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S. Aila. University of Houston, Victoria.

This study would appear to be solid evidence supporting hereditary influences cheap 20gm diclofenac gel fast delivery arthritis in old dogs symptoms, but it is weakened by several sources of potential bias specific to twin studies (Cantor 1992 diclofenac gel 20gm low price arthritis in fingers natural treatment, Fine 1981) that are worth examining in detail because they again illustrate the difficulties in isolating genetic components from differences in exposure cheap 20 gm diclofenac gel amex rheumatoid arthritis in feet joints, and the importance of experimental design diclofenac gel 20gm lowest price physiotherapy for arthritis in dogs. Table 6-1: Twin studies Monozygotic Dizygotic Monozygotic Dizygotic Total Pairs Concordant pairs Reference N % N % N % N % Diehl 1936 80 39 125 61 52 65 31 25 Dehlinger 1938 12 26 34 74 7 58 2 6 Kallman 1943 78 25 230 75 52 66 53 23 Harvald 1956 37 26 106 74 14 38 20 19 Simonds 1963 55 27 150 73 18 32 21 14 The Prophit study set out to re-examine the conclusions of Kallman and Reisner’s study by trying to correct all its shortcomings (Simonds 1963). A conservative conclu- sion might be that some inheritable component exists, but it has a maximal pene- trance of only 65 %, and the most careful study ever performed found only 31. While the near fixation on this topic by authors such as Rich (Rich 1951) might be ascribed to the prevailing racism of the period, the as- sumption of greater susceptibility of Africans and African Americans continues to be cited in current literature, with investigators now using molecular findings to try to explain it (Liu 2006). While Rich gave equal credit to “the marked influence of environment… in different economic strata of individual communities within a given country” for Whites, he attributed the higher rates in Africans and African- Americans predominantly to the effects of genetic composition. James McCune Smith in de- bunking the notion that African Americans were genetically predisposed to rickets by showing that whites of the same low socioeconomic status were similarly pre- disposed (Krieger 1992). It’s interesting that these three commonly cited examples all involve foreign conscripts or internees on a colonizer’s military base, and rely on the dubious assumption that their physical and emotional environments were the same as those of the host soldiers. This theory, though still cited in current literature (Fernando 2006), is completely unproven and will likely remain so. Nonetheless, the abundance of literature describing increased susceptibility and a more progressive disease course in Africans and Native Americans suggests that some racial difference may, in fact, exist. Putting aside the theory for the origin of racial differences, are there any studies that have sufficiently controlled for environment and exposure, in order to credibly document a difference? The difficulty in proving a genetic component for human susceptibility 215 rates of 936 and 725 per 100,000 were much higher than rates seen in any other study, but there is no data on other risk factors. In the Alabama study, the overall racial difference was predominantly due to very high rates in young Black women. The best single study was among Navy recruits, because the environment and follow-up were usually equivalent, at least once they were in the Navy. In that study, African Americans had an annual rate only 17 % higher than whites (91/78), but the Asians (195) had a rate more than double that of African Americans. The difficulty in proving a genetic component for human susceptibility 217 residents with positive skin tests. Al- though the nursing home setting convincingly controls for sources of bias, includ- ing age and sex, there is no data on the residents’ weights, general health, or pat- terns of association and rooming. Even if African-Americans have a slightly increased rate of infection, the fact that there was no difference in the rate of progression to disease deflates the credibility of arguments that their immune system is less capable of controlling the infection. No racial differences were found, leading the authors to question the validity of the conclusions from the nursing home study (Hoge 1994). McKeown concluded that improved nutrition was responsible for the decline in mortality and the increase in population, while others later argued that more im- portant factors were the general improvements in living standards and such public health measures as improved housing, isolation of infectious individuals, clean drinking water, and improved sanitation (Szreter 2002). Nonetheless, it is generally accepted that this dramatic decrease was mainly the result of societal factors. There are over 100 different primary genetic immunodeficiencies that predispose to infections with a variety of viruses, bacteria, fungi and protozoa, but only a few have been associated with severe mycobacterial infections (Casanova 2002). A patient was recently described, who had been clinically diagnosed with hyper IgE syndrome and was unusually susceptible to various microorganisms including mycobacteria, as well as virus and fungi (Minegishi 2006). A mutation was found in the gene for tyrosine kinase 2 (Tyk2), a non-receptor tyrosine kinase of the Janus kinase family. This defect in neutrophil killing makes them susceptible to severe recurrent bacterial and fungal infections. Affected patients are predisposed to dis- seminated infections with atypical mycobacteria, septicemia from pyogenic bacte- ria, and viral infections. Overall, mycobacterial infections occur in perhaps a third of patients with severe combined immunodeficiency and anhydrotic ectodermal dysplasia with immunode- ficiency. Mendelian susceptibility to mycobacterial disease Perhaps the most convincing evidence for genes involved in human susceptibility to mycobacteria has come from studying those rare patients with genetic mutations that selectively increase their susceptibility to mycobacteria, salmonella and occa- sionally virus (Casanova 2002, Fernando 2006, Ottenhoff 2005). Most of the my- cobacterial infections in these unfortunate children and adolescents are not caused by M. The mutations responsible for this susceptibility have been identified in many af- flicted individuals, and found to be transmitted by classic Mendelian inheritance. Although the defects are heterogeneous, they often occur in children of consan- guineous parents, with several cases in the same family. The inheritance is most commonly autosomal recessive, but autosomal dominance has been reported in some families, and there is at least one example of X-linked recessive inheritance. The severity and prognosis correlate with the immune response to the infections: children who form lesions typical of lepromatous leprosy - poorly defined, with many mycobacteria but no epithelioid or giant cell - generally succumb to overwhelming infections that are often resistant to cure even with intensive antibiotic therapy. In contrast, patients who form granulomas similar to those of tuberculoid leprosy - paucibacillary, well defined, with giant and epithelioid cells - generally respond to therapy and survive (Ottenhoff 2005). The mycobacteria involved were both slow- and fast-growing species, and even included the generally innocuous M. Only one death has been reported, and there is wide variation in the clinical presentation between family kindreds and even among family members affected by the same mutation. Some of these mutations confer susceptibility to mycobacterial infections in the heterozygous state (dominant trait), but susceptibility to viral infections only when homozygous (recessive trait). Surprisingly, they did not display the classical features of anhydrotic ectodermal dysplasia with immunodefi- ciency mentioned above. Candidate genes in common tuberculosis The identification of the genes where mutations lead to extreme susceptibility has helped to identify the essential components of the human immune defense to my- cobacteria. A correction is necessary because when the statistical significance is defined at the 95 % level, as many as one in 20 alleles 226 Host Genetics and Susceptibility tested can appear, by pure chance, to be associated. One means of correction is to multiply the probability of the association by the number of alleles tested. The reason given for this is that the nomen- clature varied in reports using the different methods, making comparisons very difficult. Because family studies generally have fewer subjects, they have less statistical power than case-control studies to find significant associations, and 100-200 families might be regarded as a minimum required to obtain reliable data. The study design strengthened the case for this association because it was done in two stages with two separate groups of patients. In vitro studies have shown that the addition of vitamin D to infected macrophages augments their ability to eliminate M. They were initially thought to influence bone density and osteoporosis (Sainz 1997), but subsequent studies found no convincing evidence 232 Host Genetics and Susceptibility that they are associated with an increase in fractures (Uitterlinden 2006). This created sufficient interest to motivate at least eight other studies, which have reported diverse results. A meta-analysis of studies on the FokI and TaqI polymorphisms found the results to be inconclusive, and that the studies had too few participants (low statistical power) to prove the weak increases or decreases in susceptibility identified in those studies that found associations (Lewis 2005). In summary, while there is evidence that vitamin D promotes macrophage killing of M tuberculosis (Liu 2006, Rockett 6. How- ever, the relevant gene does not appear to be the vitamin D receptor, or else its effect is so minimal that it is easily obscured by other genetic or environmental factors. Pattern recognition receptors One of the first lines of defense of the immune system is the recognition and uptake of microorganisms by professional phagocytes: macrophages and dendritic cells. On the surface of phagocytic cells are several different pattern recognition recep- tors, which, in the absence of adaptive immunity, bind to different patterns on mi- crobes to promote phagocytosis and activate signaling that leads to cytokine pro- duction, antigen presentation, and the development of adaptive immunity. The latter two polymorphisms are present at a fairly high frequency in sub-Saharan African and Eurasian populations, and have been associated with an increased risk of infection (Neth 2000). A calcium-dependent phospholipase D pathway is also activated, promoting phago-lysosomal fusion and mycobacterial killing.

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Site matters: Multisite randomized trial of motivational enhancement therapy in community drug abuse clinics buy 20gm diclofenac gel amex nonerosive arthritis definition. A 6-month controlled naltrexone study: Combined effect with cognitive behavioral therapy in outpatient treatment of alcohol dependence diclofenac gel 20 gm sale arthritis in neck prognosis. The cost-effectiveness of buprenorphine maintenance therapy for opiate addiction in the United States buy diclofenac gel 20gm on line arthritis pain bracelets. Randomized controlled trial of motivational interviewing discount 20gm diclofenac gel otc define arthritis disease, cognitive behavior therapy, and family intervention for patients with comorbid schizophrenia and substance use disorders. Department of Health and Human Services, Public Health Service, Alcohol, Drug Abuse, and Mental Health Administration, National Institute on Drug Abuse. Increased attributable risk related to a functional mu-opioid receptor gene polymorphism in association with alcohol dependence in central Sweden. Medicaid reforms in the Patient Protection and Affordable Care Act and the Health Care and Education Reconciliation Act. A randomized clinical trial of a new behavioral treatment for drug abuse in people with severe and persistent mental illness. An exploratory study of recreational drug use and nutrition-related behaviors and attitudes among adolescents. Accountable care organizations in Medicare and the private sector: A status update: Timely analysis of immediate health policy issues. Screening and brief intervention to reduce marijuana use among youth and young adults in a pediatric emergency department. To treat or not to treat: Evidence on the prospects of expanding treatment to drug-involved offenders. Does attention-deficit hyperactivity disorder impact the developmental course of drug and alcohol abuse and dependence? Familial transmission of substance dependence: Alcohol, marijuana, cocaine, and habitual smoking: A report from the Collaborative Study on the Genetics of Alcoholism. Substance abuse training and perceived knowledge: Predictors of perceived preparedness to work in substance abuse. Effect of smoking cessation counseling on recovery from alcoholism: Findings from a randomized community intervention trial. Seeking safety treatment for male veterans with a substance use disorder and post-traumatic stress disorder symptomology. Multisystemic treatment of serious juvenile offenders: Long-term prevention of criminality and violence. Guidelines for linking addiction treatment with primary healthcare developed for the Behavioral Health Recovery Management Project. Department of Health and Human Services, Public Health Service, Alcohol, Drug Abuse, and Mental Health Administration, National Institute on Drug Abuse. Association between attention- deficit/hyperactivity disorder in adolescence and substance use disorders in adulthood. Child care in outpatient substance abuse treatment facilities for women: Findings from the 2008 National Survey of Substance Abuse Treatment Services. The prevalence and detection of substance use disorders among inpatients ages 18 to 49: An opportunity for prevention. Performance-based contracting within a state substance abuse treatment system: A preliminary exploration of differences in client access and client outcomes. Examining the effects of academic beliefs and behaviors on changes in substance use among urban adolescents. The looming expansion and transformation of public substance abuse treatment under the affordable care act. Naltrexone - Treatment for alcoholism and addiction: Blocks effects of opioids, reduces alcohol craving. A comparison of self-report measures of nicotine dependence among male drug/alcohol-dependent cigarette smokers. Racial and ethnic differences in response to medicines: Towards individualized pharmaceutical treatment. Black grandparents rearing children of drug-addicted parents: Stressors, outcomes, and social service needs. Alcohol-related health disparities and treatment-related epidemiological findings among whites, blacks, and Hispanics in the United States. The effectiveness of limiting alcohol outlet density as a means of reducing excessive alcohol consumption and alcohol-related harms. Culturally competent treatment practices and ancillary service use in outpatient substance abuse treatment. Psychometric evaluation of the alcohol use disorders identification test and short drug abuse screening test with psychiatric patients in India. Motivational interviewing to improve treatment engagement and outcome in individuals seeking treatment for substance abuse: A multisite effectiveness study. Targeting behavioral therapies to enhance naltrexone treatment of opioid dependence: Efficacy of contingency management and significant other involvement. Efficacy of disulfiram and cognitive behavior therapy in cocaine-dependent outpatients: A randomized placebo- controlled trial. Integrating psychotherapy and pharmacotherapy for cocaine dependence: Results from a randomized clinical trial. Sixth version of the Addiction Severity Index: Assessing sensitivity to therapeutic change and retention predictors. Critical issues in the development of culturally relevant substance abuse treatments for specific minority groups. Paternal, perceived maternal, and youth risk factors as predictors of youth stage of substance use a longitudinal study. Demand/withdraw communication between parents and adolescents: Connections with self-esteem and substance use. Improving patient access to buprenorphine treatment through physician offices in Maryland: Summary of findings, recommendations, and action steps. Department of Health and Human Services, Substance Abuse and Mental Health Services Administration, Center for Substance Abuse Treatment. Department of Health and Human Services, Substance Abuse and Mental Health Services Administration, Center for Substance Abuse Treatment. Screening and assessment for alcohol and other drug abuse among adults in the criminal justice system. Department of Health and Human Services, Substance Abuse and Mental Health Services Administration, Center for Substance Abuse Treatment. Department of Health and Human Services, Substance Abuse and Mental Health Services Administration, Center for Substance Abuse Treatment. The role and current status of patient placement criteria in the treatment of substance use disorders. Department of Health and Human Services, Substance Abuse and Mental Health Services Administration, Center for Substance Abuse Treatment. Department of Health and Human Services, Substance Abuse and Mental Health Services Administration, Center for Substance Abuse Treatment. Department of Health and Human Services, Substance Abuse and Mental Health Services Administration, Center for Substance Abuse Treatment. Department of Health and Human Services, Substance Abuse and Mental Health Services Administration, Center for Substance Abuse Treatment. Department of Health and Human Services, Substance Abuse and Mental Health Services Administration, Center for Substance Abuse Treatment. Department of Health and Human Services, Substance Abuse and Mental Health Services Administration, Center for Substance Abuse Treatment.

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Investigate the environmental conditions such as food sanitation buy 20 gm diclofenac gel with mastercard arthritis for dogs, suspected breeding sites discount diclofenac gel 20 gm mastercard symptoms of arthritis in horses feet, animal reservoirs discount 20gm diclofenac gel amex is arthritis in the back a disability, according to the type of disease outbreak being investigated effective diclofenac gel 20 gm arthritis in the back nhs. Management of epidemic and follow up Although it is discussed late, intervention must start as soon as possible depending on the specific circumstances. For example, an outbreak might be controlled by destroying contaminated foods, disinfecting contaminated water, or destroying mosquito breeding sites or an infectious food handler could be suspended from the job and treated. General principles in the management of epidemics Management of epidemics requires an urgent and intelligent use of appropriate measures against the spread of the disease. However, the actions can be generally categorized as presented below to facilitate easy understanding of the strategies. Measures Directed Against the Reservoir 62 Understanding the nature of the reservoir is necessary in the selection of an appropriate control methods and their likelihood of success. The following are examples of control measures against diseases with various reservoirs: Domestic animals as reservoir: Immunization. This is not suitable in the control of diseases in which a large proportion are inapparent infection (without signs and symptoms) or in which maximal infectivity precedes overt illness. Quarantine- is the limitation of freedom of movement of apparently healthy persons or animals who have been exposed to a case of infectious disease. Cholera, Plague, and yellow fever are the three internationally quarantinable diseases by international agreement. Now quarantine is replaced in some countries by active surveillance of the individuals; maintaining close supervision over possible contacts of ill persons to detect infection or illness promptly; their freedom of movement is not restricted. Measures that interrupt the transmission of organisms Action to prevent transmission of disease by ingestion: i. Example vaccination for meningitis Chemoprophylaxis: for example, use of chloroquine to persons traveling to malaria endemic areas. After the epidemic is controlled, strict follow up mechanisms should be designed so as to prevent similar epidemics in the future. Report of the investigation At the end prepare a comprehensive report and submit to the appropriate/concerned bodies like the Woreda Health Office. The report should follow the usual scientific format: introduction, methods, results, discussion, and recommendations. Passive surveillance Passive surveillance may be defined as a mechanism for routine surveillance based on passive case detection and on the routine recording and reporting system. The information provider comes to the health institutions for help, be it medical or other preventive and promotive health services. Advantages of passive surveillance covers a wide range of problems does not require special arrangement it is relatively cheap 69 covers a wider area The disadvantages of passive surveillance The information generated is to a large extent unreliable, incomplete and inaccurate Most of the time, data from passive surveillance is not available on time Most of the time, you may not get the kind of information you desire It lacks representativeness of the whole population since passive surveillance is mainly based on health institution reports Active surveillance Active surveillance is defined as a method of data collection usually on a specific disease, for relatively limited period of time. It involves collection of data from communities such as in house-to-house surveys or mobilizing communities to some central point where data can be collected. This can be arranged by assigning health personnel to collect information on presence or absence of new cases of a particular disease at regular intervals. Example: investigation of out-breaks 70 The advantages of active surveillance the collected data is complete and accurate information collected is timely. The disadvantages of active surveillance it requires good organization, it is expensive it requires skilled human power it is for short period of time(not a continuous process) it is directed towards specific disease conditions Conditions in which active surveillance is appropriate Active surveillance has limited scope. These conditions are: For periodic evaluation of an ongoing program For programs with limited time of operation such as eradication program 71 In unusual situations such as: New disease discovery New mode of transmission When a disease is found to affect a new subgroup of the population. In this strategy several activities from the different vertical programs are coordinated and streamlined in order to make best use of scarce resources. The activities are combined taking advantage of similar surveillance functions, skills, resources, and target population. Integrated disease surveillance strategy recommends coordination and integration of surveillance activities for diseases of public health importance. Diseases included in the integrated disease surveillance system Among the most prevalent health problems 21 (twenty one) communicable diseases and conditions are selected for integrated disease surveillance to be implemented in Ethiopia. Epidemic-Prone Diseases 74 Cholera Diarrhea with blood (Shigella) Yellow fever Measles Meningitis Plague Viral hemorrhagic fevers*** Typhoid fever Relapsing fever Epidemic typhus Malaria B. Principles and Practice of Public Health Surveillance, second edition, Oxford University Press, Oxford, 2000. They are intended to provide the clinician, especially trainees, easy access to basic information needed in day-to-day decision-making and care. Grade A One (or more) mucosal breaks no longer than 5 mm that do not extend between the tops of two mucosal folds. Grade B One (or more) mucosal breaks more than 5 mm long that do not extend between the tops of two mucosal folds. Grade C One (or more) mucosal breaks that are continuous between the tops of two or more mucosal folds but involve <75% of the esophageal circumference. All newly diagnosed cirrhotics and all other cirrhotics who are medically stable, willing to be treated prophylactically, and would benefit from medical or endoscopic therapies. Secondary prophylaxis -Beta-blockers: Meta-analyses suggest that the risk of bleeding is decreased by 40%, the risk of death by 20%. Inject air through the gastric suction port and auscultate over the stomach (for presumptive evident that the tube has been properly inserted). Use of a pulley-weight system traction on the tube is discouraged because if the gastric balloon should deflate, the esophageal balloon (if inflated) could be pulled up and obstruct the airway. Monitor the pressure in the esophageal balloon by attaching its port to a sphygmomanometer; check pressure every 30-60 minutes. Removal of the tube Do not leave either the gastric or the esophageal balloon continually inflated for more than 24 hours! Before endoscopy: two doses of 40 or 80 mg permitted After endoscopy: may be used for bleeding duodenal or gastric ulcer at 8mg/hr gtt. Important: These tests should not be performed sooner than four weeks after the cessation of antibiotic treatment and not sooner than one-two weeks after the cessation of proton pump inhibitor treatment. Endoscopic surveillance: at one year (if no recurrence – then every 3-5 years); more frequently if polyp is atypical histologically or if surrounding metaplasia is present. Antibiotics Rifaximin 400mg tid x 10days Laxatives Osmotic laxitives (mag citrate or sodium phosphate) Hyperosmotic laxative (polyethylene glycol) ***Avoid regular use of stimulant laxitives. If excessive gas/bloating present, advise against carbonated beverages, beans, gum chewing, excess fats. Lab abnormalities also may include macrocytic anemia (folate deficiency), coagulopathy (vitamin K deficiency), hypocalemia or elevated alkaline phosphatase (vitamin D def) and hypertransaminasemia. The term diarrhea can mean loose or watery stools, increased stool frequency (normal is <3/d and >1 q 3 d), or excessive volume of stool. Evaluation only needed if patient has clinical toxicity, is immunocompromised, has bloody stools or worsening symptoms over 7days. Also consider laxative abuse, cancer, alcohol, endocrine abnormalities, neuroendocrine tumors, food allergy and medications. Early dumping symptoms occur <30 min after eating (diarrhea, orthostasis, flushing, nausea, abdominal pain). Late dumping (hours after eating) is due to rapid carbohydrate emptying into the small bowel, with physiologic hyperinsulinemia and resulting hypoglycemia (anxiety, tremulousness, palpitations, diaphoresis. Treatment options include clonidine, oxybutynin, cholestyramine, opiates and trial of antibiotics for possible small bowel bacterial overgrowth. If still unable to wean off steroids start immunomodulator therapy (such as azathioprine and/or infliximab). Add broad spectrum antibiotics if no response or fulminant (high fever, leukocytosis with left shift and/or megacolon). Metronidazole B 250-500 mg tid Seems safe, but use is limited to 2d and 3d trimesters because of potential mutagenicity in the first trimester.

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Introductory Examination Process  Initially a cursory physical examination and gross examination of the head and ocular region prior to any sedation or local anesthesia is advisable buy diclofenac gel 20 gm arthritis medication for eczema. First and foremost one should determine if the animal is sighted  The menace response is acceptable discount 20 gm diclofenac gel visa swollen joints in dogs front legs, but even prior to that purchase diclofenac gel 20gm amex arthritis neck lump, note how the animal is reacting to its surroundings diclofenac gel 20gm generic arthritis neck pain headaches. For example, how the animal behaves while being unloaded from a trailer, or while turned out in the paddock. Watch carefully as the animal is being led on a lead and how it reacts to other animals and its environment. First and foremost one should determine if the animal is sighted  An obstacle course would be ideal yet in my experience it is not always practical. First and foremost one should determine if the animal is sighted  The history with these animals will commonly include frequent trauma and difficulty navigating at night or in dim light. Vision Testing The menace response is a learned response which will not generally be present in foals less than two weeks of age. A hand or finger(s) thrust is made toward the eye, avoiding setting up stimulating air currents, or touching tactile hairs (vibrissae). Therefore, the seventh cranial nerve and orbicularis oculi muscle must also be intact along with visual pathways up to and including the cortex. When performing this test the examiner should stand on one side of the animal to assure that his hand motion is not in the visual field of the contralateral eye. The strength of the blink response can be amplified by actually touching the periocular region on the first one or two thrusts and then stopping short of this on the next two or three. Some animals need to be reminded, if you will, that the thrusted finger may touch them. Vision Testing  Throwing cotton balls, wads of cotton or a glove in the air can be helpful in visual assessment but it is not always reliable. Vision Testing  The end point with this method would be head motion and /or reflex blink, which can be subtle. The examiner needs to be assured that the object thrown is large enough to be seen, that the object does not make a noise, set up stimulating air currents, nor is thrown into the visual field of the opposite eye. A few repeated responses are necessary to avoid interpreting a coincidental blink or head motion with a positive sign. Vision Testing  Throwing Cotton Balls Gross Evaluation  Symmetry  Ocular discharge  Normal Position of the Upper Eyelid Cilia  Ptosis  Blepharospasm  Photophobia  Surface Topography  Pupillary symmetry Symmetry  Evaluate symmetry of the head and facial expression. Ocular discharge  Ocular discharge if present should be characterized as serous, mucoid, purulent, hemorrhagic, seromucoid, mucopurulent, or serosanguinous. Normal Position of the Upper Eyelid Cilia  The position of the upper eyelid cilia normally should be directed nearly perpendicular to the corneal surface. Blepharospasms  Blepharospasm (forced blinking) is usually a sign of ocular pain and commonly is also associated with an ocular discharge. Photophobia Ocular pain that results in blepharospasm can stem from superficial sites (eg: cornea) or deep intraocular ones (eg: uvea-ciliary spasm). Surface Topography  Surface topography of the periorbital and ocular structures such as eyelid creases and folds, as well as the supraorbital fossal depression may be accentuated or lost. Conditions resulting in enophthalmia such as a painful globe or a globe undergoing atrophy (phthisis bulbi) and loss of orbital contents due to emaciation, muscle atrophy (denervation, post inflammatory) would emphasize these topographical structures. Surface Topography  Conversely, conditions that would increase the orbital contents such as inflammation, hemorrhage or obliterate these. Careful comparison of both orbital and peri- ocular areas, along with the appreciation of these surface topographical structures, can assist in the early recognition of ocular problems. Palpation  Palpation of the orbital zone is also important to confirm topographical changes and characterize them as hard or soft, moveable or fixed, and sensitive or insensitive. Percussion of the frontal and maxillary sinus area may be indicated, especially in animals with orbital disease. A stethoscope is helpful to critically assess the sounds generated during percussion and certainly comparison of both sides will identify subtle fluid accumulations. Retropulsion  Retropulsion or pushing the globe deeper into the orbit through the closed eyelids is a technique that is used to determine if there is an abnormal amount of orbital contents. Resistance to retropulsion, especially as compared to the contralateral orbit would signify increased orbital mass and perhaps a localization of a focal swelling could be identified with this method combined with the direction of any apparent deviation of the globe. This technique would not of course be used in an eye that is in danger of rupture. The maximal amount of valuable information gained from the findings of these procedures results when the examiner is familiar with the normal bony and soft tissue anatomy. Palpation  Palpation used in a stimulatory manner (Palpebral Reflex) to evaluate sensory and motor nerve function is important to evaluate the fifth, sixth and seventh cranial nerves. Touching the periocular area should normally produce a blink reflex, verifying that the fifth and seventh cranial nerves are intact as well as the orbicularis oculi muscle. Corneal Reflex  Touching the cornea with the wisped end of a cotton tipped applicator (Corneal Reflex) will evaluate the ophthalmic branch of the fifth nerve and a normal reflex will elicit a head jerk, blink and retraction of the globe with secondary prolapse of the third eyelid. Pupillary symmetry  Pupillary symmetry can be evaluated by viewing the animal head on from about 6 feet through a direct ophthalmoscope set a 0 diopters and stimulating a tapetal reflex. At the same time, the fellow pupil should also constrict, resulting in the consensual pupillary light reflex. Observation of this reflex may require a second person due to the lateral placement of the globes. The equine pupil responds slower than the cat or dog and as with all animals, its presence does not confirm sight. Finnoff Transilluminator Excitement or opacity of the ocular media from blood, pus or cataract will not override the reflex from a bright focal light source. Inexpensive Lights Intermediate Examination Process  Now a more through evaluation of the external eye can be done and systemic analgesic/sedatives could be given at this point if deemed necessary, which will not affect the subsequent portions of the examination. Use of an neck twitch or lip twitch is also often necessary during the moment of more uncomfortable examination procedures. Such as, at the time the periocular nerve block injections are made, eversion of the eyelids, especially the third eyelid and perhaps when the nasolacrimal system is flushed. Close Inspection For the majority of the examination minimal restraint is usually optimal and holding the horse by the halter seems to work well. Close evaluation of the eyelid margins, conjunctiva, cul de sacs and cornea for abnormalities can effectively be done with a bright light source and magnification. A head loupe such as an "Opti-Visor" is very helpful in addition to an adequate light source. The otoscope will provide a 3 x – 5x magnification and a powerful light source all in one. Opacities in the Ocular Media  With the direct ophthalmoscope set at 0 diopters and viewing the eye from a distance of about one to two feet, an evaluation of the of the ocular media for opacities. Opacities in the Ocular Media  The best situation is when the pupil is dilated artificially with tropicamide (1%) – do not use atropine for diagnostic purposes. This will allow the examiner to briefly evaluate the lens and vitreal space in this indirect manner for synechia, cataracts, vitreal floaters and retinal detachments. Opacities in the Ocular Media  Later, when it is more appropriate to use a mydriatic, this indirect examination with the direct ophthalmoscope can be repeated when the pupil is large. Opacities that are anterior to the center of the lens will move in the same direction of the globe and ones posterior to the center of the lens will move in the opposite direction. Retinal detachments, if large will be seen easier with this method than looking directly.

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