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The degree of disability is related to the number of concussions that the individual has suffered B generic 10mg zetia cholesterol levels during lactation. T h e t yp e of sp or t an d p layer st yle st r o n gly in flu en ce the r isk of con cu ssion s C generic zetia 10 mg line cholesterol foods help lower. Male athletes are more likely to sustain concussions than female athletes purchase cheap zetia on line cholesterol comparison chart meat, and this is related to the types of sports that male athletes compete in, and the gen er al d iffer en ce b et ween player st yles of m ale an d fem ale at h let es. O ver all, the rates of concussions are higher for female athletes competing in the same types of sports activities. Improving t his pat ient ’s oxygenat ion and ven- tilation are the immediate priorities for this patient. At this t ime, he is found t o have bifront al cerebral con- tusions, cerebral swelling, and subarachnoid hemorrhage. Midline shifts and focal mass lesions are generally consid- ered injuries t hat are more amenable t o operat ive int ervent ions. The primary goals for this patient are t o op t im ize h is oxygen at ion, vent ilat ion, an d blood pressures with ventilation and intravenous fluids. Intracranial pressure moni- toring is also helpful to guide the management of ventilation and direct phar- macologic therapy if needed (eg, mannitol administration). Balance dist urbance is a specific indicat or of concussion, alt h ough it is not a highly sensit ive indicator. Balance t est ing of at hlet es on t he sidelines can be helpful in identifing individuals with concussions. American Medical Society for Sports Medicine position statement: concussion in sport. Risk of traumatic intracranial hemorrhage in patients with head injury and preinjury warfarin or clopidogrel use. He denies back trauma, heavy lifting, or problems voiding or with bowel movements. On physical examination, his blood pressure is 130/78 mm Hg, pulse rate is 80 beats/minute, and he is afebrile. Co n s i d e r a t i o n s This 55-year-old man presents with a 4-month history of low back pain with radia- tion of pain to the posterior aspect of his right leg. H is h ist ory and findings are t ypical for ch ronic back pain (defined as greater than 3 months duration) possibly related to herniated lumbar pulposu s, possibly cau sin g compression of the n er ve root that are t ypically at t he levels of L4-5 (L4: m ed ial asp ect of calf an d an kle; L5: lat er al an kle an d foot ). Pain radiation to the lateral or posterior aspect of the leg is a common complaint, as are parest hesias in the affected dermatome dist ribut ions. In some pat ient s, motor weaknesses associat ed wit h the affect ed nerve root s can also be det ect ed (L4: ant e- rior tibialis; L5: extensor hallicus longus). Import ant ly, if t he pat ient had significant motor deficits or bladder/ bowel dysfunction, a more urgent evaluation and treatment would be paramount t o preserve nerve funct ion. Rough ly t wo-t hirds of adult s will experience at least one episode during his/ her lifetime. Most pat ient s wit h mechanical low back pain will have spont aneous symptoms resolut ion wit hin 2 to 4 weeks. Common sympt oms associat ed wit h this syn- drome include bladder and bowel dysfunctions, pain and/ or weakness in the legs. Identification of the process early during the course of disease is important in avoiding ner ve ent rapment t hat ends up producing long-t erm dysfunct ions. It is on e of the m ost com - mon reasons leading to activity limitation and work absence. Lower educational st at us is associat ed wit h increased prevalence of low back pain and associat ed wit h worse out comes associat ed wit h the problem. O ccupat ional act ivit ies are cont rib- utors of low back pain, with higher prevalence reported in manual workers. For majority of individuals, low back pain is self-limiting within a 2 to 4 weeks period; however, one in three individuals reports persistent pain up to 1 year after initial presentation, and one in five reports long-term substantial limitation in activities. His t o r y The focused history during the work-up should include duration of symptoms, description of symptoms along with exacerbating and alleviating factors, pres- ence of absence of neurologic funct ions, bowel and bladder funct ions, and infec- tion-related symptoms such as fevers or night sweats (see Table 39-1). Important informat ion in t he past medical h ist ory includes h ist ory of ost eoporosis, prior history of back pain, previous spine surgeries, cancers, and active infections. A number of symptoms and historical items have been identified as indicators of potentially serious conditions (red-flag symptoms or factors) which include age >50, presence of systemic symptoms such as fever, night sweats, weight lo ss, his- tory of malignancy, night pain, immune suppressed status, history of intravenous drug use, failure to respond to initial treatments, prolonged corticosteroid use, diagnosis of osteoporosis, and trauma. Nig h t p a in, abscess often with motor and sensory deficits Ma lig n a n c y Hist o ry o f ca n ce r, n e w o n se t b a ck p a in ; o ft e n a g e > 50; fre q u e n t ly with radiculopathy and/or motor/sensory deficits Cauda equina syndrome Urin a r y re t e n t io n o r fe ca l in co n t in e n ce ; d e cre a se d re c t a l t o n e ; saddle anesthesia Co n u s m e d u lla r is Sa m e a s ca u d a e q u in a b u t a lso wit h u p p e r m o t o r n e u ro n sig n s (e g, syndrome hyperreflexia, clonus) Ve r t e b r a l c o m p r e s s i o n Hist o ry o f o st e o p o ro sis o r co rt ico st e ro id s u se ; o ld e r p a t ie n t s fracture Tr a u m a Va r i a b l e f i n d i n g s d e p e n d i n g o n the i n j u r y s i t e a n d e x t e n t Ph ysica l Exa m in a t io n Complete neurologic examination is import ant in the lower and upper extremities to try to identify upper motor neuron disorders and spinal cord related symptoms. Examination of deep tendon reflexes and sensory examination correlating to vari- ous dermatomes, and motor examination related to the various nerve root levels are import ant t o ident ify t he affect ing anatomic sit e (See Table 39-2). La b o r a t o r y The s t i n g General laboratory testing is not indicated but there are specific laboratory tests that can be helpful to identify certain abnormalities. Imaging st udies sh ould be considered in pat ient s wit h “red flag” symptoms or factors and in pat ient s whose symptoms persist for gr eat er t h an 4 t o 6 weeks of con ser vat ive man agement. T h e r ole of imagin g in t h ese patients is to rule out fracture, tumor, or infections. The initial radiographic study can be plain r adiogr aph y of the lu mbar r egion. Tr e a t m e n t The majority of patient s with low back pain without worrisome neurologic symp- toms will improve within a few weeks. For some patients, the combination of oral analgesics, antidepres- sant s, and opioids seem to produce better responses. It is important to closely moni- tor long-term opioids use for some of the patients to avoid habituation. Patient education is import ant to help define expect at ions and a long range goal. For t hese pat ient s, the realistic goals might be improvement in function and reduction in pain rather than cure. For certain patients with persistent pain, anatomic lesions are identified that may respond to surgical care. The indications for surgical treatment include ident ifiable anat omic nerve compression, neurologic deficit s, and/ or int ract able pain. Surgical treatment for herniated discs involves laminectomy and removal of the protruding disc(s). If several levels of disc spaces are involved, posterior spinal fu sion in ad d it ion t o the d isc ext r act ion is in d icat ed. Which of the following physical examination fin d in gs most likely cor relat es wit h this pat h ology? D ecr eased p at ellar t en d on r eflex an d n u m b n ess of the d or su m of r igh t foot and plant ar region C.
In the past cheap zetia 10 mg amex cholesterol levels percentage, these polyps were believed to be of no clinical relevance; however order line zetia cholesterol test margin of error, with the recognition of serrated adenomas/ polyps order zetia without prescription cholesterol medical term definition, there has been increased interest in hyperplastic polyps. A sessile polyp has a flat-appearance with a broad base and complete resection endoscopi- cally can be t ech n ically mor e ch allen gin g. Phenotypically, these lesions appear flat or sessile and are easy t o overlook during colonoscopy. H ist o- logically, t h ese lesion s appear arch it ect urally similar t o hyperplast ic polyps. Most serrated adenomas or polyps are larger t han 5 mm and are found in t he right colon. Serrated adenomas are high-risk lesions with approximately 15% of the lesions progress to become cancers. Epidemiologically, these lesions occur more commonly in females, and cancers arising from t hese lesions t end t o occur lat er in life wit h peak incidences in the mid-to-late 1970s. This proce- dure can be done by open surgery or laparoscopically and is often applied when the patient has a low-lying invasive rectal cancer that is at the level of the levator and rectal sphincter muscles. T his can be done when the cancer is above the levator muscles and the anal sphincters. Prior to initiating a screening or surveillance plan for any patient, it is important to classify the pat ient based on r isk (aver age-r isk, mod er at e-r isk, or h igh -r isk). Clin ic a l Pr e s e n t a t i o n Symptoms of colorectal cancer vary depending on the locat ion of the tumor. The most common presenting symptom is bleeding per rectum that is either occult or gross. Ch ange in bowel h abit is also common an d is r epor t ed in 77% t o 92% of patients. O nly 6% to 16% of patient s present with intest inal obstruction, and 2% to 7% of patients present with colonic perforation. Some of the bowel habit ch an ges r ep or t ed by pat ient s wit h left -sid ed t u mor s in clu d e ch an ge in st ool caliber and diarrhea whereas pat ient s wit h right -sided colon cancers tend to present more often with anemia. Tr e a t m e n t Polyp s Patients with colonic polyps are best treated with endoscopic resection. Roughly, 65% to 80% of colon polyps are tubular adenomas, 10% to 25% are tubulovillous adenomas, and 5% to10% are villous adenomas. W h en the can cer wit h in the polyp does n ot pen et rat e the submucosa, polypectomy with clear margins is considered sufficient treatment. H owever, with submucosa penetration by the cancer, the spread of tumor to the regional lymph nodes become possible, and treatment should include resection of the involved area of the colon/ rectum. For the majority of patients with invasive colon cancers, t he t reat ment begins wit h resect ion of t he colon segment that contains the cancer. The length of colon that is removed is generally dictated by the blood supply to the cancer-involved segment of colon (see Figure 25– 1). For example, resection for a pat ient wit h cancer in t he cecum involves a right colect omy t hat removes a seg- ment of intestine including the distal ileum, cecum, ascending, and right side of the transverse colon (ileocolic artery, right colic artery, and right branch of the middle colic ar t er y d ist r ibut ion ) (see Figu r e 25– 1). Elect ive colon r esect ion are com m on ly performed by the laparoscopic approach, which has been shown to be associated wit h less postoperat ive pain, shorter hospit alizat ion, and earlier return to work in compar ison t o op en colect om ies. For example, for a pat ient wit h can cer in t he right colon t hat is minimally symptomat ic but has significant tumor burden in the liver, we would t reat t he met ast at ic disease first wit h syst emic chemot her- apy and/ or t argeted biologic agent s. In some cases, t he primary tumor would not be addressed at all if it remains asymptomatic. On the other hand, if the patient wit h the right colon cancer is profoundly anemic from bleeding or has obst ruct ive sympt oms, t he pat ient will undergo resect ion of t he colon prior t o syst emic adju- van t t h er ap y. P at ien t s wit h ad van ced co lo r ect al can cer s are m o st o p t im ally m an - aged by a mult ispecialt y team made up of surgeons, medical oncologist s, radiat ion oncologist s, radiologist s, nurses, and social workers. N early all patient s with colon can cer s wit h lymph n od e involvem ent will ben efit from adjuvant syst emic t h er apy following colon resect ion s. Re c t a l Ca n c e r The rectum is generally defined as the last 12 to 15 cm of the most distal end of the large bowel. From the oncologic standpoint, the rectum differs from the colon in that it is extraperitoneal in location, it is not covered by the visceral peritoneum, and it is in close proximit y to neighboring st ructures. For these reasons, invasive rect al cancers have a much great er ri sk o f lo cal recurrences followi ng t reat ment. Another important difference between the rectum and colon is the difference in venous drainage. Venous drainage of the colon and upper part of the rectum is por- tal venous, therefore making the liver the most common site of distant metastasis. For the lower rect um the ven ou s, drain age event u ally en ds up in the ven a cava, making the lung a common site of distant metastases. Due to the increased risk of local recurrence, patients with rectal cancers not only benefit from resection of the rectum with total mesorectal resection, most patients also seek benefit from adjuvant radiation therapy. Rig h t c o le c t o m y (A), rig h the m ico le ct o m y wit h d ivisio n o f middle colic pedicle (B), t ra n sve rse co le ct o m y (C), re se ct io n o f sp le n ic fle xu re sp arin g le ft co lic art e ry (D), le ft h e m ico le ct o my (E), sig m o id co le ct o m y sp arin g le ft co lic art e ry (F). While receiving their radiation therapy, patients are usually given adjuvant ch em ot h er apy t o in cr ease the effect iven ess of r ad iat ion t r eat m ent s. In select ive cases wh en the t u mor is locally advan ced, ch emor adiat ion t h er apy is given befor e surgery t o h elp improve t he probabilit y of having a complet e resect ion. Similar to patients with colon cancers, patients with node-positive rectal can- cer s also b en efit from syst em ic ch em ot h er apy u sin g the r egim en s that h ave b een described for colon carcinoma. An important difference regarding rectal cancer is that aggressive local resection with radiation therapy can frequently cause sexual and urinary dysfunct ion in male pat ient s, and urinary and fert ilit y dysfunct ion in female pat ient s. T h ese pot ent ial complicat ion s sh ou ld be discu ssed an d addressed wit h each pat ient prior to t he init iat ion of t reat ment s. Because of these additional concerns, rectal cancer patients should be provided with extensive counseling and appropriate support before, during, and after treatment. H ow- ever, t here are small subset s of pat ient s wit h hepat ic or pulmonary met ast ases who benefit from local treatments such as surgical resection or ablation of the metas- tases. Metastases are classified as synchronous (identified the same time as the primary tumor) or metachronous (identified after the primary had been treated). Prognostically, the patients with metachronous metastases do better than patients wit h synchronous met ast ases. R ep eat colo n o sco p y in 5 year s, an d if n egat ive, r ep eat ever y 5 t o 1 0 year s C. Su r gical r esect io n, r ad iat io n t h er ap y, an d ch em o t h er ap y if n o d e p o sit ive C. A m an wit h a 2 0 - year h ist o r y of u lcer at ive co lit is in volvin g the left co lo n wit h pseudopolyps in t he rectum C.
Cephalic resections buy cheap zetia 10mg on-line cholesterol levels when to take statins, inter- and intradomal sutures resulted in more tip refinement buy discount zetia 10 mg on-line cholesterol foods high list. A composite graft was inserted to recreate a neocolumella cheap zetia 10 mg visa cholesterol medication bad for you, subse- quently followed by osteotomies and insertion of a big cap graft. The columella turned out to be too broad, and there was retraction of the lateral crus of the left alar cartilage due to soar tissue. Reconstruction of the columella was done with tragus cartilage and a composite graft from the other ear. Despite massive improvement, the columella still shows a lot of scar tissue formation. On the years and during puberty, when the nose grows faster than other hand, significant disturbances of midfacial growth after during the other periods of life. Consequently, surgery per- septorhinoplasty have been suggested by animal research. It was formed in the period between growth spurts can disguise a apparent from our serial photography results spanning a decade possible surgically induced growth disturbance until the final that good results achieved after initial surgery can be lost to growth spurt. One of the major problems after surgery of the the second spurt of growth during puberty (1 through 5). Instead of cartilaginous eﬀects are perhaps due to the changes in cartilaginous frame- healing, there is always a fibrous layer in between the surgically work, which is more vulnerable during the growth phases. If induced cartilaginous wound edges, which leads to distortion surgery is contemplated around this period, a higher possibility and or deviations of the cartilaginous structure based on the of revision surgery should be discussed with the patient. Guidelines for Rhinoplasty Osteotomies of the bony pyramid do not give rise to midfa- Guidelines for Nasal Septal Surgery cial growth disturbances. Transcolumellar incision of an Elevation of the mucoperichondrium on one or both sides does open approach does not disturb the nasal growth per se, if not interfere with normal growth. Conser- rior chondrotomy or separation of the cartilaginous septum vative alar base wedge resections will not disturb nasal from the perpendicular plate should be avoided. Autogenous carti- sphenodorsal ‘‘growth center’’ leads to disturbance in out- lage grafts are preferable above homologous (irradiated) car- growth of the nasal dorsum, and resection of the sphenospinal tilage grafts. When performing rhinoplasty in children, the surgeon should A longitudinal study of a pair of monozygotic twins. Rhinology 1997; 35: 6– weigh the functional and aesthetic improvement against the 10 possible growth disturbances. Anatomy of the upper lat- integrity of the cartilaginous skeleton should be respected as eral cartilages in the human newborn. Experimentele toetsing van de beginselen van enige chirurgische methoden tial of the graft. De invloed van partiele resectie van het neustussenschot porate the eﬀects of pubertal growth spurt on the midface by op de uitgroei van bovenkaak en neus. An investigation into the results of the submucous resection of Erasmus University, Rotterdam; 1984 the septum in children. The cartilaginous nasal dorsum and post natal growth of the Pediatr 1942; 1: 378 nose. Wound synthesis of five years of research at the Iowa Maxillofacial Growth Labora- healing of autologous implants in the nasal septal cartilage. J Dent Res 1971; 50: 1488–1491 laryngol Relat Spec 1991; 53: 310–314  Kvinnsland S. The correction of deflections of the nasal septum with a minimum Pediatr Otorhinolaryngol 1998; 43: 241–251 of traumatism. Beitrage zur sub submukosen Fensterresektion der Nasenscheide- distortion of nasal septal cartilage: a model to predict the eﬀect of scoring wand. Reimplantation of 1958–1959 autologous septal cartilage in the growing nasal septum. Nasal skeletal trauma and the interlocked stresses of the nasal septal resection and reimplantation of septal cartilage upon nasalgrowth: an exper- cartilage. Surgery of the nasal septum; new operative proce- production in the growing rabbit. Eye Ear Nose Throat Mon 1951; 30: 32– growth after functional endoscopic sinus surgery. Septum surgery in children; indications, surgical technique and growing septal cartilage after surgery in an animal model: new aspects of long-term results. Rhinology 1979; 17: 91–100 cartilage healing and regeneration (preliminary results). Clin Otolar- implications for stress and trauma as illustrated by a complex fracture in a yngol Allied Sci 1997; 22: 453–458 4-year-old boy. J Otolaryngol 1990; 19: 274–278 522 Open Rhinoplasty in Children 66 Open Rhinoplasty in Children Simon C. The use of both hands allows precise transcolumellar incision for approach to the nasal tip was pub- sculpturing and suturing of struts, battens, and grafts, again lished in 1934 by Rethi from Budapest. This is particularly useful for the use of the external approach in children was published in severe septal deformity or dorsal septal deviation where exci- 1960. Hage used this technique for excision of a nasal glioma in sion, remodeling, and reimplantation (decortication) may be two children and found no alteration of the growth of the nose required. The operation was based on wide cartilagi- One disadvantage of the open approach both in children and nous resection and led to severe growth disturbances of the adults is the columellar scar, although with meticulous techni- nose and retroposition of the maxilla. Enthusiasm for pediatric que, this scar is rarely noticeable and disappears with time. It is prevented by dissection growth spurt showed evident growth inhibition of the nose and under the musculoaponeurotic plane, preferably in the subper- maxilla. Prolonged operating time is expected with the Subsequently, several studies looked at the use of the exter- external approach. The bony-cartilaginous exhibit clinically significant retardation of growth after external skeleton is left intact and thus no growth disturbance is approach septoplasty, although there was a tendency for the observed. However, correct evaluation of the a superior cosmetic result when compared with the midline or eﬀects of trauma and surgery requires that followup should be paracanthal incisions over the dorsum, without compromising continued for at least some years after puberty, as growth is the recurrence rate. It lends itself to the philosophy of conservatism of the Dermoid cyst Severe impairment of nasal airway structural support of the nose with an emphasis on augmenta- tion and reorientation of the supportive structures as opposed Cleft lip nose Severe external deformity with psychological 19 impact to reduction and resection. It has the advantage, particularly in the growing nose, that the cartilaginous skeleton stays intact. Magnetic resonance imaging scan did not show continuity intracranially, and she underwent conservative extemal approach rhinoplasty under suspicion of a dermoid cyst, which was later confirmed by the pathologist. Due to the fact that the nasal skeleton was left intact, no growth inhibition of nose and maxilla can be expected. Preoperative (a-d), 1 year postoperatively (e-h), and 2 years postoperatively (i-l).
A: As follows: • In mild case without macular involvement: there is no visual disturbance effective zetia 10mg cholesterol test on empty stomach. My diagnosis is Hypertensive retinopathy (or grade 4 cheap 10 mg zetia fast delivery what causes cholesterol in shrimp, may be malignant hypertension) discount 10mg zetia fast delivery cholesterol ratio and treatment. A: Unknown, probable mechanisms are: • Fibrinoid necrosis of the wall of small artery and arteriole, which results in end organ damage. A: 4 grades (Keith–Wagener–Barker classifcation): • Grade I: Thickening of arterial wall, increase tortuosity, narrowing of arteriole and increased light refex (silver wiring). Presentation of the Case: • There are few haemorrhages (mention the location), some are fame shaped and some are irregular in outline. Dot haemorrhage and Dot and blot haemorrhage Dot and blot haemorrhage microaneurysm (soft exudate) (hard exudate) Q:What is microaneurysm? A: Microaneurysms are the out pouching of capillary walls due to pericyte loss, appears as small red dots. Microaneurysm is always along the vessel wall, it may be confused with haemorrhage. A: These are lipid and protein residues of serous leakage from the vessels, yellowish in colour and irregular in outline with sharply defned margin. A: As follows: • Control of diabetes mellitus, stop smoking and control of hypertension (if any). Diabetic maculopathy is one of the common causes of loss of vision in patient with non-proliferative retinopathy. Maculopathy Preproliferative Proliferative retinopathy Proliferative retinopathy retinopathy (Severe vitreous haemorrhage) Q:How to treat such a case? Plus • There are multiple photocoagulation scars (appears like exudate, with areas of small brown or yellowish spot of variable size and shape). My diagnosis is Proliferative diabetic retinopathy, treated with photocoagulation. A: Unknown, probably there is production of angiogenic factors from the area of ischaemic retina. These new vessels are very fragile and leaking, liable to rupture causing haemorrhage (intraret- inal, preretinal or vitreous). Serous protein leakage from these vessels stimulates connective tissue reaction called retinitis proliferans. Q:What are the indications of laser photocoagulation therapy in diabetic retinopathy? Presentation of a Case: • There are multiple areas of black pigmentation like bone spicules with variable size and shape, some in criss-cross pattern, at the periphery of fundus. A: It is a progressive degenerative disease of retina with pigmentary epithelium in a bone spicule pattern. A: As follows: • Isolated or congenital: Bardet–Biedl syndrome (previously called Laurence–Moon–Biedl syndrome). A: As follows: raise the upper eye lid, see the following— • Divergent squint (eyeball is fxed in downward and outward position). Nuclear lesion (causes are: infarction, haemorrhage, neoplasm and multiple sclerosis). Unruptured aneurysm of posterior communicating artery (there is painful ophthalmoplegia). Bilateral ptosis Bilateral ptosis Bilateral ptosis (senile) Bilateral ptosis (congenital) (myasthenia gravis) (ocular myopathy) Q:How to differentiate between ptosis of myopathy and ptosis due to other cause? A: It is a hereditary disorder, inherited as autosomal dominant or sporadic, common in young, charac- terized by bilateral ptosis with complete ophthalmoplegia. A: As follows: • Neck: Lymph nodes, scar, thyromegaly, aneurysm (carotid and aortic). Horner’s syndrome (left) Horner’s syndrome (bilateral) Q:What is Horner’s syndrome? A: It is a syndrome due to lesion in the sympathetic pathway characterized by: • Partial ptosis. A: Upper eye lead is controlled by Levator palpebrae superioris which is supplied by 3rd nerve. A: It originates from the sympathetic nucleus in hypothalamus and passes through the brain stem to the lateral horn of C8 and T1 segment of spinal cord. From there, pre-ganglionic fbres emerge and pass to sympathetic ganglia (usually superior cervical ganglia). Then the post-ganglionic fbres pass in the carotid sheath with internal carotid artery, enter into the skull along with it and in the cavern- ous sinus, then joins with the ophthalmic division of Vth nerve. Then it enters into the orbit via short ciliary nerve and supply the dilator pupillae, Muller’s muscle and sweat glands on the side of face. A: I want to see the features of tabes dorsalis, such as— • Wrinkling of forehead with bilateral ptosis (due to compensatory overaction of frontalis). Loss of light refex, but persistence of accommodation refex Slow reaction to light and accommodation 4. Presentation of a Case • The pupil of right (or left) eye is dilated than other, regular (or circular). A: It is an abnormality characterized by absent or delayed pupillary constriction to light or accommo- dation. During accommodation, after some delay, abnormal pupil constricts slowly, may be smaller than normal. It is also called myotonic pupil, which is a benign condition, common in young women, usually unilateral (80%), rarely bilateral. Miosis (Right eye) Mydriasis (Left eye) Anisocoria Q:What are the causes of dilated pupil (mydriasis)? It is found in encephalitis lethargica due to epidemic of von Economo’s encephalitis that causes parkinsonism. However, when light is alternately fo- cused from one eye to other, the pupil on the affected side dilates slowly, when exposed to light. The mechanism is as follows: • When light is focused on healthy eye, a rapid pupillary constriction occurs in both eyes. When light is focused again on the affected eye, the eye fails to transmit the message to continue the constriction as quickly as normal. As a result, pupils have time to recover and dilate, despite the light shining on abnormal eye. Look at the eyes from front, comment about sclera that is visible between upper eyelid and upper limbus of cornea. Look any swelling of eyelids, congestion of sclera, chemosis (oedema of conjunctiva), corneal ulcer, thyroid stare (a frightened expression). Look at the eyes from behind to confrm proptosis (eyeball may be visible above the supraorbital ridge).