Ivan Damjanov, MD

• (University of Kansas Medical Center)

http://www.kumc.edu/school-of-medicine/pathology/faculty-and-staff/clinical-faculty/ivan-damjanov-md-phd.html

Retinitis punctata albescens is an allied condition in which erectile dysfunction meds online buy zudena with paypal, with the same history and symptoms erectile dysfunction with age zudena 100 mg visa, the retina White without Pressure shows hundreds of small white dots distributed fairly uni Pale impotence guilt order zudena with amex, discrete areas of the retinal periphery without the ap formly over the whole fundus drugs for erectile dysfunction ppt best order for zudena. A stationary form exists; but plication of any external pressure are thought to be the re other cases are progressive and almost certainly represent sult of vitreous traction which could result in the formation atypical varieties of the pigmentary dystrophy impotence in men cheap zudena express. Focal Pigment Proliferation or Clumping this occurs in the equatorial region or near the ora serrata erectile dysfunction statistics 2014 100mg zudena sale. In the Angioid Streaks equatorial region focal pigment proliferation may be found Dark brown or pigmented streaks which anastomose with with a retinal tear. Secondary detachments may be due to the retina be Retinoschisis ing pushed away from its bed by an accumulation of Senile retinoschisis is characterized by splitting of the fuid or a neoplasm. The fuid may be blood (as from a retina at the level of the outer plexiform layer. It is more choroidal haemorrhage) or exudate (exudative choroidi common in hypermetropes, usually bilateral, occurring in this or retinopathy, angiomatosis, toxaemia of pregnancy). It If such an exudate is absorbed, the detached retina may produces an absolute feld defect starting in the upper nasal well become spontaneously replaced. When choroid have a similar effect, partly by lifting up the retinoschisis affects the macula, an extremely rare occur retina mechanically, partly by the transudation of fuid rence, the central feld is lost. Breaks may occur in the inner due to the circulatory disturbances caused by the mass of or outer layers of a retinoschisis. For this reason such detachments habitu Retinoschisis can be confused with retinal detachment ally cause an extensive separation of the retina, particu and is differentiated from it by the presence of an absolute larly in the lower part of the eye where the fuid tends to feld defect as well as by the immobility and transparency gravitate. No treatment is indicated, except in cases due to the retina being mechanically pulled away from of progressive symptomatic retinal detachment. The appro its bed by the contraction of fbrous tissue in the vitre priate management of patients with senile retinoschisis ous, tractional detachment, such as occurs in plastic containing holes in the outer layer is periodic observation cyclitis, proliferative retinopathy or the retinopathy of because so few of them develop progressive detachment. The prognosis in such cases is, of course, When schisis is accompanied by rhegmatogenous retinal not so good. A rhegmatog enous retinal detachment occurs when a tear in the retina Juvenile Retinoschisis leads to fuid accumulation with a separation of the neuro Juvenile retinoschisis is a hereditary disorder in which there sensory retina from the underlying retinal pigment epithe is a splitting of the retina in the nerve fbre layer with the lium. This may be as Retinal breaks are frequently very diffcult to fnd, sociated with cystoid changes in the fovea manifesting as but it is extremely important to fnd them. In the frst retinal folds radiating from the foveal centre in a petalloid place, the presence of a break designates a detachment pattern. Retinal tears are usually horse the neuroepithelium and the pigmentary epithelium of the shoe or arrow-shaped with a lid-like tongue pulled retina normally lie in apposition, the potential space be inwards by the vitreous (Fig. Those involving more occurs when subretinal fuid accumulates in the potential than a quadrant of the circumference are called space between the neurosensory retina and the underlying giant retinal tears. Depending on the mechanism ora serrata causes a large tear known as retinal dialysis. A of subretinal fuid accumulation, retinal detachments tradi dialysis may be large, in which case the choroid is seen tionally have been classifed into rhegmatogenous, trac through it and the edge of the detached retina is sharply tional and exudative. Focal vitreoretinal traction is seen pulling the flap of the tear up and to the left. Fluid vitreous has seeped through the tear into the subretinal space, elevating the retina into a bullous detachment. A round retinal tear is surrounded by a small retinal detachment in the inferior retina. Edinburgh: Mosby; 2008) Pathophysiology retina which irritates the neuro-epithelium. The patient occurs; if it is fuid or partially detached, and particularly if experiences a fall in visual acuity when the macula becomes it is adherent to the retina in some portions so that with detached, or a large bullous detachment obstructs the fovea. Diagnosis and Management Vitreoretinal traction is responsible for the occurrence of most rhegmatogenous retinal detachment. In cer but the diagnosis may be diffcult in the case of shallow tain eyes, strong vitreoretinal adhesions are present in certain detachments. By preliminary examina Predisposing Factors tion with the mirror alone, a difference in the nature of these include myopia, previous intraocular surgery such as the refex as the eye is turned in various directions will at aphakia or pseudophakia, a family history of retinal detach once arrest attention, while examination with the indirect ment, trauma and infammation. Eventually, and sometimes rap idly, the detached portion of retina assumes a different tint Clinical Features from the normal fundus. In the most typical condition it is the symptoms of a shallow detachment may be non white or grey, with folds which show a bright sheen at the specifc in the initial stages, for the retina may obtain suf summits and appear grey in the depressions (Fig. During slight movements of the eye the folds show retain its functions, which may be only partially impaired oscillations and the retinal vessels are seen coursing over for a considerable period. Owing to the fact that they are separated from observed is transient fashes of light (photopsia) in a par the choroid, they cut off the light refected from this mem ticular part of the visual feld, due to slight traction of the brane and therefore look much darker than usual. Pigment in the anterior vitreous (tobacco retina becomes detached, it assumes a slightly opaque co dusting or Shaffer sign) is usually present. After a few lour secondary to intraretinal oedema and the normal cho weeks, a retinal detachment may present with more fxed roidal pattern of vessels is no longer seen. It has a convex folds, retinal thinning, intraretinal cysts, subretinal fbrosis confguration, and moves freely with eye movements unless and demarcation lines. Even though At the edges of the detachment a considerable degree of they represent areas of increased retinal adhesion to the pigmentary disturbance may appear, as well as white spots retinal pigment epithelium, it is not uncommon for subreti of exudation, haemorrhages and greyish-white lines due to nal fuid to spread beyond the lines. There is a growth of cellular Still later it becomes largely bunched behind the lens, the membranes within the vitreous cavity and around the retina, part attached to the disc being pulled out into a straight and is noted as stages A, minimal; B, moderate; C, marked cord. This scar tissue exerts traction on the retina that ophthalmoscopic examination becomes impossible. Chapter | 20 Diseases of the Retina 333 A retinal break is identifed and localized in most eyes with rhegmatogenous retinal detachment; 50% have more than one break. More than half of all retinal breaks are located in the upper temporal quadrant, although any quadrant may be affected. Lincoff proposed rules to localize retinal breaks by observing the confguration of the retinal detachment (Fig. Even identifying predisposing retinal breaks and other lesions, after prophylactic laser treatment, a lifelong follow-up of and treating them with cryotherapy or laser (Fig. These include eral retinal degenerations that could lead on to a retinal symptoms suggestive of vitreoretinal traction, a history of break. Since more than one hole may exist, a thorough and pains taking examination of all parts of the fundus must be done in every case; this may be time-consuming but is essential. Since many holes are in the extreme periphery, full mydriasis is necessary, and for this purpose the indirect method of oph thalmoscopy, using strong illumination, is more useful and effective than the direct. Sometimes such a lesion is rendered visible only by pressing gently on the sclera near the ora ser rata with a scleral indentor. The retinal periphery should also A B be examined using a Goldmann three-mirror fundus lens, which provides a magnifed view of the ora and its environs through the slit-lamp microscope. A careful drawing showing the position of retinal holes, pathological lesions, retinal ves sels and other landmarks, is made of the fundus. Examination should be carried out with the patient in different postures sitting, supine, lateral, and so on; of these the supine is the most important, since this is the position in which the opera tion is usually performed. Changes in posture may reveal a retinal tear that has hitherto been hidden by a retinal fold. The fluid has tracked down further nasal implying the break is slightly to the nasal side. London: ment, depending on the extent and duration of the condition Saunders; 2013. Subsequently, the retina and choroid are approximated a retinal detachment are as follows: to allow development of chorioretinal adhesions by using methods of external or internal tamponade. These individual components of surgery can be com Pneumatic retinopexy can be used in eyes with fresh bined in various permutations, depending upon the clinical retinal detachments having a single retinal break or a group state of the individual eye and the choice of the surgeon. The of breaks that are clustered within 1 clock hour in the supe surgical options include pneumatic retinopexy, scleral buck rior two-thirds of the fundus. In this procedure, a bubble of ling, or vitreoretinal surgery (see Chapter 21, Diseases of the gas is injected intravitreally through the conjunctiva and Vitreous). The surgical goals are to identify and to close all postoperatively the patient is positioned so that the bubble retinal breaks with minimum iatrogenic damage. This is tamponades the retinal break against the pigment epithe achieved by good indirect ophthalmoscopy followed by the lium. This closes the break and allows resorption of the creation of chorioretinal infammation using cryotherapy or subretinal fuid. A chorioretinal adhesion is achieved by Chapter | 20 Diseases of the Retina 335 applications of laser or cryotherapy to the edges of the reti procedures such as paracentesis or vitrectomy to allow ade nal break. In non-drainage surgery, subretinal fuid Scleral buckling or external plombage (Fig. In such cases, subretinal fuid opacities such as vitreous haemorrhage or lens fragments, if does not need to be drained if the hole is well supported by present, are removed. A vitrectomy with removal of the vitre the buckle and the circulation of the central retinal artery is ous from the margins of the breaks and the vitreous base is not compromised. The subretinal fuid is drained to relieve the pull on the underlying retinal periphery. Stiff retinas as in second eye if the frst presents with a non-traumatic giant tear. Once the retina is fat, endolaser is omy or internally by a fute needle is indicated in eyes with used to treat the area of retina surrounding any retinal tears bullous retinal detachments where chorioretinal apposition is or holes. Complications that may result from drainage of in the eye to tamponade the retina internally. Sulphur hexafuoride is an inert gas of high molecu tive, but needs close monitoring of the intraocular pressure lar weight, low water solubility and low diffusion coeff during surgery and in the immediate postoperative period. Gases such as sulphur hexafuoride have a higher surface tension than silicone oil and are absorbed in a couple of weeks, but they expand with changing atmo spheric pressure. Patients with an intraocular gas bubble should not fy in non-pressurized aircraft. Silicone oil offers certain advantages over gas in the treatment of selected complicated retinal detachments. Visual rehabilitation is faster with silicone oil than with gas tamponade, and laser therapy of retinal defects can also be done more easily than with a gas bubble in the vitreous. They appear the prognosis in rhegmatogenous detachment of the retina, ophthalmoscopically as white patches, the peripheral untreated by operation, is unfavourable. The detachment edges of which are radially striated, looking as if frayed becomes total, the photoreceptors start to degenerate within (Fig. Usually the patches are contiguous with the a couple of weeks, impairing visual recovery and compli disc; occasionally they are isolated, but rarely far from cated cataract and iridocyclitis follow. The retinal vessels are covered in places by the surgery now has an anatomical success rate of over 95%. When present, the blind spot is enlarged, the visual prognosis depends on the duration of macular or a scotoma is present corresponding with the position detachment and the presence of proliferative vitreoretinop of the patch. The prognosis is poor if the holes are large or multi the macula, so that central vision is abolished. If glau ple, when the vitreous, retina and choroid are grossly coma or optic atrophy causes the fbres to degenerate, the degenerated especially in the presence of multiple vitreous medullary sheaths disappear and no trace of the abnor bands, when there is high myopia and if the detachment has mality remains. It is important to be able to diagnose ment surgery is the proliferation and contraction of mem such fbres, since they may be mistaken for exudates, as branes on both surfaces of the detached retina and on the in hypertensive retinopathy. Strictly speaking, they are not congenital, era of vitrectomy, scleral buckling alone was used, which for myelination of the optic nerve progresses from the had a reattachment rate of 47%. At present, scleral buck brain towards the periphery, and is not completed until ling is combined with vitrectomy or with the use of sili shortly after birth. Visual results, on the other Coloboma of the Retina and Choroid hand, are somewhat disappointing. In cases that can be treated without the use of silicone oil there is a 50% chance See Chapter 18, the Lens. When sili cone oil is needed the chance of achieving a visual acuity Albinism of 20/400 or better after 30 months is just under 20%.

If outward deviation of one eye Eye movements are of different types such as saccades doctor of erectile dysfunction order zudena 100 mg amex, occurs before this point is reached erectile dysfunction 27 order zudena 100 mg line, the power of conver pursuit erectile dysfunction drugs nz cheap 100mg zudena free shipping, voluntary erectile dysfunction shake drink generic 100mg zudena visa, involuntary and so on hcpcs code for erectile dysfunction pump discount zudena 100mg without prescription. The amount of convergence can also be movements and transmitting signals to other centres for measured by prisms erectile dysfunction treatment options injections buy zudena without a prescription, as an extension of the method de perfect coordination and the final command passes to the scribed to measure fusional capacity (Fig. In this motor nuclei in the brain stem so that the motor impulses case, the prism is directed base outwards; the strongest can be executed via the appropriate nerves and muscles. These relationships between the refrac Incomitant and Comitant Squint tive condition and direction of the squint are, however, by Incomitant no means invariable. Squint (Paralytic Comitant If the fusion mechanism is well-developed and the Clinical Features or Restrictive) Squint deviation slight, visual alignment may be maintained in normal circumstances by a continued effort of fusion: the Magnitude of squint Varies with eye Same in all position positions squint is then latent and can only be made manifest * when fusion is made impossible (as by covering one eye). Diplopia Usually present Usually absent this condition is called heterophoria or latent squint. If, Ocular movements Restricted Full on the other hand, the maintenance of alignment becomes False projection Present Absent impossible, a true or manifest comitant squint develops. Comitant strabismus may be intermittent (periodic) or Abnormal head Usually present Absent constant, convergent or divergent. It may become manifest after an attack of whooping cough, measles or other debilitating illness, and is often popularly attributed to some such cause. There is an undoubted tendency for the deviation in all cases of convergent strabis mus to diminish with the diminution of accommodation or the fusional refexes have not or have been weakly devel with age. The deviation is not always purely horizontal; in oped and have broken down so that an ocular deviation many cases the eye deviates upwards as well as inwards. The cause or causes of this failure are unknown In cases where there is a vertical element it is hypothesized and various theories have been stated and restated so that the deviation may have been originally primarily pa frequently that they are often accepted as proved. Congenital esotropia may also be associated with remains, however, that no theory of the fundamental causa neurological disorders and may be hereditary. The better eye is then used and the other is tion of them is essential for rational treatment. Spontaneous cure rarely if ever occurs in l In the first place, defective vision in one eye, such as divergent strabismus, which tends to increase with time. Apart from the loss of binocular vision and the cosmetic l Disturbances in muscular equilibrium, usually due to a disfgurement, comitant squint is asymptomatic. Diplopia congenital malinsertion or defective development of one may be present in the initial stages, the history of which is or more of the extrinsic muscles, may act in the same not available, as the onset is usually early, in small babies way, the squint being perhaps preceded by a period of or very young children, and it rapidly disappears due to heterophoria during which fusion was maintained. In most cases suppression is aided by an tion and convergence, a matter originally pointed out by actual visual defect in the eye, but it also occurs in alter Donders, is also of importance. The continuous effort of nating squint, in which both eyes have normal vision or accommodation in the hypermetrope to see clearly, even in have the same degree of ametropia. Suppression is un the distance, stimulates convergence to a greater degree doubtedly aided, in all cases, by the peripheral situation of than is compatible with binocular fxation; faced with the the image in the squinting eye, but the essential seat of sup dilemma of either relaxing his accommodation and not pression is the brain. Since the image of any object falling seeing clearly or converging too much and suffering diplo on disparate points results in diplopia and since the brain pia, he chooses the latter, squints inwards and suppresses fnds this intolerable, it actively inhibits the image of the Chapter | 26 Comitant Strabismus 417 squinting eye. In contrast, it is noteworthy that, because this purposeful and active inhibition is not involved in a visually Suppression affects mainly the fovea, and the acuity of mature eye, an eye which has been blinded for many years vision may become greater at an eccentric point of the retina by cataract in adults, attains good vision after a successful where the new fxation axis falls in the squinting position, operation. This abnormal system may two lines less than the fellow eye in unilateral cases) without become so fxed that the fovea remains suppressed and any local ophthalmoscopic abnormality, which is reversible the eccentric retinal point may gain prominence such that if treated appropriately at the proper time. Amblyopia com the eye may continue to fx with the eccentric point when the monly results from conditions that produce a blurred image other eye is covered. When the fxing eye is covered with on the retina (amblyopia ex anopsia or stimulus deprivation the screen the deviating eye usually moves so as to take amblyopia) or cause diplopia (image of the same object up fxation. In unilateral squints of long standing, this eye falling on disparate retinal points) or confusion (images of may remain motionless or move only slightly, a condition different objects falling on the foveae of the two eyes as which is called eccentric fxation. Since it occurs only occurs in strabismus, strabismic amblyopia) and in high with marked deviation of long standing, there is generally anisometropia with aniseikonia (a difference in the retinal no diffculty in distinguishing it from apparent squint. Amblyopia occurs during the critical result and the eyes naturally tend to return to their old or sensitive period of development and maturation of the squinting position. In some cases, instead of developing eccentric blyopiogenic factors are summarized in Table 26. Single letter vision is better than if the letters are presented in a row as is the norm in visual acuity charts. After taking the history, the frst step in evaluating a patient this is known as crowding phenomenon. Visual acuity drops less when viewed through grey assessment of ocular motility and general examination of neutral-density filters compared to normal eyes. Sometimes fxation is retained by either eye Evaluation of a Patient with Strabismus in which case the squint is said to be alternating. Usually, Case history Chief complaint in a divergent squint an object towards the right in the feld of vision will be fxed with the right eye, in the left Onset and duration of the feld by the left eye, while the converse may occur Previous treatment in convergent squint (cross-fxation). Occasionally, patients Family history with alternating strabismus can fx with either eye volun tarily, but are usually unconscious of which eye is fxing. Treatment goals and expectations the next step is to differentiate a comitant squint from an Diagnostic Visual acuity and monocular fxation pattern incomitant squint. In tests Cycloplegic refraction and fundus examination incomitant squint, we have already seen that the secondary deviation is greater than the primary, while in comitant Look for any change in head posture and test ocular movements squint, both deviations are equal. In comitant squints, when either eye is covered and then uncovered, the deviation Determine details of deviation (Table 26. Moreover, the Tests for binocularity movements of the eye are found to be full in all directions, Forced duction test (if movements are restricted) and there is no complaint of diplopia if the squint is long standing. In acute comitant squint a patient may report diplo Management Estimate prognosis pia but the distance between the images is the same in all plan Patient/parent counselling directions. It must be remembered, however, in performing this test in a marked squint of long duration that the eyes do not move as much as usual in the direction opposite to that of the deviation. Thus, in convergent squint it may be very diffcult to get the eyes to move outwards to the full extent so Estimating the deviation: In assessing the deviation an that on maximum attempted abduction of the affected eye the important step is to ensure that any apparent deviation is margin of the cornea may still lie inside the lateral canthus. If, for example, muscle synergistic to movement of the squinting eye in the as commonly occurs in children, a fat nasal bridge with direction of squint, for example, in a constant left convergent epicanthus is present and the medial canthi approach the squint the medial rectus of the left eye may develop contrac cornea, the appearance of a convergent squint results. This may mistakenly be diagnosed as a left lateral may prove valuable in such cases. The infant is seated on the rectus paresis if one is not aware of this phenomenon. The light tive range of eye movement is due to muscle weakness or a beam must be wide enough to illuminate both eyes simulta physical restriction is the forced duction test. When the patient is orthotropic, the colour and especially the Forced Duction Test brightness of the fundus refex is equal in the two eyes. The difference in bright range of eye movement is purely paralytic or whether there ness is more important than the difference in colour. The test is performed under In establishing the presence of a true deviation or squint local anaesthesia, but sometimes under general anaesthesia and further determining if it is latent or manifest, intermit in the case of very young children. The patient is asked to tent or constant, alternating or unilateral, convergent or look in the direction in which movement is being tested divergent, comitant or incomitant the cover test is useful and the maximum range noted. In an apparent squint the opposite limbus with a toothed forceps and rotated there is no deviation, so there is no restitutional movement maximally further in the same direction. The charac Interpretation: the test is said to be positive if there teristics of the ocular deviation must be determined as is a resistance to full passive movement and negative if it outlined in Table 26. If one eye habitually fxes and the is possible to passively rotate the eye fully with the forceps. Chapter | 26 Comitant Strabismus 419 Hirschberg test No obvious squint Manifest squint Cover either eye (Cover test) Cover the fixing eye (Cover test) Other eye moves to No movement Other eye remains Other eye moves to take up fixation deviated take up fixation Blind Eccentric Immobile Pseudosquint Microtropia Intermittent squint eye fixation Remove cover Remove cover (Uncover test) Squint remains momentarily and then eyes fuse or become straight. Cover test: cover apparently fixing eye and watch movement of suspected deviating eye. Alternate cover: quickly cover each eye alternately and watch the behaviour of each eye when the cover is removed and transferred to the other eye. Hirschberg test: shine the light of a torch on the nasion of the patient asking him/her to fixate on the light, and watch for symmetry of the corneal reflexes. If corrective movement is outwards, the squinting eye was convergent or esotropic. A negative result on testing forced duction implies a para fracture of the orbit, where both muscle entrapment and lytic or innervational squint. Force Generation Test Assessment of Binocular Vision An additional useful test in immobile eyes is the active force generation test. Cover the apparently fixing eye with an occluder and observe the response of the other eye. Diagram of the position of the corneal Constant reflex as a guide to the angle of the squint. Magnitude For distance and near fxation with and without glasses Comitancy Comitant or incomitant Hirschberg Test Laterality Unilateral A rough indication of the angle of the squint can be obtained from the position of the corneal refex when light is thrown Alternating (which eye is preferred for fxa into the eye from a distance of about 60 cm with the ophthal tion or which eye is dominant) moscope or a focused light beam from a torch (Figs. The patient is asked to look at the light; an infant does convergence/ this refexly. If the refex is about half-way between the centre of the pupil and the corneal margin, there is a deviation of about binocular vision. The angle of deviation of the squinting eye can also be measured on the perimeter or the tangent scale; in either case Measurement of the Angle of Deviation the patient fxes the central point with the good eye, and the Measurement of the angle of deviation is important in surgeon carries a light along the arc of the perimeter or all cases of squint for diagnosis and as a guide to treat the arm of the tangent scale until the corneal refex thus ob ment. The commonly used methods are (i) the Hirschberg tained is centred on the pupil of the squinting eye. The surgeon carries a light (S) along the arc of the perimeter until the corneal reflex in R is central. Prism Bar Test this is the most commonly used method in routine clinical practice. The strength of prism which is needed for neutraliza tion gives the objective angle of deviation. Children are treated at weekly intervals and the functions of the patient must be evaluated to determine the non-amblyopic eye is not occluded. Patients without In very young children or in recent squinters in whom any degree of binocular function will be treated for purely the habit of suppression has not become fxed, the less cosmetic reasons. The treatment options for strabismus drastic procedure of instilling atropine into the fxing eye can be either conservative or surgical. Conservative therapy (penalization of the normal eye) every 2 days may be includes observation, optical (refractive or prisms) and or suffcient; as this forces the squinting eye to be used for thoptic treatment (fusion exercises or pleoptics). As with To allow an amblyopic eye to be used, the other must be all deviations, the tendency is equally shared between the prevented from seeing, or at any rate from seeing clearly. Since the position of rest is usually one of slight the only satisfactory method of ensuring this is by com divergence, some degree of heterophoria is almost universal plete occlusion, affected by a patch covering the better eye and few people are orthophoric. If the latent deviation is fxed on the skin by adhesive material to prevent the child one of convergence the condition is called esophoria, removing it. The patch is changed when it becomes dirty or of divergence, exophoria, if vertical, hyperphoria. Occlusion should be total since, if both eyes are impossible to be sure whether there is absolute hyperphoria used together, active inhibition of the squinting eye rapidly of one eye or hypophoria of the other, the condition being undoes any improvement achieved. Horizontal deviations are the most is a danger of occlusion amblyopia in the good eye due to common, due often to overstimulation of convergence with constant occlusion of that eye. This is avoided by alternat accommodation in hypermetropia (esophoria) or under ing occlusion proportional to the age of the child. The younger the child, the higher the risk of occlusion am blyopia; the alternation should be more frequent. In very Symptoms young children less than 1 year of age, part-time occlusion is tried initially, i. Beyond 8 years the symptoms of heterophoria may be considerable since of age, constant occlusion can be prescribed. Symptoms of eye occluded for a time in the hope that foveal fxation will strain are, therefore, encountered in the higher degrees; develop in the other.

The general practitioners meet with a psychiatrist once a month to review patient care and for ongoing education erectile dysfunction psychological treatment techniques zudena 100 mg on-line. There were no signifcant changes in mental health outcome crestor causes erectile dysfunction order zudena 100 mg amex, though an unexpected result was a reduction in occupied bed days in hospital lipo 6 impotence purchase generic zudena. The project has subsequently been extended to include 20 general practitioners in the Division and all case managers of the Service erectile dysfunction drugs compared discount 100 mg zudena mastercard. These projects constitute changes in the culture of mental health service delivery towards greater cooperation between public and private sectors and specifcally between mental health services and general practitioners gluten causes erectile dysfunction purchase 100mg zudena overnight delivery. The aims are improved patient outcomes erectile dysfunction rings for pump cheap zudena 100mg otc, more efcient service delivery and a lessening of psychiatric morbidity in the community. The aim of educational and shared care projects is to improve health outcomes in the population by changing the culture of mental health care delivery towards greater cooperation between the public and private sectors. A Manual of Mental Health Care in General Practice 7 Chapter 2 Mental health assessments this chapter begins with a discussion of eight principles of the psychiatric interview. In the fnal section, I discuss the diferences between a diagnosis and a formulation and provide several sample formulations. Unfortunately, the pressure of work in general practice makes it difcult to fnd this time. Moreover, the fnancial incentives of Medicare are towards shorter, not longer, consultations. Although you may mean well, he or she may perceive a reassuring comment as presumptuous or rejecting. Transference and countertransference Transference can be broadly defned as the feelings that the patient has for you. Some of these Box 2-2: Examples of efective interview techniques Clarifcation You ask a man to give you an example of what he means when he says he has sufered a panic attack. Response to a verbal cue A 47-year-old man complains of a number of vague physical symptoms including fatigue, abdominal discomfort and headaches. Response to a non-verbal cue A woman who has been attending your practice over the past fve years is not herself. Her afect is fat and she speaks in a soft voice giving unelaborated responses to your questions. Empathic style A middle-aged man becomes depressed after being overlooked for a promotion at work. Further questions may address the other developmental challenges of middle age that he is presently facing. Maintaining control An elderly man speaks at length about how unjustly he is treated by his neighbours. For example, being perceived by a young man as an authority fgure, you may elicit transference feelings that he has towards his parents, teachers and other authority fgures in his life. Some will be similar to feelings that are elicited in other people who deal with that person, while others will refect aspects of your own past and present relationships transferred on to the patient. By acknowledging these feelings to yourself and making them conscious you are much less likely to act inappropriately upon them. For example, it is quite normal to feel angry with certain people, but it is likely to be damaging and unprofessional to act out this anger. By acknowledging to yourself your countertransference responses, you lessen the likelihood of acting out upon them. Monitoring your countertransference responses can provide you with valuable information about a person. For example, when seeing a young woman who repeatedly self-harms, you may feel frustrated and angry and you may even imagine being cruel to her. Refecting upon them, you recognise their origin in the physical and sexual abuse that she sufered at the hands of her foster father. By containing the impulse to act out, you avoid repeating and reinforcing the abusive patterns of her previous relationships. There is a clear power diferential in the relationship between patient and doctor. In particular, people presenting for counselling or any type of psychological therapy are often at their most vulnerable. To exploit such a position to fulfl ones own needs is unethical and potentially damaging to patients. For professional therapists, it is prohibited to have intimate relations even after therapy has fnished. Monitor your countertransference feelings and impulses and take care not to act out in ways that breach professional boundaries. They may begin with the acceptance of expensive gifts, fnancial or stock broking advice, or even betting tips. Appointments may be made that are longer than usual, or regularly scheduled A Manual of Mental Health Care in General Practice 11 at the end of the day when other staf members have left the practice. This may progress to the performance of unnecessary physical examinations, meeting patients outside the consulting room, and to involvement in social situations and sexual relations. Doctors who are vulnerable to boundary transgressions include those experiencing life crises, in particular those with problems in their own marriages or personal relationships. Perfectionists1 who are excessively self-sacrifcing and work unnecessarily long hours may have difculty setting limits on the demands of certain patients and begin taking extraordinary measures in attempt to rescue them. Patients with histories of sexual abuse may be particularly prone to evoke such countertransference responses, especially when they express recurrent suicidal ideation. Doctors who deny their dependency needs and give the appearance of being self-contained may be prone to seeking gratifcation for their needs for love and nurturance through their patients: while denying their own dependency needs, they may perceive others as being dependent on and needy of them. A doctor sufering a psychosis might violate professional boundaries as a consquence of the illness. Psychopathic doctors who wilfully exploit patients for the gratifcation of their own needs have no place in the medical profession. For example, we understand the grief of the bereaved, the anger of someone who is frustrated, the guilt of the person who has hurt another and the shame of someone who has done something foolish. We can also understand the meaning of an event for that person, and we can look for reasons why he or she feels that way. We can understand the grief of the bereaved, the anger of someone who has been frustrated, the guilt of the person who has hurt someone else, and the shame of someone who has done something foolish. For example, there is no understandable reason for the memory loss of someone with dementia. Similarly, we cannot understand how a person with schizophrenia starts hearing voices. Instead, we seek explanations in terms of neurotransmitters, abnormalities in information processing and other physical causes. For example, you might understand why a high-achieving man becomes depressed following a myocardial infarction. However, this should not stop you from diagnosing major depression if his depressed mood persists and he expresses feelings of worthlessness and guilt, and suicidal ideation. Although a problem may be understandable, its treatment may require pharmacological or other physical interventions. Since all mental disorder is both a disorder of mind and of the brain, it is always possible to both understand and explain diferent aspects of the same problem. The grief of a bereaved woman will be refected in biochemical and other events in her brain. However, the fact that her reaction is clearly understandable indicates that our initial treatment would be through grief counselling. If her grief is prolonged, and she begins to sufer prominent and distressing feelings of guilt, and is contemplating suicide, we would use an anti-depressant drug as an adjunct to the grief work. Similarly, in the case of a man with schizophrenia, although we may not be able to understand the evolution of his auditory hallucinations (the form of his experience), we may be able to empathise with their content. We can also empathise with his reactions to the disability and handicap that he sufers as a consequence of the illness. For the person with dementia, the feelings of loss, fears about the future, and the change to a more dependent role are all issues that are understandable and amenable to psychotherapy and counselling. While the form of a delusion proper is not understandable, it is often possible to empathise with its content. The dialectical principle In the philosophy of Hegel, dialectics is a process in which a proposition is made (thesis), then negated (antithesis), and fnally replaced by a new proposition that resolves the confict between the two (synthesis)1. Although this may seem a little obscure, this way of thinking is common in making decisions about mental health problems. You will often have to make choices between apparently contradictory propositions. Always consider the possibility that the best course of action lies in a synthesis of the two. In psychiatry, the best solution to a problem is often a synthesis of two apparently contradictory possibilities. Impairment, disability and handicap When assessing people with mental health problems, it is useful to classify their complaints as impairments, disabilities or handicaps. Disability is any restriction or lack in ability to perform an activity normal for a human being. Handicap is a disadvantage, resulting from impairment or disability, that limits or prevents the fulflment of a 1 Brown L, Ed. A Manual of Mental Health Care in General Practice 13 Box 2-3: Some dialectical dilemmas Since she has a terminal illness, it is understandable that she is depressed, so I should not prescribe medication. Her panic attacks are probably just secondary to her depression so if I treat the depression they should also improve. Isolated panic attacks can occur in major depression, but if they are recurrent and accompanied by persistent concern about having more attacks, worry about the implications of the attacks, or signifcant behaviour change, then both diagnoses should be made. In general practice settings, mixed anxiety/depression is more common that either one alone. Make a working diagnosis in the frst session, but be prepared to tolerate some uncertainty about the fnal diagnosis. The formulation will continue to evolve and deepen so long as you continue to see the person. For example, if the person makes a direct threat against someone else, you may be obliged to contact the police or to warn the intended victim. With most mental health treatment now being delivered in the community, a larger responsibility for care now falls on the family or other carers. Unless expressly forbidden to do so by the individual, carers should, whenever possible, be involved in treatment. Ask the person if you can meet his or her spouse and family at the next consultation. Note: Like the other propositions in psychiatry, the dialectical principle itself does not always apply. An elderly woman becomes delirious post-operatively and experiences hallucinations and persecutory delusions.

Purchase zudena 100mg overnight delivery. Where To Touch A Girl Before You Kiss Her (Live Demonstration).