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Can be minimized with careful application and removal of iridotomy lens treatment 4 toilet infection buy generic paroxetine on line, and post-treatment lubrication with artificial tears 6 symptoms 89 nissan pickup pcv valve bad proven 20 mg paroxetine. Minimized by perioperative use of alpha agonist or other topical glaucoma medications B medicine 123 cheap 20mg paroxetine otc. Can occur within days/weeks due to medicine ads purchase paroxetine with american express blood and pigment dispersion and require touchup once eye is quiet b medications gabapentin best buy paroxetine. Closure common in neovascular glaucoma and uveitis due to inflammatory membranes or pigment dispersion. Consider peripheral laser iridoplasty to open angles further, in plateau iris syndrome 6. An attack of angle-closure glaucoma that is unresponsive to medical therapy and in which corneal edema or shallow anterior chamber precludes laser iridotomy b. Residual angle-closure following laser iridectomy is not caused by pupillary block but abnormal iris angle configuration 3. Phacomorphic glaucoma (lens intumescence) with secondary angle-closure where the pupillary block is not the principal mechanism b. Anterior lens displacement secondary to ciliary body swelling or anterior choroidal expansion after central retinal vein occlusion, inflammation, and ciliary body swelling after sulfa medications (especially topiramate) ii. Most of angle visible but with areas of focal narrowing due to iris irregularities 5. Persistent angle closure after acute attack or subacute angle-closure glaucoma to open angle; may be attempted before goniosynechialysis 7. Treatment consists of placing approximately 24 to 36 spots over 360 degrees, leaving approximately 2 spot-diameters between each spot. Glaucoma medications recommended immediately following laser procedure and the corticosteroid treatment is continued until anterior segment inflammation is resolved 7. Rarely, emergency incisional surgery if elevation sustained and unresponsive to conservative management B. In an extremely shallow peripheral anterior chamber, an initial contraction burn should be placed more centrally before placing the peripheral burn; allows for peripheral deepening b. In virtually all cases, the endothelial burns disappear within several days and have not proved to be a major complication b. Often temporary treatment is pending definitive treatment, especially in case of lens-induced indication E. Long-term effectiveness is possible, but patients need to be followed closely for recurrence of angle closure (especially with plateau iris syndrome) with repeat gonioscopy at routine follow-up intervals. Advise patient that they may experience aching sensation because of longer duration of laser application. Use topical anti-inflammatory agent in addition to other glaucoma medications given 2. Keep scheduled follow-up appointment but call sooner if pain or change in vision is noticed Additional Resources 1. Laser Peripheral Iridotomy with and without iridoplasty for Primary Angle Closure Glaucoma: 1 year results of a Randomized Pilot Study. Long-Term Success of Argon Laser Peripherla Iridoplasty in the Management of Plateau Iris Syndrome. Argon Lser Peripheral Iridoplasty versus Conventional Systemic Medical Therapy in Treatment of Acute Primary Angle-closure Glaucoma. Angle-closure glaucomas that are poorly controlled despite medical and laser surgery interventions a. Laser peripheral iridotomy should be attempted prior to incisional surgery in many types of angle closure C. Performed when laser iridotomy is not possible, due to cloudy cornea, iris too thick to penetrate or poor patient cooperation a. Clear cornea, limbal, or scleral tunnel approach to peripheral anterior chamber. Peripheral iris prolapsed with posterior wound pressure or grasped with forceps and withdrawn through incision f. Ensure that the wound is watertight and that there is a deep anterior chamber at the end of the case C. Core vitrectomy performed with special emphasis on rupture of hyaloid face and creation of a unicameral eye with complete communication of posterior and anterior chambers via a patent iridectomy F. Discontinuation of anticoagulation and antiplatelet therapy pre-operatively if there are no medical contraindications C. Minimize risk by tightly suturing scleral flap and judicious use of cycloplegia post-operatively F. Minimize risk by tightly suturing scleral flap and judicious use of cycloplegia post-operatively G. Compress conjunctiva with Zeiss goniolens or lens designed for suture lysis (Hoskins, Ritch, Mandelkorn) b. Avoidance in early postoperative period after antimetabolites due to increased risk of hypotony 4. Aqueous suppressant to decrease flow through bleb leak and to modulate wound healing in encapsulation c. Needling of a failing or encapsulated bleb with subconjunctival injection of antimetabolites D. Primary phacoemulsification and intraocular lens implantation for acute primary angle-closure. Traditionally reserved for refractory glaucoma cases where conventional filtering surgery has failed or has a high likelihood to fail 2. Examples of appropriate clinical settings follow, although timing of shunt surgery may vary amongst surgeons a. Neovascular glaucoma, after adequate treatment to reduce vascular endothelial growth factor levels ii. Congenital glaucoma, failed angle surgery or anatomy precludes standard angle surgery x. Anterior chamber placement in eyes with endothelial dysfunction or shallow anterior chamber 2. Note the status of the sclera at the proposed tube placement site as well as external reservoir site D. Plate sutured between vertical and horizontal rectus muscles posterior to muscle insertion (anterior plate edge 8 -12 mm posterior to limbus) c. Different methods to cover tube (patch graft) to help prevent erosion through conjunctiva or epithelial ingrowth i. Non-valved devices need flow restriction until encapsulation of plate occurs (timing varies by case) a. Suture in lumen (externalized or subconjunctival) for postoperative removal ("rip-cord" technique) b. Risk reduced by using valved device or temporary occlusion of non-valved device 2. If persistent serous choroidal detachments present, drainage should be considered b. In high risk cases, consider placement via pars plana (previous or concomitant vitrectomy/lensectomy) a. The vitrectomy must be fastidious and complete, including special attention to the vitreous cuff at the site of the tube insertion C. Best avoided with bevel-up cut on intraocular portion of tube and parallel positioning to iris ii. In eyes with high peripheral anterior synechiae or shallow anterior chambers, consider tube placement in ciliary sulcus b. Usually self-limiting, can be treated with intensive topical corticosteroids or intracameral tissue plasminogen activator to dissolve clot 2. Best prevented with meticulous surgical technique (non-occluding mattress suture under patch graft is helpful) 2. May require in situ flushing of tube, removal of fibrovascular ingrowth, or removal of valve mechanism G. Management options include observation, prism, muscle surgery, or removal of the shunt I. Antibiotics and/or corticosteroids may be given intraoperatively and are usually continued topically after surgery B. Non-valved implants i) Glaucoma medications useful until tube function established. Valved implants i) Ensure patency of tube and presence of bleb over reservoir; reinstitute glaucoma medications b. Early may be due to leakage around tube entry into anterior chamber; usually transient b. Emphasize the importance of compliance with postoperative drop regimen (antibiotics, anti-inflammatory) B. Discuss signs and symptoms of postoperative infection and need for immediate examination if present Additional Resources 1. Long-term follow-up of primary glaucoma surgery with ahmed glaucoma valve implant versus trabeculectomy. Ahmed Glaucoma valve implant vs trabeculectomy in the surgical treatment of glaucoma: a randomized clinical trial. Intermediate-term results of a randomized clinical trial of the 350-versus the 500-mm2 Baerveldt implant. Anterior chamber tube shunt to an encircling band (Schocket procedure) in the treatment of refractory glaucoma. Treatment outcomes in the tube versus trabeculectomy study after five years of follow-up. Postoperative complications in the tube versus trabeculectomy study during five years of follow-up. When incisional procedures are refused or are not possible because of medical or ocular conditions 6. Patient refuses incisional surgery and is uncontrolled on maximal medical treatment 7. Patients with high risk of intraocular complications with standard outflow procedures B. Relatively contraindicated in eyes with good vision because of risk of loss of visual acuity 2. Review of patient history, as well as, careful ocular examination to determine underlying cause of glaucoma and likelihood of success/failure with other surgical options B. Patient counseling regarding other surgical options, benefits and risks, including 1. Initial power setting of 1750 mW, increased by 250 mW increments until a "pop" is heard, power then decreased by 250 mW, maximum power of 2500 mW f.

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This strategy has been shown to medicine vocabulary order paroxetine australia reduce the incidence of candidemia and candidiasis-related mortality medicine 4 times a day paroxetine 10mg overnight delivery. Continue for 10 months after transplant prior to mueller sports medicine purchase paroxetine with amex anticipated start of routine vaccinations medicine head generic 10mg paroxetine with visa. Select immunoglobulin product according to treatment of gout order cheap paroxetine online precautions to decrease adverse effects as applicable (see cautionary note below). All patients with absent pre-transplant serum IgA levels should be evaluated for the presence of anti-IgA antibodies. The following evaluation should be instituted promptly in all patients with fever. Empiric treatment with antibiotics may be indicated after cultures have been obtained. Sudden, overwhelming sepsis syndrome with Pneumococcus or other encapsulated organisms can occur, especially in patients who have poor compliance with antibiotic prophylaxis. Stains specific for viral inclusions and general morphology to rule out malignancy (Papanicolaou, Wright-Giemsa, Hematoxylin & Eosin) 3. When available, immunohistochemistry staining and in situ hybridization are recommended for detection of viral infection. The clinical evaluation of diarrhea depends on its duration and volume, the presence of blood, and the occurrence of fever and other constitutional symptoms. A more directed approach can be taken if there is a history of foreign travel or history of exposure to children from day-care setting. If the diarrhea does not resolve with these measures or recurs after the patient resumes oral medications, a search for enteric pathogens including, for example, norovirus, c. Adequate platelet count and coagulation parameters should exist to do biopsy safely. If there are no macroscopic abnormalities found, we suggest 6-8 biopsies of the gastric antrum. To minimize the risk of bleeding, avoid biopsies of the duodenum unless this is the only site of abnormalities. Please send slides and biopsy blocks to the address below if you wish our pathologists to review the specimen. Send the material to the following address: Seattle Cancer Care Alliance / Fred Hutchinson Cancer Research Center 825 Eastlake Ave. Please call (206) 667-4415 to notify our office when to expect the arrival of shipments. Fluids should be administered at twice the daily maintenance level during treatment with high dose acyclovir. Prophylactic treatment with acyclovir should be resumed after high–dose treatment has been completed. Renal function tests must be followed closely during treatment with high dose acyclovir. Nonetheless, vaccine-preventable diseases continue to pose risks to the population. The vaccination recommendations shown in the following schema were formulated based on review of the approaches taken by these organizations. The earliest time to start vaccinations is 6 months post transplant in Non-Primary Immune Deficiency patients and should be considered in conjunction with factors that significantly delay immune reconstitution. A 1:A dultV accination S ch em a-Inactivated V accines: V accinationbefore 12 m onth s (ifeligible)1,6 M inim alTim e Interval B etween Vaccine >6m 1 >8m >10m >12m >14m >16m >18m >24m >60m Vaccinations Influenz ae (inactivated) (Sept–M arch) F lu H. H ighdose(40m cg/dose)h epatitisB vaccinationisrecom m endedinim m unocom prom isedorhem odialysispatients. A 2:A dultV accination S ch em a-Inactivated V accines: Ifpatientnotvaccinated before 12 m onth s 1,6 M inim alTim e Interval Vaccine >12m >14m >16m >18m >22m >24m >60m B etweenVaccinations Influenz ae (inactivated) (Sept–M arch) F lu H. H ighdose(40m cg/dose)h epatitisB vaccinationisrecom m endedinim m unocom prom isedorhem odialysis patients. Counselpatientsregarding risks/benefits #ThisindicationisnotyetF D A approvedandinsurancecoveragem ightbevariableforpatientsyoungerthan50yearsof age. P 1:P ediatric V accination S ch em a: V accination before 12 m onth s (ifeligible)1,8 M inim alTim e Interval >6m 1 >8m >10m >12m >14m >16m >18m >24m >25m Vaccine B etweenVaccinations Influenz ae (inactivated) < 9 years F lu F lu 1 month (September–M arch) > 9 years F lu H. P 2:P ediatric V accination S ch em a: Ifpatientnotvaccinated before 12 m onth s 1,8 M inim alTim e Interval Vaccine >12m >14m >16m >18m >22m >24m >25m B etweenVaccinations Influenz ae (inactivated) < 9 years F lu F lu 1 month (September–M arch) > 9 years F lu H. Detectable serum IgA (> 6 A detectable IgA level indicates potential ability to “class mg/dL) switch” 3. Donora B cell count Arbitrarily set at 1-log higher than our standard practice for > 200 per microliter those transplanted for malignancy 4. Isolation is necessary if live (oral) polio vaccine is administered to family members or other persons in close contact with the patient during the first year after the transplant or at any time during treatment with immunosuppressive medications. Smallpox vaccine should not be administered to any family members or other persons who share living space with the patient during the first year after transplant and beyond one year if the patient continues on treatment with immunosuppressive medications. Currently, anthrax vaccination is not routinely recommended for anyone except certain high-risk groups such as persons working directly with the organism in the laboratory or certain military personnel. Histological confirmation is necessary in the absence of diagnostic clinical features or distinctive features confirmed by other pertinent test (Table 2). Esophagus Esophageal web formation, stricture or dysmotility demonstrated by barium swallow, endoscopy or manometry. Blood Thrombocytopenia (usually 20,000-100,000/microliter), eosinophilia (> 500/microliter), hypogammaglobulinemia. Approximately 80% of patients require systemic immunosuppressive for 2 years and 40% of them requires therapy for at least 4 years. Meet criteria for obstruction (a-c) after bronchodilator challenge even if there is a bronchodilator response 2. Evaluate for upper respiratory infection or other etiologies of airflow decline i. If alternative diagnosis is made, repeat spirometry monthly for at least 3 months i. Peripheral ground glass opacities or centrilobular ground glass opacities/nodules c. Bronchoscopy is indicated when there are signs and symptoms of potential infection. Infection: Diagnostic evaluation as directed by clinical symptoms include the following: a. After 2 weeks of therapy, begin taper over next 3 weeks to get down to a total dose of 0. If prednisone is not required, taper prednisone off within 6-8 weeks as tolerated (including adrenal insufficiency issues). After initial diagnosis: Q4-6 weeks x 6 months (Qmonthly) while on prednisone taper. This step may be skipped if the patient prefers to remains on a combination inhaler (such as Symbicort). If a reversible etiology is not identified, stop the taper and resume all components. Glucocorticoid myopathy and muscle weakness may contribute to osteoporosis by removing the normal forces on bone that are produced by muscle contraction. In hematopoietic transplant recipients, other factors that may contribute to osteoporosis include electrolyte imbalances, inactivity, significant weight loss, and endocrine deficiencies. Osteopenia is defined as bone mineral density less than -1 standard deviation but above –2. It measures urinary excretion of the cross-linked N-telopeptide of type I collagen which is a marker of bone resorption. Elemental Calcium requirement between diet and supplement the Medical Nutrition Therapy staff educates patients to consume the following amounts of calcium during steroid therapy: Age 7-12 months 600 mg/day Age 1-3 years: 1000 mg/day Age 4-8 years: 1200 mg/day Age > 9 years: 1500 mg/day the nutritionist recommends appropriate levels of calcium supplementation for patients unable to meet daily requirements with diet. Calcium requirement for patients not on steroid therapy: Age Daily Minimal Calcium requirements (milligrams) Children 7-12 months 250 Children 1-3 years 700 Children 4-8 years 1000 Children 9-18 years 1300 Adult Males 1000-1200 Adult Females On hormone therapy 1000-1200 Not on hormone therapy 1500 53 C. Vitamin D requirement Currently there is not substantive benefit by choosing Vitamin D2 or vitamin D3 over the other with regard to correcting Vitamin D (25 Hydroxy) levels. Magnesium Hypomagnesemia may result in hypocalcemia, peripheral vitamin D resistance and resistance to parathyroid hormone. Normal serum magnesium levels are necessary to prevent osteopenia and bone fragility. Exercise A combination of weight bearing and resistive exercise is recommended for 30-60 minutes daily to promote cardiovascular function, minimize bone loss, strengthen skeletal muscles and improve balance, helping to prevent falls. Appropriate forms of exercise include swimming, biking (on a stationary bike if the patient has poor balance), Nordic tracking, rowing, low impact aerobic dancing. Gonadal hormone replacement Females: Women who are not on hormonal therapy with estrogen can be treated with biphosphonates. Testosterone replacement should be given to men if the serum testosterone level is low, unless contraindicated. Anti-resorptive therapy can be considered in patients who are at high risk for subsequent fractures. Flowers Bone Loss and Avascular Necrosis of Bone After Hematopoietic Cell Transplantation. Semin Hematol 49:59-65, January 2012) Bisphosphonates are effective for prevention and treatment of post-menopausal and glucocorticoid-induced osteoporosis. Because the risks and benefits of bisphosphonates during the early posttransplant period are unclear, consideration of bisphosphonate therapy is not recommended for osteoporosis until at approximately 3 months posttransplant. Therapy is usually continued until glucocorticoid therapy has been discontinued and the T score enters the normal range (-1. In patients taking alendronate for 5 years or more, post-marketing reports have recently highlighted the occurrence of atypical hip fractures. While these analyses did not demonstrate an increase in risk associated with bisphosphonate use, the study was underpowered for definitive conclusions. Higher risk patients may be treated for 10 years, and then consider having a bisphosphonate holiday for 1-2 years, with nonbisphosphonate therapy during that time. If it is determined that bisophosphonate therapy is appropriate, the specific bisphosphonate regimen will be decided by the Pediatrician, often in collaboration with a consulting Pediatric Endocrinologist. Cautionary Notes about Bisphosphonates: Intravenous bisphosphonates are not recommended for patients with creatinine clearance <35 ml/minute. Oral administration should be discontinued if patients develop esophageal symptoms. Alendronate (Fosamax) Osteoporosis treatment: Administer alendronate as a single dose of 70 mg weekly (or 35 mg twice weekly). Risedronate (Actonel) Osteoporosis treatment: Administer risedronate as a single dose of 35 mg weekly (or 150 mg monthly). Zoledronate (Reclast) Zoledronate may be given as a single 5 mg intravenous dose once a year. Forteo and Prolia are newer drugs but to date there has not been much experience in their use in the posttransplant setting. Calcitonin as secondary therapy for osteoporosis Calcitonin (100-200 International Units nasal spray daily) may be given to adults if the measures described above are not adequate. Therefore, consuming a diet rich in omege-3-fatty acids is the preferable method of supplementation (major sources include flaxseed oil, canola oil, walnut oil, wheat germ, soybeans, mackerel, herring, salmon, sardines in oil, and swordfish). Other agents may be indicated for patients with other co-morbidities (see Table 1).

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Pathogenesis Iridociliary melanomas can produce glaucoma by a variety of mechanisms symptoms of strep discount paroxetine 20 mg otc. Glaucoma with circumscribed iris melanoma most commonly results from direct extension of the tumor16 medicine clip art paroxetine 10 mg with amex,19 or by seeding of tumor cells and macrophages into the trabecular meshwork symptoms pinched nerve neck buy paroxetine uk. These include standardized echography melanoma from a benign nevus include documented for eyes with coexisting posterior lesions medications covered by medicare order paroxetine pills in toronto, retinal detach growth and distortion of the normal iris architecture symptoms kidney stones buy generic paroxetine on line, ments, or vitreous opacity. Ciliary body melanomas are on the ability of fluorescein angiography to distinguish generally hidden and may not present until quite large, iris melanomas from benign lesions,24,27 transillumination although they may develop early signs, such as hypotony of the ciliary body can help distinguish melanotic tumors or dilated episcleral vessels in the involved quadrant and hemorrhage, which transmit light poorly, from more (Fig. In one series, death from metastases occurred in 50% of such individuals within 2 years of diagnosis. Although diffuse iris melanomas require similar initial management, eyes with evidence of growth or uncon trollable glaucoma generally require enucleation. The tive procedures are alternatives for debilitated patients or lesion was solid echographically. Up to 50% of these individ those treated initially with iridectomy or iridocyclectomy will require eventual enucleation. Glaucoma Juvenile xanthogranuloma is a benign disorder of infants and young children, and, rarely, adults. This may present as a localized iris nodule, or epithelial tumors present as gray-white, lobulated masses, as diffuse iris thickening, producing iris heterochromia. The differential with thin-walled blood vessels, spontaneous hyphema is common and may often be the presenting sign. The presence of uveitis, an Glaucoma is another common presenting sign and may occur in over 80% of cases. The few reported cases associated with glaucoma enlargement and anterior displacement of the iris can produce angle-closure glaucoma. However, initial iridectomy, iridocyclectomy, or partial lamellar sclerou A spontaneous hyphema in a child should always viectomy can preserve useful vision in eyes with well suggest the diagnosis of juvenile xanthogranuloma, par circumscribed tumors and demonstrated growth or ticularly when associated with characteristic skin lesions 1,36,40 and an iris infiltrate. The teratoid variety can include cartilage, rhab Filtering procedures should be avoided if possible, given domyoblasts, and neuroglial tissue. Even now, this distinction choroidal melanoma from other lesions, including remains difficult, in spite of the availability of ultrasonog choroidal metastases and hemangiomas. These may be isolated or the median age at diagnosis is about a decade older than diffuse. Glaucoma, which is more com choroidal nodule and resembles a neurilemoma or ame mon in larger tumors with associated retinal detachment lanotic melanoma,57,66 the latter presents as multiple, and inflammation, may result from a variety of mecha amelanotic, minimally elevated nodules. The most common of these include neovascular neurilemoma generally appears as a smooth, minimally glaucoma (over 50%) and angle-closure glaucoma from pigmented, elevated mass, and may be complicated by anterior displacement of the iris–lens diaphragm (over cataract or serous retinal detachment. A choroidal melanoma can appear circumscribed, as Glaucoma with a choroidal neurofibroma generally an elevated choroidal nodule, or as a diffuse area of thick results from invasion and obstruction of the trabecular ened choroid. Both varieties can have variable pigmenta meshwork or anterior iris displacement and angle-closure, tion. Whereas the former usually lacks systemic Uveitis associations, the latter nearly always appears with the Neurofibroma/ Anterior displacement of iris and angle cutaneous or central nervous system findings of Sturge neurilemoma closure Weber syndrome (Chapters 27 and 30). Neovascular glaucoma may compli hemangioma cate as many as 40% of eyes with advanced tumors and retinal detachment. Microscopically classified into capillary, cav Tumor Mechanism ernous, or mixed types, depending on the caliber of the predominant blood vessels,44,71 the tumor clinically Retinoblastoma Neovascular glaucoma appears as a well-defined, orange-red mass in the macu Anterior displacement of iris and angle closure lar and peripapillary regions. Standardized echog Astrocytoma Anterior displacement of iris and angle closure raphy 25and fluorescein angiography72 may also aid the Neovascular glaucoma (total retinal detachment) diagnosis. Treatment of neovascular glaucoma from choroidal hemangiomas nearly always involves repairing the serous retinal detachment. Although photocoagulation results in Clinically, retinoblastomas may exhibit an endo subretinal fluid resolution and retinal reattachment in phytic, exophytic, or diffuse growth pattern. In addition, magnetic resonance imaging offers to 35% of cases are bilateral,76,77 in which the average age excellent contrast resolution for distinguishing retinoblas at diagnosis is 10 to 12 months, as compared with 21 to 25 toma from various simulating lesions. Although con exudative material can also contribute to extensive serous tinued therapeutic advances have reduced the 5-year mor retinal detachment, setting the stage for neovascular tality rate to 5 to 7%,75 the presence of glaucoma implies a glaucoma. All reported cases associated with secondary toma have an excellent visual prognosis, and effective inter glaucoma have required enucleation, usually due to vention in bilateral cases provides a reasonable chance for severe retinal damage and visual loss. Generally diagnosed between the ages of 10 and 30,87 this tumor may occur as an isolated lesion metastases varies with the site of the primary tumor. Advanced noma to the iris and ciliary body can develop cases may develop a total retinal detachment, providing the secondary glaucoma as opposed to only 1% of setting for the development of neovascular glaucoma. Unfortunately, cases with neovascu Ocular metastases can produce glaucoma through sev lar glaucoma often have extensive retinal damage and eral mechanisms. Unlike astrocytic hamartomas associated with tuberous Angle-closure glaucoma arises from anterior displace sclerosis, an acquired retinal astrocytoma has no cuta ment or thickening of the iris as well as the development of peripheral anterior synechiae. This tumor is composed of whorls of fusiform or polygonal Whereas iridociliary metastases directly involve the astrocytes with an eosinophilic, fibrillar cytoplasm. External blood cells, and tumor cells may seed the anterior cham beam or, less frequently, plaque radiotherapy may be ber and produce a pseudohypopyon or lodge in the tra used if the tumor continues to grow or if it threatens becular meshwork. In contrast, anterior uveal melanomas visual function, such as with foveal involvement. Rarely, 105 remaining undiscovered behind the iris until severe visual intractable pain necessitates palliative enucleation. Both may appear Leukemia and lymphoid tumors can involve all intraoc as single lesions or multifocal plaques in the posterior ular structures, especially the uveal tract. In the retina, metastatic carcinomas and have revealed intraocular leukemic infiltrates in approx melanomas both present as tissue plaques with intrareti imately 3% of leukemic patients, whereas 39 to 50% nal exudates or hemorrhages, although the former appear 98,100,109 develop secondary changes from hematologic abnor yellow-white and the latter gray-brown. Lymphoid tumors, such as benign reactive metastases commonly involve the vitreous, varying from lymphoid hyperplasia and primary intraocular lym white tumor cells in carcinomas to yellow-brown tumor phoma (reticulum cell sarcoma), may also locally or dif globules in melanomas. Intraocular Detecting the primary tumor requires a comprehen lymphoma, which occurs primarily in older adults, is sive history and ocular examination, and a thorough sys often associated with systemic lymphoma, and over 50% temic evaluation that includes appropriate imaging and of cases eventually develop central nervous system laboratory tests. If the diagnosis remains uncertain, fine-needle present a diffuse infiltration of the uvea or retina by the aspiration biopsy of aqueous humor, vitreous, and occa characteristic neoplastic lymphocytes. Although infiltration of the trabecular meshwork by tumor cells can cause open-angle glaucoma,116,120,121 angle closure generally results from chronic iridocyclitis and peripheral anterior synechiae. Prevalence infiltrates in the retina and choroid, along with intrareti and mechanisms of secondary intraocular pressure nal hemorrhages, cotton-wool spots, and white-centered elevation in eyes with extraocular tumors. Glaucoma with trabecular melanocyto tis,117,125 or white-yellow choroidal plaques with minimal sis. A case of open Because ancillary ophthalmic studies such as fluores angle glaucoma associated with nevus of Ota: elec cein angiography and ultrasonography provide little spe tron microscopic study of the anterior chamber cific information,24,126 the medical history and systemic angle and iris. Although fine-needle-aspiration angle glaucoma in melanosis oculi: response to laser biopsy for cytopathological analysis of aqueous or vitreous trabeculoplasty. Malignant hyperplasia consists of local or systemic corticos 122,128,129 melanoma of the choroid in in the nevus of Ota of a teroids, followed, if necessary, by low-dose ocu 124,130 black patient. Proliferative leukemia, ocular radiotherapy can be added to the endotheliopathy with iris abnormalities: the irido appropriate chemotherapy for the underlying systemic 118,119,121 corneal endothelial syndrome. These cases require an ante 123 cytomalytic glaucoma in eyes with necrotic iris rior chamber washout. Melanocytoma of In leukemia and benign reactive lymphoid hyper the iris with rapidly developing secondary glau plasia, the prognosis for vision varies with the extent and coma. Arch Oph in this condition is often delayed and extensive chori thalmol 1958;60:193–205. Melanoma of the iris: report final vision, despite effective treatment of the tumor of 72 cases treated surgically. Adenocarcinoma of ciliary rochromia and glaucoma by diffuse malignant epithelium in a young boy. Melanomalytic glaucoma: neoplasms of the nonpigmented ciliary epithelium report of a case. Graefe’s cein angiography and ultrasonography of malignant Arch Clin Exp Ophthalmol 1986;224:407–413. Arch Ophthalmol lar sclerouvectomy for ciliary body and choroidal 1984;102: 1523–1527. Br J Ophthalmol nile xanthogranuloma of the iris and ciliary body in 1995; 79:306–312. Nevoxanthogranuloma (juvenile xan ciliary body melanomas for evidence of growth prior thogranuloma of the iris). Retinoblas peripheral nerve tumor of the choroid: a clinopatho toma in Great Britain 1969–80: incidence, treatment, logic correlation and review of the literature. Current management of hemorrhage as initial manifestations of uveal malig retinoblastoma. Plaque melanoma associated with rhegmatogenous retinal radiotherapy in the management of retinoblastoma: detachment. Int Ophthalmol Clin 1962;2: ization, increased intraocular pressure and vitreous 369–385. Am J Ophthalmol neurilemmoma arising from the posterior ciliary nerve 1931;14:389–411. Solitary reti a clinicopathological study of 71 cases and a review nal astrocytoma. Circumscribed Giant cell astrocytoma of the retina: clinicopathologic choroidal hemangiomas. Arch Ophthalmol 1989;107: report of a case not associated with Bournville’s dis 1338–1342. Emerging chemotherapeutic histopathologic study of 716 unselected eyes in strategies in the management of intraocular retino patients with cancer at the time of death. Ophthalmol 1997; py for choroidal metastases: interim analysis of a 104:1265–1276. Oph patients with carcinoma metastatic to the anterior thalmic manifestations of leukemia. Bron phoid hyperplasia: an unusual form of intraocular chogenic carcinoma with metastases to the retina. Reticu in a patient with self healing cutaneous malignant lum cell sarcoma of the retina and uvea. Retinal Metastatic colloid carcinoma versus primary carci manifestations of ocular lymphoma (reticulum cell noma of the ciliary epithelium. Breast carcinoma metastatic to Ophthalmic, ultrasonographic findings in primary the choroid: analysis of 67 patients. Other hypertension, where microangiopathic changes increase chapters contain a more thorough discussion of some resistance to perfusion, could alter these compensatory entities. These nocturnal ciency, and retinal vascular occlusive disorders can all blood pressure “dips” are greater in patients with normal cause neovascular glaucoma. Although causality is often uncertain, these complicating factors include cataract extraction or posterior associations have prompted many studies into how 16 capsulotomy, and traction retinal detachment. How Graves’ ophthalmopathy, is an autoimmune, organ-spe ever, comparisons of optic disc morphology do not consis cific disease characterized by inflammation, edema, and tently show a difference between diabetics and nondiabetics, secondary fibrosis of the orbital tissues. Stimulated orbital except that the former have decreased visible nerve fiber fibroblasts produce glycosaminoglycans and collagen in layer and increased optic disc pallor.

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Motor skills – Coordinated muscle movements involved in move Medical home – Primary care that is accessible, continuous, ment, object control, and postural control perceived as occurring comprehensive, family centered, coordinated, compassionate, after a stage (or stages) involving birth refexes, with the idea that and culturally effective. The child health care professional works in fundamental motor skills must be mastered before development of partnership with the family and patient to ensure that all the medical more sport-specifc skills. Childhood motor skill profciency as a predictor of futures: Guidelines for health supervision of infants, children and adolescent physical activity. Mucous membranes – Membranes that line body passages and Medications – Any substance that is intended to diagnose, cure, cavities which communicate directly or indirectly with the exterior treat, or prevent disease or is intended to affect the structure or (as the alimentary, respiratory, and genitourinary tracts), that func function of the body of humans or other animals. Glossary 556 Caring for Our Children: National Health and Safety Performance Standards tions in protection, support, nutrient absorption, and secretion of and dressing). Ear infections are commonly caused by Streptococcus pneu Nasogastric tube feeding – the administration of nourishment us moniae or Haemophilus infuenzae. Necrotizing enterocolitis – A condition when the lining of the Ref: Merriam-Webster. Medical Encyclo objects (natural and manufactured) within the space, the specifc pedia. Over-the-counter medi of radio stations broadcasting continuous weather information cines. Non-transient, non-community water supply – A non-community Paradichlorobenzene – A white crystalline compound C6H4Cl2 water system in a location that serves the same non-resident users made by chlorinating benzene and used chiefy as a moth repellent daily. Medical Diction Ref: Colorado Department of Public Health and Environment, Water ary. Nutritionist/Registered Dietitian – A professional with current Ref: Merriam-Webster. Merriam-Webster On registration with the Commission on Dietetic Registration of the line. American Dietetic Association or eligibility for registration with a Pediatric frst aid – the immediate care given to a suddenly ill or Bachelor’s and Master’s degree in nutrition; a Master’s degree from injured child until a medical professional or a parent or legal guard an approved program in public health nutrition may be substituted ian assumes responsibility for the medical condition from becoming for registration with the Commission on Dietetic Registration. They are Physical therapy – the use of physical agents and methods (such used in products, such as vinyl, adhesives, detergents, oils, plas as massage, therapeutic exercises, hydrotherapy, electrotherapy) tics, and personal-care products. Physical activity generally refers to the subset of activity use in insect repellents. Insect repel Ref: National Center for Chronic Disease Prevention and Health lent use and safety. Age-appropriate physical activity – Physical movement that is Plagiocephaly – Refers to a head that is abnormally shaped from a suitable for a specifc age. Ref: Eunice Kennedy Shriver National Institute of Child Health and Moderate physical activity – Levels that are at intensities faster Human Development. Pneumonia – An acute or chronic disease marked by infammation Ref: Nemours Health and Prevention Services. Best of the lungs and caused by viruses, bacteria, or other microorgan practices for physical activity: A guide to help children grow up isms and sometimes by physical and chemical irritants. Poison centers are Structured physical activity – Caregiver/teacher-led, develop staffed by pharmacists, physicians, nurses, and poison information mentally appropriate, and fun physical movement. Unstructured activity should include: a) Activi Pooling – A practice in larger child care settings where children of ties that respect and encourage children’s individual abilities and various ages are brought together as they arrive at the beginning of interests; and b) Caregiver/teacher engagement with children, the day or depart at the end of the day to consolidate the number of support for extending play, and gentle prompts and encourage staff needed to meet child:staff ratios. Glossary 558 Caring for Our Children: National Health and Safety Performance Standards Postural drainage – Body positioning resulting in the gradual fow such as bollards and posts. Barriers must pass impact tests for the of mucous secretions from the edges of both lungs into the airway highest speed limit allowed and posted on the street, road or park so secretions can be removed from the lungs by coughing. Preschooler – A child from achievement of self-care routines (such Pseudomonas aeruginosa – A type of organism that is commonly as toilet learning/training) and the age of entry into a regular school; a contaminant of skin sores but that occasionally causes infection usually three to fve years of age (thirty-six to ffty-nine months of in other parts of the body and is usually hospital-acquired. Psychosocial – Involving aspects of social and psychological Prescription medications – Medications that can only be pre behavior (as in a child’s psychosocial development). Purulent conjunctivitis – Also known as “Pink eye,” a white or Primary care provider – A person who by education, training, yellow eye discharge, often with matted eyelids after sleep, and certifcation, or licensure is qualifed to and is engaged in providing including eye pain or redness of the eyelids or skin surrounding the health care. This type of conjunctivitis is more often caused by a bacterial with the child’s specialist and therapists. Radon is considered grams typically lead to an associate’s, baccalaureate, or graduate to be a health hazard that may lead to lung cancer. These programs provide the foundations for a lifetime of professional practice, expanded Refux – An abnormal backward fow of stomach contents into the upon through experience and ongoing professional develop esophagus. Education programs also may include continuing education Registration – Permission from a state that is required to oper programs that lead to the award of continuing education units ate a child care facility. Training programs are specifc to an regulatory process instead of the word licensing. The tion of training participation can lead to assessment for award of 2008 child care licensing study. How people learn: Bridging Rescue breathing – the process of breathing air into the lungs of research and practice, 12. Medline Plus Medical Diction Respiratory tract – the nose, ears, sinuses, throat, and lungs. Return demonstration – An individual demonstrating what (proce Prosthetic devices – An artifcial body replacement adapted to dure, technique, etc. Rheumatic fever is characterized by fever and Protective barrier – Type of containment or defector system that painful infammation of the joints and may result in permanent dam surrounds and obstructs primarily vehicle passage into a play area, age to the valves of the heart. Rifampin – An antibiotic often prescribed for those exposed to an School-age child care facility – A facility offering activities to infection caused by Haemophilus infuenzae type b (Hib) or Neis school-age children before and after school, during vacations, and seria meningitidis (meningococcus), or given to treat an infection non-school days set aside for such activities as caregivers’/teach caused by tuberculosis. Roseola – A viral infection causing rash in infants and children Screening – Examination of a population group or individual to that primarily occurs between six and twenty-four months of age. Managing infectious from the originally infected person is said to have contracted a diseases in child care and schools: A quick reference guide. Secretion – Wet material, such as saliva, that is produced by a cell Rubella – A mild viral illness usually lasting three days, with symp or a gland and that has a specifc purpose in the body. Sensory table – A piece of equipment consisting of a liner set inside of a frame; water and sand are popular fllers, but almost Salmonella – A type of bacteria that causes food poisoning (salmo anything can be used. What happens when a child plays at the sen Salmonella paratyphi – the bacterium responsible for paratyphoid sory table Sepsis – An infection that involves the presence of pathogenic Ref: Centers for Disease Control and Prevention. Serotype – A group of intimately related microorganisms distin guished by a common set of antigens. For example, Salmonella has Salmonella typhi – the bacterium responsible for causing the life many serotypes including typhimurium and enteritidis. Medline Plus Medical Dic Salmonellosis – A diarrheal infection caused by Salmonella bacte tionary. Sanitize – See Appendix J: Selecting an Appropriate Sanitizer or Serum – the clear liquid that separates in the clotting of blood. Sexual orientation – An emotional or affectional attraction to an Scabies – An infestation of the skin by small insects called mites. Managing infectious site sex), homosexuality (attraction to the same sex), and bisexuality diseases in child care and schools: A quick reference guide. Managing infectious Glossary 560 Caring for Our Children: National Health and Safety Performance Standards Shelter-in-place – the process of staying where one is located and autopsy, examination of the death scene, and review of the clinical taking shelter, rather than trying to evacuate. Ref: National Association of Child Care Resource and Referral Ref: American Academy of Pediatrics, Task Force on Sudden Infant Agencies, Save the Children. Shigellosis – A diarrheal infection caused by the Shigella bacte Ref: Healthy Children. Special facility for children who are ill – See Facility for children Systemic – Pertaining to a whole body rather than to one of its who are mildly ill parts. Managing infectious Stackable cribs – Cribs that are built in a manner that there are two diseases in child care and schools: A quick reference guide. Staff – All personnel employed at the facility, including directors, Toddler – A child between ambulation to accomplishment of caregivers/teachers, and personnel who do not provide direct care self-care routines such as use of the toilet, usually thirteen through to the children (such as cooks, drivers, and housekeeping person thirty-fve months of age. Touch supervision – Within an arm’s reach or able to touch Standard precautions – Use of barriers to handle potential expo the child at all times. This concept has derived from the supervision sure to blood, including blood-containing body fuids and tissue of children during water play. Standing orders – Orders written in advance by a health care Toxoplasmosis – A parasitic disease usually causing no symptoms. Streptococcal pharyngitis (strep throat) – A disease caused by Transmission – the passing of an infectious organism or germ from a Streptococcus bacterium. Managing infectious Tremolite – A mineral that can occur in fbrous form (an asbestos). Suction – the removal of respiratory secretions or mucous of a Tricolosan – A chemical with antibacterial properties; used in con child to aid in breathing. Tummy time – the time an infant spends on his stomach (tummy) Viandas – Root vegetables common in some diets. Virus – A microscopic organism, smaller than a bacterium, that may Ulcerative colitis – A disease that causes infammation and sores, cause disease. Unitary surface material – A cushioned surface material (such as womenshealth. Universal precautions – See Standard precautions Water play activities – Activities that involve the use of water such Vacuum breaker – A device put on a pipe containing liquid (such as swimming, wading, sprinklers, and water play tables. Varicella-zoster – An illness with rash and fever caused by the varicella-zoster virus, also known as chickenpox. Vector borne diseases – A disease in which the pathogenic microorganism is transmitted from an infected individual to another individual by an arthropod. Vegan – Individual who does not eat meat, poultry, fsh, eggs, or dairy products; the individual only eats plant foods. Variations of vegetarians include: Lacto-ovo-vegetarians who con sume eggs, dairy products, and plant foods and lacto-vegetarians who eat dairy products and plant foods but not eggs. See Child abuse and neglect Audits, reports of annual, monthly mainte Alcohol Abusive head trauma.

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