the semi-permanent make up treatment. If your client admits to having one of these conditions, you should not carry out the treatment. This list below is not exhaustive, but these are the most common contraindications preventing a client from having treatment. You should also check with your insurance company as they may put exclusion clauses in your public and product liability insurance relating to certain conditions. Consent Forms and Eligibility Your client must declare their medical history and give their signed consent to you carrying out the treatment before you begin. Client Questions Here are typical answers that we give to our clients frequently asked questions: How long will my Permanent Make up lastfi The majority of clients require 2 initial permanent make-up treatments after which you will require at least one treatment per year to ensure that your make-up stays fresh and fabulous looking for the whole year. Depending on the treatment, we recommend at least 2 hours for each new procedure to ensure that the client receives a detailed and personalized consultation and treatment. However, it cannot be truly classed in the same category as a tattoo for in many cases the pigment will fade and may even disappear completely. If the procedure was classed as semi-permanent this would imply that the skin will return to its pre-tattooed stage at some point (this usually would not be the case). The procedure would only be truly classed as semi-permanent if the penetration of pigment only affected the epidermal layers. The layers of the epidermis are constantly renewing themselves so therefore any pigmentation implantation to this level only, would be desquamated out of the skin within a 4 -6 week period. Traditional tattooing procedures are practiced using inks and dyes which are dissolved in a wetting agent and implanted at a deeper level into the lower reticular layer of the dermis. Micro-pigmentation procedures implant iron oxides into the upper reticular layer of the dermis, therefore there may be a degree of colour visible in the skin for a lifetime. However the degree of colour will usually fade and maintenance procedures are required every 12-18 months to ensure clarity of colour and design. Clients should be informed that the procedure will leave a degree of pigmentation in the skin that is likely to fade over time. There is an exception to this rule when discussing lip tissue type 1 in comparison to the vermilion border or peri-oral skin. Due to the vascular nature of lip tissue type 1, infused pigment will usually only last about 2-3 years maximum before they need re-treating. The vermilion border and peri-oral skin are more likely to retain pigment and therefore a definite lip line may become apparent as the body of the lip tissue pigment colour fades. Any area of enhancement can have colour changes as the pigments fade over time, although this is more obvious in eye and eyebrow procedures. Reviewing the clarity and colour every 12 -18 months will ensure the client is satisfied with the overall results and allow for any changes that need to be made. Remember that pain is experienced at differing levels with each individual client and that it is felt as a result of causing damage to the tissues of the body. It is likely that your client will experience some level of pain, and while you should use anaesthetics to minimize this, your client should not be deluded into thinking that this is a pain-free procedure, nor should they be made to worry that this painful sensation is abnormal. You may wish to mention to your client that she will be more sensitive during her period and also that it is normal to experience pain more on one side of the body than the other because of the positioning of our nerve endings. Pre-Procedural Advice First Platform to Permanent Make Up See Appendix B for standard document of pre-procedural advice. Severe swelling and blistering within in this timescale would indicate allergic reaction to the healing balm. Eyelid procedures can cause discomfort for around 72 hours post treatment in line with the normal inflammatory response period. The client should be advised to use topical anti-viral creams as a precautionary method for a week following micro-pigmentation enhancement to the lips. It slows the growth and spread of the herpes virus so that the body can fight off the infection. The bacterium enters into a cut or opening in the skin and is a common secondary infection following on from herpes simplex. Good hygiene and aftercare practice can minimise the chances of contracting this infection It is not possible to predict whether a client is likely to be allergic to pigments which may be Organic, Inorganic, Synthetic Organic or Synthetic Inorganic.

Persons who have Asperger syndrome manifest deficits in social domain and have unusual behaviors and interest; however symptoms congestive heart failure purchase retrovir amex, they typically do not have deficits in language or intellectual ability ad medicine cheap retrovir 100 mg fast delivery. Persons with perva sive developmental disorder treatment juvenile arthritis cheap retrovir 100mg mastercard, not otherwise specified treatment zona buy cheap retrovir 100 mg line, have some features of autistic disorder and some features of Asperger syndrome medicine nausea buy retrovir in united states online, but do not meet all the criteria for either disorder [30] medicine ball core exercises discount retrovir 300 mg fast delivery. It is unclear if there is something inher ent in those syndromes that predisposes to the development of autistic features or whether the risk is secondary to the intellectual impairment that is commonly seen in many genetic disorders. This trend is partly explained by the fact that most low birth weight and premature babies now survive. Although any segment of spinal level can be affected, 75% of cases involve the lumbosacral level [49]. In Wales and Ireland, the prevalence is three to four times higher, whereas in Africa it is much lower [49]. Hearing Loss Sounds can be described in terms of their frequency (or pitch) and intensity (or loudness). Someone who cannot hear high-frequency sounds will have a hard time understanding speech. A person with hearing within the nor mal range can hear sounds ranging from 0 to 140 dB. Sounds that are 120 dB or louder can be painful and can result in temporary or permanent hearing loss. Hearing loss severity is based on how well a person can hear the frequencies or 1 Neurodevelopmental Disabilities: Introduction and Epidemiology 9 intensities most often associated with speech. Hearing loss can affect one or both ears and can be conductive, sensorineural, mixed, or central. Approximately 30% of children who are deaf or hard of hearing also have one or more other developmental disabilities, such as intellectual dis abilities, cerebral palsy, vision impairment, or epilepsy. This is especially true if the child is born with a hearing loss or loses his/her hearing before 2 years of age. People with hearing loss may communicate using speech (sometimes called oral communication), sign language (sometimes called manual communica tion), or a combination of both. Oral communication focuses on speech, listening with hearing aids, and sometimes lip reading. Vision Impairment the incidence, prevalence, and causes of childhood vision impairment vary widely in different parts of the world depending on the available health resources, general nutritional status and well-being, socioeconomic status, screening, and preventive practices. Vision impairment may be caused by a loss of visual acuity, where the eye does not see objects as clearly as usual. It may also be caused by a loss of visual field, where the eye cannot see as wide an area as usual without moving the eyes or turning the head. Someone with a visual acuity of 20/70 can see at 20 ft what someone with normal sight can see at 70 ft. Someone with a visual acuity of 20/400 can see at 20 ft what someone with normal sight can see at 400 ft. Legal blindness is defined as a visual acuity of 20/200 or worse, with the best possible correction, or a visual field of 20fi or less. A functional vision evaluation can answer questions such as these: can the person scan a room to find someone or somethingfi Nearly two-thirds of children with vision impairment also have one or more other developmental disabilities, such as mental retardation, cerebral palsy, hearing loss, or epilepsy. Children with more severe vision impair ment are more likely to have additional disabilities than are children with milder vision impairment. The three key components of functioning and disability are inter-related and may interact with the health condition. The reported prevalence of intellectual disability refiects consideration of the definition used, method of ascertainment of the data, and the characteristics of the population studied. Based on the typical bell-shaped distribution of intel ligence in the general population and 2 standard deviations below the mean as a cutoff point, approximately 2. The prevalence and causes of vision impairment vary in different parts of the world depending on multiple factors. The sections on hearing loss and vision impairment are adapted from (public domain) United States Centers for Disease Control. The international classification of functioning Disability and Health: its development process and content validity. Reported biomedical causes and associated medical conditions for mental retardation among 10-year-old children, metropolitan Atlanta, 1985 to 1987. Learning disabilities: definitions, epidemiology, diagnosis, and intervention strate gies. Reading disability in adjudicated youth: prevalence rates, current models, traditional and innovative treatments. Academy of neurology practice parameter: diagnostic assessment of the child with cerebral palsy. Mental health disorders among individu als with mental retardation: challenges to accurate prevalence estimates. Intellectual disability co-occurring with schizophrenia and other psychiatric illness: population-based study. Psychiatric disorders in children with autism spectrum disorders: prevalence, comorbidity, and associated factors in a population-derived sample. Multi-informant reports of psychiatric symptoms among high-functioning adolescents with Asperger syn drome or autism. Psychiatric and psychosocial problems in adults with normal-intelligence autism spectrum disorders. The predominant signs and symptoms of atypical development vary depending on the age of the infant or the child. For example, a delay in achieving motor milestones as expected is generally recognized early in infancy, atypical language development is more often recognized in early child hood, and academic difficulties are recognized in late childhood and adolescence. This chapter reviews the basic concepts and definitions applied in the study of developmental problems, the main features of common conditions considered in the differential diagnoses of developmental disorders, and describes signs that should prompt further developmental evaluation. These key concepts are useful when applied in developmental screening, surveillance, and evaluation (see Table 2. Atypical development can be described as a delay, deviation, dissociation, or regression (see Table 2. Clinical Features Infants Predominant Delay in Motor Milestones Generally, in infants, delayed or atypical motor development manifests earlier than other domains of development. Because there is a range of periods during which infants attain typical milestones, the most common cause of apparent motor delay is a normal variation or maturational lag [2, 4]. The most significant cause of motor delay in infancy is cerebral palsy which consists of motor delay, abnormal tone, and posture [2, 3, 7, 8, 16, 17]. Clinical presentation and features of infants and children with cerebral palsy may vary depending on its type and severity [16, 17]. A child over 2 months of age with cerebral palsy may have poor head control, stiff legs, and scissoring. A child over 6 months of age may still not have head control, may not sit unsupported, and might preferentially use only one extremity. A child over 10 months of age might crawl by pushing off with one hand and leg while dragging the opposite hand and leg and may not sit without support. A child over 12 months of age might not be crawling and may not stand with support. A child over 24 months of age may not be yet walking or able to push a toy with wheels. A deficiency in joint attention, that is, the ability to attend both an object and a person at the same time. Other conditions to consider in infants with predominant language, cognitive, and social delays include hearing impairment, severe cognitive deficits, genetic disor ders, inborn errors of metabolism including hypothyroidism, and severe nutritional or environmental deprivation. Airfiow obstruction accompanies the production of consonant sounds, whereas it does not in the case of vowel sounds. Children with autism have qualitative impairment in communication skills, qualitative impairment in social relatedness, and a range of atypical stereo typical behaviors [6, 26]. Autism spectrum disorders typically are recognized by age 3 years, some as early as 18 months or earlier [6]. Parents usually first notice unusual behaviors and language difficulties in the child. They may describe the child as not socially responsive to others or who may intensely focus on one item for a long period of time. Children with intellectual disability have predominant deficits in cognitive and language abilities. Their social development is consistent with their mental age, and they have no motor deficits. There is no identifiable specific cause in most children with mild intellectual disabilities.

The aqueous humor is continually refilled hair treatment purchase retrovir cheap, and its principal function is to maintain the normal pressure of the eye medications on carry on luggage purchase retrovir australia. The lens is a transparent structure located behind the iris that focuses light rays entering through the pupil to form an image on the retina medicine 4211 v purchase retrovir without a prescription. The vitreous humor (also known as vitreous body) is a transparent medications and grapefruit interactions generic retrovir 300mg with visa, jelly-like structure occupying the back (posterior) cavity of the eyeball behind the lens medications to avoid during pregnancy purchase retrovir 100 mg without a prescription. The optic nerve is a nerve cord that comes out of the back of the eyeball and transmits to the brain images that are registered by the eyes treatment quotes retrovir 100 mg line. The eyelids are two mobile structures whose function is to protect the eyes from foreign bodies. The eyelashes are implanted on the free edges of the eyelids and help the eyelids to carry out their function. The lacrimal apparatus consists of thelacrimal (tear) gland and the lacrimal ducts. The gland produces the tears, whose function is to maintain the moisture of the cornea and to protect the eye against microbes and foreign bodies. The lacrimal ducts extend from two openings, calledlacrimal points, at the inner corner of the eyelids, to the nasal cavities; these ducts eliminate excess tears. Basic Eye Anatomy and Vision 7 Mechanism of Vision Your eyes and brain work together to make it possible for you to see. The cor Your eyes and brain nea bends the light, which then passes through the fluid called the aqueous work together to form humor, through the pupil, and to the lens. The lens bends the light even one three-dimensional more, sending it through the fluid in the back of your eye, the vitreous hu image. Shortly after leaving the eye, the optic nerves from each eye cross and separate, sending their fibers to both sides of the brain. Instead of seeing two of everything, the brain fuses the images together to form one three-dimensional image. Common Vision Problems Refractive Errors: Hyperopia (farsightedness): A refractive condition in which light focuses behind the retina, resulting inclear distance vision but blurred near vision. Hyperopia is a condition present at birth where the length of the eye is too short or the focal length of the lens inside the eye is too long. Young, mildly hyperopic patients are often asymptomatic, that is, they are able to see clearly both at distance and up close. However, as we age, we edness)-Ability to see lose the ability to accommodate and can no longer make this adjustment to distant objects clearly. Myopia (nearsightedness): A refractive condition in which light focuses in front of the retina. However, almost one third of the population in any industrialized society will become myopic after several years of schooling or during the adult years. Myopia is an inherited condition in most cases, and may also occur as a result of prolonged tension on the eyes during close work and elongation of the visual axes. The primary sign of myopia is the inability to view distant objects clearly and distinctly. Myopes may also find themselves squinting when looking into the distance in order to make the fuzzy image dearer. After long periods of close up work, highly myopic patients may complain of eye strain and fatigue. Corrective lenses spread out the incoming rays of light by an appropriate amount, so they will focus on the retina. There are other treatment procedures, such as orthokeratology, where a hard flat contact lens 8 Chapter 2 is prescribed to flatten the cornea, and radial keratotomy, in which surgeons make incisions into the cornea in order to flatten it. Astigmatic corneas are most commonly steeper in the vertical direction than in the horizontal direction. The use of contact lenses may reduce astigmatism, because of the changes they can produce on the cornea. Thus, when looking at an object, portions of it (perhaps vertical components) may appear clearer than other portions. Some patients find that it takes some time to adjust to spectacles with a correction for astigmatism. When a correction is applied, the brain may take a few days to modify its interpretation of the visual scene, but will ultimately receive a clearer image. Presbyopia (accommodation problems): Presbyopia is a vision condition in which the lens of the eye loses its flexibility as it matures through life. This results in decreased near vision because of the difficulty of focusing on close objects. Presbyopia is an adult condition and is present in nearly everyone over the age of 40. The eye stops growing at about the age of ten; however, the lens (which focuses the light entering the eye) continues to grow in layers. As the lens produces more layers throughout life, it becomes very dense and compact. The lens eventually loses its youthful elasticity and cannot curve as much during accom modation (the process needed to focus), resulting inblurry vision up close. Presbyopia can usually be cor rected with reading glasses, bifocals, or trifocals. Once presbyopia occurs, it typically progresses for 10-12 years and then stabilizes. An increase in hypero pia (farsightedness) may also occur with the progression of presbyopia. After reading this chapter you will know how to: 1) take a medical history, 2) ask four basic questions that can indicate disease or injury, and 3) conduct vision testing (including special considerations for screening children). Included in this chapter are screening and referral tools which can be adapted to local sites. A full eye examination by an outreach or clinic worker will consist of the screening process both a vision test and an examination for eye disease or injury. Later in the chapter are sample history and assessment forms that can be used for taking an eye history and for referring a patient. As the flow chart indicates, first, a history is taken that identifies symptoms or events that may indicate possible eye problems. Following the screen, it is the responsibility of the outreach/clinic worker to provide preventive educa tion. If the person is found to have a vision problem, eye injury, disease or any combination of these problems, they should bereferred to a medical professional who either treats or refers to a specialist. If the primary eye care project is dispensingglasses, the patient will return after receiving his prescrip tion to purchase the glasses. Checklist of Materials Needed to Perform the Eye Exams t Flashlight and batteries t Pencil, clipboard t Hand cleaner t Magnifying glass t Tape measures t Latex gloves t History and Assessment Forms t Referral cards t Occluders or cardboard t Activities for children t Prevention Education Materials t Sample safety equipment and glasses for education and display t First aid kit (including eye drops, sticks for everting the eye lid, etc. During the screening of the eyes, use the vital in determining eye assessment form to walk through the process. Primary Eye Care: Recognizing and Treating Eye Problems 13 Migrant Health Primary Eye Care History Form Print Name (Last): (First): Date: Location or Camp where screened: Sex: M / F Age: Contact information (address, phone, work location): Best time to contact: What types of farm work do you do throughout the yearfi It is important to remember that the patient plays a key role in the vision screening process. It is very important to test vision in children about 3 years of age as early detection can be vital in correction. Eye Chart (Snellen) the Snellen chart is an excellent tool for testing because it does not depend What is 20/20 visionfi The glasses prescription is then read on a linear scale on the side of the instrument. The top or first number (numerator) specifies the testing distance (usually 20 feet); the bottom or second number (denominator) specifies the letter size in rela tion to the letters on the 20/20 line. Thus, the 20/100 letters are 5 times larger than the 20/20 letters, and a reading of 20/100 means that the patient can see at 20 feet what a normal eye can see at 100 feet. The patient may be standing or seated, provided that the line corresponding to number 20/30 is at eye level, and he should be 20 feet (6 meters) from the chart. There should be no windows or objects beside it to distract the patient or produce light reflections to cause discomfort. Stand beside the eye chart in such a way that you can point to the letters with a finger, a pencil, or small stick, without covering them and, at the same time, can observe the patient. Have on hand several occluders or pieces of cardboard approximately 2 inches wide x 4 inches tall. Explain to the patient that you will point to the letters on the different lines of the chart one at a time. Using their hand, he or she will have to tell you in which direction the parallel lines of the E are pointing. If the patient normally wears eyeglasses to seeat a distance (not for read ing), tell him or her to keep them on during this examination. To see if the patient has understood how the examination will work, ask is important. When the patient can no longer distinguish at least half of the letters on a line, that is considered the smallest line that they can see. When this is done, have him or her cover the right eye and test his or her left eye. Interpretation of the Snellen Chart Test Normal vision: Visual acuity ranges from 20/20 to 20/40. For example, 4/200 means that the patient was 4 feet from the 20/200 letter, or that the patient can see at four feet what the normal eye sees at 200 feet. How to write up visual acuity in the primary Eye Care Assessment Form First, write the symbol for visual acuity, which is a large V. Write down the visual acuity to the right of the V, first for the right eye and then below that for the left eye, preceded by the letters R and L. For example: V R: 20/20 V L: 20/25 the above example shows that, at 20 feet (6 meters), the patient read with his or her right eye the line that can normally be seen at that distance; with the left eye and at the same distance, he or she could read the following line. Primary Eye Care: Recognizing and Treating Eye Problems 19 Children: Special Considerations for Vision Screening In order for vision to develop properly, visual stimuli must reach the brain through the eyes. If this does not happen, even though the eyes appear normal, a permanent loss of sight may occur. Children from 6 months to 2 years of age: Again, there are no simple methods of testing vision with precision. Children from 2 to 4 years of age: At this age, it is already possible to test vision by having the child recognize objects or drawings of objects, at various distances from his eyes, while one eye and then the other is covered.

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