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Offer women experiencing mild symptoms of heartburn advice on lifestyle modifications and avoiding foods that cause symptoms on repeated occasions treatment zone lasik purchase online seroquel. Available evidence from lower level studies suggests that the use of antacids symptoms strep throat buy 300mg seroquel fast delivery, proton pump inhibitors and H2 blockers for reflux during pregnancy presents no known significant safety concern for either the mother or baby: • antacids are considered safe in pregnancy and may be preferred by women as they give immediate relief; calcium-based formulations are preferable to medications osteoarthritis pain discount seroquel express those that contain aluminium (Tytgat et al 2003) • the use of proton pump inhibitors during pregnancy is not associated with an increased risk for major congenital birth defects symptoms you are pregnant discount 50mg seroquel otc, spontaneous miscarriage treatment tmj 300 mg seroquel, preterm birth, perinatal mortality or morbidity (Diav Citrin et al 2005; Gill et al 2009a; Gill et al 2009b; Pasternak & Hviid 2010; Majithia & Johnson 2012; Matok et al 2012) • the use of H2 blockers in pregnancy is not associated with any increase in risk of spontaneous miscarriage, preterm birth or small-for-gestational-age baby (Gill et al 2009b). Recommendation Grade C 56 Give women who have persistent reflux information about treatments. Sleeping on the left side, raising the head of the bed, and not lying down after eating may also help. Reassure women that symptoms usually subside after pregnancy, but may recur in a subsequent pregnancy. Advise women that if symptoms persist or become more severe, medication can be considered. Cherian S, Forbes D, Sanfilippo F et al (2008) the epidemiology of Helicobacter pylori infection in African refugee children resettled in Australia. Diav-Citrin O, Arnon J, Shechtman S et al (2005) the safety of proton pump inhibitors in pregnancy: a multicentre prospective controlled study. Matok I, Levy A, Wiznitzer A et al (2012) the safety of fetal exposure to proton-pump inhibitors during pregnancy. Pasternak B & Hviid A (2010) Use of proton-pump inhibitors in early pregnancy and the risk of birth defects. Advice on avoiding constipation may assist women to prevent or lessen the effects of haemorrhoids. While the mechanism is not clear, this is thought to be a result of prolapse of the anal canal cushions, which play a role in maintaining continence. Pregnancy also facilitates development or exacerbation of haemorrhoids, due to increased pressure in rectal veins caused by restriction of venous return by a woman’s enlarged uterus (Avsar & Keskin 2010). Haemorrhoidal symptoms are most common in the second and third trimesters of pregnancy and after birth (Avsar & Keskin 2010). One observational study found that 8% of pregnant women (n=165) experienced thrombosed external haemorrhoids in the last 3 months of pregnancy (Abramowitz et al 2002). Digital rectal examination and endoscopy (sigmoidoscopy and colonoscopy) may also be used. It is important to rule out more serious causes of bleeding (Avsar & Keskin 2010). Most evidence for the effectiveness of haemorrhoid treatments comes from studies of non-pregnant patients. Given the overall lack of evidence, there is consensus in clinical reviews for conservative management in pregnancy including avoiding constipation, dietary modification, dietary fibre supplementation and stool softeners (Avsar & Keskin 2010; Dietrich et al 2008; Wald 2003). Topical products with analgesics and anti-inflammatory effects provide short-term local relief of symptoms. There is no evidence on the effectiveness or safety of creams used in pregnancy; however, the small doses and limited systemic absorption mean that they are unlikely to harm the baby when used in the third trimester (Staroselsky et al 2008). While surgical removal of haemorrhoids may be a consideration in extreme circumstances, surgery is rarely an appropriate intervention for pregnant women as haemorrhoidal symptoms often resolve spontaneously after the birth (Staroselsky et al 2008). Offer women who have haemorrhoids information about increasing dietary fibre and fluid intake. If clinical symptoms remain, advise women that they can consider using standard haemorrhoid creams. Advise women who are increasing their fibre intake to make sure they drink adequate fluids. Buckshee K, Takkar D, Aggarwal N (1997) Micronized flavonoid therapy in internal hemorrhoids of pregnancy. Wald A (2003) Constipation, diarrhea, and symptomatic hemorrhoids during pregnancy. While there is little evidence to support any specific treatment, use of compression stockings may help to relieve symptoms. They can occur as blue swollen veins on the calves, the inside of the legs and the vulva, and may cause itching and aching. In 70–80% of women who develop problems with varicose veins during pregnancy, the symptoms appear during the first trimester, often within 2 to 3 weeks of gestation (Carr 2006). A family history of varicose veins, increasing number of full term pregnancies and increasing age have been found to be risk factors for the development of varicose veins (Dindelli et al 1993; Jawien 2003; Beebe-Dimmer et al 2005). Given the overall lack of evidence, there is consensus in clinical reviews that advice to women should be based on reassurance, conservative management and symptom relief. Avoiding long periods of standing, use of compression stockings and elevating the feet have been found to improve symptoms in the general population (Carr 2006). As symptoms of varicose veins often improve after the birth (Bamigboye & Smyth 2007), surgery is rarely considered an appropriate intervention for pregnant women. Advise women that varicose veins are common during pregnancy, vary in severity, will not generally cause harm and usually improve after the birth. Asking about itching or discomfort in the legs can assist in identifying varicose veins. Bamigboye A & Smyth R (2007) Interventions for varicose veins and leg oedema in pregnancy. Dindelli M, Parazzini F, Basellini A et al (1993) Risk factors for varicose disease before and during pregnancy. Jawien A (2003) the influence of environmental factors in chronic venous insufficiency. Lenkovic M, Cabrijan L, Gruber F et al (2009) Effect of progesterone and pregnancy on the development of varicose veins. Symptoms occur due to relaxation of the pelvic ligament and increased joint mobility in pregnancy. Symptoms vary from mild discomfort to severe and debilitating pain that can hinder mobility. Other causes of pain in the pelvic area (eg urinary tract infection, preterm labour) should be excluded (Kanakaris et al 2011). Pelvic girdle pain usually resolves spontaneously after the birth (Elden et al 2008), although symptoms may recur during subsequent pregnancies (Leadbetter et al 2004). The wide variation can be attributed to various factors including the absence of a precise definition and diagnostic criteria, differences in study design and selection of the study population. The evidence on age as a risk factor for pelvic pain in pregnancy is inconsistent (Eberhard-Gran & Eskild 2008; Bjelland et al 2010). Subsequent evidence is limited by the heterogeneity and low quality of studies and the inconsistency of findings. No serious adverse effects were reported (minor side effects included bruising, pain on needle insertion, bleeding, haematoma and fainting). Recommendation Grade C 57 Advise women experiencing pelvic girdle pain that pregnancy-specific exercises, physiotherapy, acupuncture or using a support garment may provide some pain relief. Biering K, Aagaard Nohr E, Olsen J et al (2010) Smoking and pregnancy-related pelvic pain. Bjelland E, Eskild A, Johansen R et al (2010) Pelvic girdle pain in pregnancy: the impact of parity. Eberhard-Gran M & Eskild A (2008) Diabetes mellitus and pelvic girdle syndrome in pregnancy – is there an associationfi Ee C, Manheimer E, Pirotta M et al (2008) Acupuncture for pelvic and back pain in pregnancy: a systematic review. Ekdahl L & Petersson K (2010) Acupuncture treatment of pregnant women with low back and pelvic pain — an intervention study. Leadbetter R, Mawer D, Lindow S (2004) Symphysis pubis dysfunction: a review of the literature. Morgren I (2005) Previous physical activity decreases the risk of low back pain and pelvic pain during pregnancy. Morgren I & Pohjanen A (2005) Low back pain and pelvic pain during pregnancy: prevalence and risk factors. Pennick V & Young G (2007) Interventions for preventing and treating pelvic and back pain in pregnancy. Richards E, Van Kessel G, Virgara R et al (2012) Does antenatal physical therapy for pregnant women with low back pain or pelvic pain improve functional outcomesfi Robinson H, Veierod M, Mengshoel A et al (2010) Pelvic girdle pain – associations between risk factors in early pregnancy and disability or pain intensity in late pregnancy: a prospective cohort study. Robinson H, Eskild A, Heiberg E et al (2006) Pelvic girdle pain in pregnancy: the impact on function. Van de Pol G, Brummen J, Bruinse H et al (2007) Pregnancy related pelvic girdle pain in the Netherlands. There is little evidence to support intervention in pregnancy and symptoms are likely to resolve after the birth. It is characterised by tingling, burning pain, numbness and a swelling sensation in the hand that may impair sensory and motor function. Activity modification, avoiding positions of extreme flexion or extension of the wrists and avoiding exposure to vibration have been suggested as adjuncts to splinting (Mabie 2005; Borg-Stein et al 2006; Ablove & Ablove 2009) but there is no evidence that these are effective for carpal tunnel syndrome. While carpal tunnel syndrome usually resolves after the birth (Pazzaglia et al 2005), persistence of symptoms has been reported in more than 50% of women after 1 year and in about 30% after 3 years (Padua et al 2010). Advise women who are experiencing symptoms of carpal tunnel syndrome that the evidence to support either splinting or steroid injections is limited and symptoms may resolve after the birth. Borg-Stein J, McInnis C, Dugan S et al (2006) Evaluation and management of musculoskeletal and pelvic disorders of pregnancy. Eogan M, O’Brien C, Carolan D et al (2004) Median and ulnar nerve conduction in pregnancy. Mondelli M, Rossi S, Monti E et al (2007) Prospective study of positive factors for improvement of carpal tunnel syndrome in pregnant women. Niempoog S, Sanguanjit P, Waitayawinyu T et al (2007) Local injection of dexamethasone for the treatment of carpal tunnel syndrome in pregnancy. Padua L, Pasquale A, Pazzaglia C et al (2010) Systematic review of pregnancy-related carpal tunnel syndrome. Palmer K, Harris C, Coggon D (2007) Carpal tunnel syndrome and its relation to occupation: a systematic literature review. Pazzaglia C, Caliandro P, Aprile I et al (2005) Multicenter study on carpal tunnel syndrome and pregnancy incidence and natural course. At this stage, antenatal care becomes more frequent and includes planning and preparing for the birth. Some situations will require additional discussion, and women should be given advice and information to help them make informed decisions about options for interventions and birth. For example, identifying the presentation of the baby (eg breech) from 35 weeks allows for timely discussion, planning and referral if necessary. For women who have prolonged pregnancy, the longer the pregnancy the more complex the decisions may become, as the risks to the baby increase. Recommendations are based on the evidence for interventions that aim to reduce the need for unnecessary induction or unplanned caesarean section.

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Hypochondriacal tigraphic technique moroccanoil oil treatment order seroquel online now, is associated with male sex patients may devalue the laboratory results medicinenetcom symptoms generic seroquel 50mg visa, and high levels of hypochondriasis medicine prescription discount seroquel online mastercard, while claiming laboratory error and the like x medications purchase seroquel with amex, or delayed gut transit is associated with female sex promptly return to medicine clipart generic 300mg seroquel the clinic claiming a new and low levels of hypochondriasis [61]. In addition, maintenance of a the presentation of hypochondriasis in an infec close alliance with the primary care physician tious disease setting will generally be in the con and consulting mental health provider may help text of excessive fear of a life-threatening to foster a team-based approach to the patient’s infectious disease [64]. Among those seeking treatment for obsessional thinking and hypochondriacal sexually transmitted diseases, there is increased behavior [60]. Patients may also report with con Cardiovascular diseases cerns of parasitic infection, called delusions of Cardiology is one of the clinical settings where parasitosis (see Dermatology), which is some hypochondriacal patients are most likely to times considered to be a psychotic disorder, present and at a relatively low threshold due to a although it conceptually fits well as an example perceived medical emergency. Atypical chest pain patient’s reported symptoms may be innocuous and chest pain without cardiac risk factors for or even absent [67]. Even when no lesions may partially account for their seeking medical were present, patients were concerned regarding consultation [69]. We matologist may apply a combination of benign propose the following clinical approach in the dermatologic therapies. First, empathic confronta bacterial creams for secondary bacterial infec tion of the excessive health-related anxiety is tions). Second, scheduled the dermatologist may prescribe psychiatric med follow-up examinations and the regular use of ications shown to be effective for a variety of dis noninvasive, low-risk procedures. Pimozide and newer second diogram or exercise treadmill test as tolerated) are generation antipsychotics. Antidepressants, sometimes should be shifted to risk reduction and cardiac chosen for their sedative or antihistamine effect rehabilitation. Dermatology Obstetrics & gynecology Studies have estimated the prevalence of psychi Although hypochondriasis is equally prevalent atric comorbidity to be 30–40% in patients among both genders, women reported with dermatological disorders [74,75]. The iety being out of proportion to the objective authors explained that women may have a future science group Treatment options include physical vigilance, leading to increased gynecologic and therapy, Thiele massage, pelvic floor exercise obstetric visits [81]. Women During pregnancy, women have more hypo with vulvodynia have more psychological distress chondriacal fears and conviction of disease than than women with other vulvar pathology. Fear of dying and bodily ment includes surgery, which results in complete preoccupations predominate during the third tri resolution in 72% of women, and pelvic floor mester [82]. The culmination Ophthalmology of these fears results in a fear of childbirth, which In ophthalmologic practice, hypochondriasis may leads women to request elective cesarean section present with a significant conviction of a vision for delivery. Cognitive therapy, group psycho threatening illness, either based on amplified education and relaxation exercises have been response to actual visual or ocular symptoms, or shown to be effective in treating fear of child based on no tangible symptoms [92]. In addition, such a patient may experience tion, intravenous fluid resuscitation and other benign visual and ocular symptoms as heralding psychological treatments, such as hypnosis. Several hypochondriacal concerns arise in the Similarly, a patient with hypochondriacal con gynecological setting. Following the Women’s cern of cataracts may present with obscure visual Health Initiative finding that unopposed estro complaints that he/she is convinced are due to gen-replacement therapy increased the risk of cataracts. Again, full functional assessment and endometrial cancer, a ‘pill scare’ erupted with examination of the crystalline lens may be at patients worrying about increased risk of disease least temporarily assuaging. As with glaucoma, with aging, especially among women with prior reassurance that even in the case of actual cata hysterectomy [202]. In a study of 1142 women ract development, the likelihood of a good surgi undergoing hysterectomy for benign conditions, cal result and good visual function 80% reported ‘a little fear’ and 29% reported ‘a postoperatively may be shared with the hypo lot of fear’ of developing gynecologic cancer chondriacal patient. Another common chondriasis score was associated with fear hypochondriacal fear comes from abnormal regarding having a cataract operation in a cohort Papanicolaou (Pap) smears. Such enced anxiety due to fear of cancer and/or col a patient is likely to present to the clinic with poscopy [87]. Consistent with our general benign complaints of ‘floaters’ and other visual management recommendations, increased symptoms, possibly referable to vitreous and reti patient education regarding Pap smears and col nal pathology. Thorough funduscopic examina poscopy, shorter wait times and mobilization of tion may serve to temporarily ameliorate these social support may help reduce patient anxiety. Other common gynecologic symptoms asso Hypochondriasis regarding the eye can be quite ciated with hypochondriasis include vulvodynia, severe. While there ment may assuage such fears and gentle confron are no established thresholds for the consider tation of the excessive illness concern may be ation of hypochondriasis, we propose that gradually introduced during each subsequent patients with more than three work-ups may be visit. Collaboration with either the primary care screened for hypochondriasis or referred for psy physician and/or a mental health provider is chiatric consultation. The clinician should exam socio not limited to, dizziness, vertigo, epistaxis, hali demographic variables and risk factors for dis tosis, pain, tinnitus, sense that the dental bite is ease. Subjects who well known [100] and age-appropriate factors for complain of tinnitus have more affective inhibi adolescents have been described [101]. If a patient tion, irritability and denial compared with sub is asked and screens positive for a history of sexual jects who can cope positively with the trauma, a psychiatric referral may be the next step symptoms. Therefore, prior to performing a fering presented higher levels of hypochondria, procedure to augment sexual function in males, it disease conviction and dysphoria [98]. Studies are limited in triaging these symptoms There is likely a psychological component in to underlying diagnoses, but it is likely that many patients with sexual complaints, whether mood, anxiety and somatoform disorders are diagnosed with hypochondriasis or not [102]. There is a spectrum between good start is setting a tone in which patients can normal and unhealthy presentation involving share concerns and feel understood, regardless of personality, help-seeking behavior, age and cul the problem or planned work-up. In addition, the presentation may be colored by the course of a true medical illness, Pulmonary medicine particularly if it presents in forme fruste fashion, the literature contains little information which confuses the clinician. This group made very frequent use of a range of Patients with more than three work-ups and a medical services and took a large amount of med negative family history for illnesses in the differ icine. Patients more negative opinion regarding their own with chronic airflow obstruction may have fear, health, despite being less ill. Psychological or psy anxiety or hypochondriasis superimposed on chiatric consultation was suggested as ‘necessary’ true illness [103]. In the latter case, some patients experi use of general treatment approaches (Table 1). Consistent with general matic behavior in the long-term if not principles of treatment (Table 1), sympathetic addressed [104]. Until more studies are per communication and treatment of psychiatric formed regarding hypochondriasis in the pul comorbidities have been recommended [114]. The exact We combined the sections of neurology and causes of hypchondriasis remain unclear but rheumatology as hypochondriasis in these two most likely involve multifactorial etiologies specialties may present similarly, most likely including psychological, social and neuro due to parallels in chronic evolution of symp biological origins. Patients with migraines [105], tension treatment process, use of reassurances, further headaches [106], chronic fatigue syndrome [107] investigations and specific treatments must be and fibromyalgia score higher on scales of hypo carefully selected. Judicious use of reassurance could be help ity, than chronic pain patients or healthy ful in the elderly and those who have suffered controls [108]. Again, the Individuals that seek medical attention for head patient–physician alliance should be utilized to aches score higher on hypochondriacal concerns guide therapy. Hypochondriasis ten Future perspective dencies also weigh heavily on osteoarthritis and As hypochondriasis has been aggravating rheumatoid arthritis severity ratings [110]. On the patients and their physicians since antiquity, it is other hand, scores of hypochondriasis increased unlikely to disappear from the clinical landscape in individuals after they developed low-back in the next 5–10 years. Greater use of noninvasive diag viduals with medically confirmed postpolio syn nostic procedures will allow for more thorough drome also score higher in depressive and evaluations while preserving safety. More pri hypochondriacal symptomatology when com mary consideration of hypochondriasis early in pared with controls without postpolio, but score the workup may allow for earlier treatment and the same on neuropsychological measures of psychiatric consultation. There is a tion for the etiologies of hypochondriasis could lack of specific recommendation for the treat improve educational efforts and the physi ment of hypochondriasis in the neurology and cian–patient alliance. Additional con foreseeable technical advancements, the physi trolled studies will in turn lead to more wide cian will continue to rely on his or her rapport spread adaptation of evidence-based specific with the patient to select the most suitable treatments in various practice settings. Executive summary • Hypochondriasis is a vexing somatoform disorder that most commonly presents in primary care and specialty medical settings in various ways. The primary care and specialty physician should consider consulting with and/or referring to a mental health provider, after establishing a mutual agreement with the patient. American Psychiatric Association: Diagnostic Psychosomatics 39(3), 263–272 (1998). Ferguson E: Hypochondriacal concerns, hypochondriasis: attention-induced Somatosensory Amplification Scale in symptom reporting and secondary gain physical symptoms without sensory general medical and general practice mechanisms. Psychiatry Hypochondriacal concerns: Management controlled study of hypochondriasis. Kellner R: Diagnosis and treatment of Rimer B, Lerman C: Excessive breast self hypochondriasis. Faravelli C, Salvatori S, Galassi F, Aiazzi L, illness behaviours in patients with cancer. Lindberg G, Smout A: Disorders of psychoeducational group approach to Pediatrics 108, E1 (2001). Fiddler M, Jackson J, Kapur N, Wells A, transit in functional gastrointestinal 317–322 (2000). Physician 64(12), 1981–1984 Psychosomatic aspects in patients with interventions for non-ulcer dyspepsia. Women’s reproductive issues Hypochondriacal concerns and somatic psychological co-morbidity in patients with chronic gynecologic pain. Neuropsychological changes after surgical Health eJournal (2002) 52(6), 602–606 (1995). It is targeted not only at those in the chemical and process industries, but also anyone likely to work with chemicals within industry and in the service sector. It embraces the entire life-cycle of chemicals during transport, storage, processing, marketing, use and eventual disposal and should appeal to chemists, occupational and environmental health practitioners and students, engineers, waste handlers, safety officers and representatives, and health care professionals. Clearly, more detailed texts or professional advice may need to be consulted for specific applications. Since the first edition in 1994 there have been no significant changes in the fundamentals of chemistry, physics and toxicology upon which the safe handling of chemicals are based. There has, however, been some increase in knowledge relating to the chronic toxicological and potential environmental effects of specific chemicals, and in legislation and government guidelines. There has been an increase in the controls applicable to the marketing and transportation of different classes of chemicals. Those applicable to major hazards have changed under the Control of Major Accident Hazard Regulations 1999. Increased concern as to the possible environmental impacts of chemical discharges and disposal has been accompanied by more comprehensive legislation for control. General safety legislation was expanded by the introduction of various separate regulations in 1993, including that dealing with management of health and safety at work; workplace health, safety and welfare; workplace equipment; and personal protective equipment. The opportunity has been taken to improve each chapter and to update the information. The main changes include an expansion of the terminology in Chapter 2 and provision of an introduction to basic chemical principles for non-chemists in a new Chapter 3. Chapter 5 on Toxic chemicals has been enlarged and the table of hygiene standards updated. Chapters 6, 7 and 8 on Flammable chemicals, Reactive chemicals and Cryogens, respectively, have been updated and expanded.

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This classification is hierarchical medicine 2020 cheap seroquel 100 mg, and you must Further medicine on airplane purchase seroquel toronto, the headache must fulfil a number of decide how detailed you wish to symptoms xanax is prescribed for purchase cheapest seroquel and seroquel make your diag other requirements described within the criteria nosis: from the first-digit level only to symptoms you have diabetes 50mg seroquel mastercard the fifth medicine urinary tract infection buy seroquel with a visa. Some First one forms an impression as to which group letter headings are monothetic; that is, they express the patient belongs to. Diagnostic criteria at the diagnoses are usually applied, while in specialist third-, fourth and occasionally fifth-digit levels practice and headache centres a diagnosis at then demand, as criterion A, fulfilment of the cri fourth or fifth-digit levels is appropriate. For most purposes, patients receive a diagnosis and onwards, state the further specific criteria to be according to the headache phenotypes currently fulfilled. For genetic and some other uses, occurrence varies widely, from attacks every one to two years during the whole lifetime is used. For example, a severely afiected patient that frequency and severity be specified in free text. When a patient receives more than one diagnosis, headache, or fulfils other criteria for causation by these should be listed in the order of importance to that disorder, the new headache is coded as a sec the patient. This remains true even when the headache fulfils two difierent sets of diagnostic criteria, all has the characteristics of a primary headache other available information should be used to (migraine, tension-type headache, cluster headache decide which of the alternatives is the correct or or one of the other trigeminal autonomic cephalal more likely diagnosis. When a pre-existing primary headache gitudinal headache history (how and when did the becomes chronic in close temporal relation to headache startfi In order to avoid a very long list, increase in frequency and/or severity) in close tem only the most important are mentioned. In the exam poral relation to such a causative disorder, both the ple, rarer causes are assigned to 9. Thesame should be given, provided that there is good evi system is used in the other chapters on secondary dence that the disorder can cause headache. Consideration of other pos ment of the underlying causative disorder before sible diagnoses (the difierential diagnosis) is a rou the headache diagnosis can be made. Criterion A is presence of the der always to consider other diagnoses that might headache; criterion B is presence of the causative better explain the headache. In In particular, this applies to assessing whether acute conditions, a close temporal relation between headache is secondary or primary. It may also onset of headache and onset of the presumed apply to alternative causative disorders: for exam causative disorder is often suficient to establish ple, headache occurring in close temporal relation causation, while less acute conditions usually to acute ischaemic stroke may be a consequence require more evidence of causation. In all cases, not of the stroke but of the cause of the stroke the last criterion must be applied as a check: ‘Not. Ask the patient types are recognized to occur; that is, headache that to describe a typical untreated or unsuccessfully was caused initially by another disorder fails to treated attack and ascertain that there have been remit after that disorder has resolved. Then cases, the diagnosis changes from the acute type include the less typical attacks when describing. When a patient is suspected of having more than Persistent headache attributed to traumatic injury one headache type or subtype, it is highly recom to the head) after a specified time interval (three mended that he or she fill out a diagnostic head months in this example). Evidence of causation ache diary in which, for each headache episode, the depends upon earlier fulfilment of the criteria for important characteristics are recorded. It has been diagnosis of the acute type, and persistence of the shown that such a headache diary improves diag same headache. Most such diagnoses are in the nostic accuracy as well as allowing a more precise Appendix because of insuficient evidence of their judgement of medication consumption. They will not usually be applied, but are helps in judging the quantity of two or more difier there to stimulate research into better criteria for ent headache types or subtypes. It helps clinical sci headaches: for example, between migraine without entists study orphan entities for later inclusion in aura and episodic tension-type headache. Most diagnoses and diagnostic the most well-known and well-established causes criteria in the Appendix are either new or alterna are mentioned and criteria for the consequent tives to criteria in the main body. However, in many chapters, entities not yet suficiently validated; these are for example 9. Headache or facial pain attributed to disorder of the cranium, neck, eyes, ears, nose, sinuses, teeth, mouth or other facial or cervical structure A11. Prodromal and postdromal symptoms include hyperactivity, hypoactiv ity, depression, cravings for particular foods, repetitive yawning, fatigue and neck stifiness and/or pain. Coded elsewhere: When a patient fulfils criteria for more than Migraine-like headache secondary to another disorder one type, subtype or subform of migraine, all should (symptomatic migraine) is coded as a secondary head be diagnosed and coded. Three rules apply of all types, subtypes or subforms, additional coding is to migraine-like headache, according to circumstances. When pre-existing migraine becomes chronic in close attacks lasting 4–72 hours Typical characteristics of the temporal relation to such a causative disorder, both headache are unilateral location, pulsating quality, the initial migraine diagnosis and the secondary diag moderate or severe intensity, aggravation by routine nosis should be given. At least five attacks fulfilling criteria B–D persisting for up to 48 hours; these are less well studied. Headache attacks lasting 4–72 hours (when Migraine attacks can be associated with cranial auto 2,3 untreated or unsuccessfully treated) nomic symptoms and symptoms of cutaneous allodynia. Headache has at least two of the following four In young children, photophobia and phonophobia characteristics: may be inferred from their behaviour. One or a few migraine attacks may be dificult to subforms if they are separate entities. Very frequent migraine attacks are distinguished as Furthermore, the nature of a single or a few attacks 1. In children and adolescents (aged under 18 years), occur, as may cortical changes secondary to pain activa attacks may last 2–72 hours (the evidence for tion. This contrasts with the pathognomonic spreading untreated durations of less than two hours in chil oligaemia of 1. Furthermore, it has been suggested that glial waves or Comments: Migraine headache in children and adoles other cortical phenomena may be involved in 1. Occipital headache in chil While the disease was previously regarded as primarily dren is rare and calls for diagnostic caution. A subset vascular, the importance of sensitization of pain path of otherwise typical patients have facial location of ways, and the possibility that attacks may originate in the pain, which is called ‘facial migraine’ in the literature; central nervous system, have gained increasing attention there is no evidence that these patients form a separate over the last decades. Postdromal symptoms, most commonly receptor antagonists have demonstrated eficacy in the! International Headache Society 2018 20 Cephalalgia 38(1) acute treatment of migraine attacks. Because of their Comments: Many patients who have migraine attacks high receptor-specificity, their mechanisms of action pro with aura also have attacks without aura; they should vide new insight into migraine mechanisms. The latter performed better in distinguishing migraine with aura from transient ischaemic attacks. One or more of the following fully reversible aura without positive phenomena may occur; this is often symptoms: perceived as being of acute onset but, on scrutiny, usu 1. At least three of the following six characteristics: of origin and afiecting a greater or smaller part of one side 1. A distinction between migraine with visual aura, migraine with hemiparaesthetic aura and migraine with speech and/or language aura is probably artificial, and Notes: therefore not recognized in this classification: they are all coded as 1. When, for example, three symptoms occur during an When aura symptoms are multiple, they usually aura, the acceptable maximal duration is 3A60 min follow one another in succession, beginning with utes. When the aura includes motor weakness, the dis persisting for up to 48 hours; these are less well studied. Common mistakes are incorrect reports of lateralization, of sudden rather than gradual Diagnostic criteria: onset and of monocular rather than homonymous visual disturbances, as well as of duration of aura and mistak A. After an initial consult aura and criterion B below ation, use of an aura diary may clarify the diagnosis. Aura with both of the following: Migraine aura is sometimes associated with a head 1. Blood fiow reduction accompanied or followed within 60 minutes by head usually starts posteriorly and spreads anteriorly, and is ache with or without migraine characteristics. After one to several hours, gradual transition into hyperaemia Diagnostic criteria: occurs in the same region. It is not rare for aura to last accompanies or follows the aura within 60 minutes. No headache accompanies or follows the aura Prodromal symptoms may begin hours or a day or two within 60 minutes. They include various combinations of fatigue, dif followed by migraine headache, but many patients ficulty in concentrating, neck stifiness, sensitivity to light have, in addition, attacks with aura followed by a less and/or sound, nausea, blurred vision, yawning and distinct headache or even without headache. Postdromal symptoms, most commonly feeling tired or weary, dificulty with concentration and! International Headache Society 2018 22 Cephalalgia 38(1) In the absence of headache fulfilling criteria for 1. Many its distinction from mimics that may signal serious dis patients who have attacks with brainstem aura also ease. Description: Migraine with aura symptoms clearly origi Diagnostic criteria: nating from the brainstem, but no motor weakness. This criterion is not fulfilled by sensations of ear ness, and at least one first or second-degree relative has fullness. Comments: Originally the terms basilar artery migraine Comments: New genetic data have allowed a more precise or basilar migraine were used but, since involvement of definition of 1. When genetic testing is done, the genetic subform (if discovered) should Description: Migraine with aura including motor weak be specified at the fifth digit. Characterization of frequently recurring headache utes, by headache generally requires a headache diary to record infor C. Appropriate investigations are required to ously, is daily and unremitting from <24 hours after exclude other causes of transient monocular blindness. The most common cause of symptoms suggestive Description: Headache occurring on 15 or more days/ of chronic migraine is medication overuse, as defined month for more than three months, which, on at least under 8. Headache (migraine-like or tension-type-like)on patients apparently overusing medication do not! Occurring in a patient who has had at least five for these (assuming that chronicity induced by drug attacks fulfilling criteria B–D for 1. Description: A debilitating migraine attack lasting for In fact, the characteristics of the headache may more than 72 hours. Such patients are extremely dificult Diagnostic criteria: to keep medication-free in order to observe the nat ural history of the headache. A headache attack fulfilling criteria B and C with and those without aura are both counted, as are B. Both of the following characteristics: lesion in the appropriate territory demonstrated by 1 1. Remissions of up to 12 hours due to medication or more aura symptoms persists for >60 minutes sleep are accepted. There may be additional symptoms attributable to order and the relevant type or subtype of migraine but the infarction. When overuse of medi cation is of shorter duration than three months, code for Comments: Ischaemic stroke in a migraine sufierer may the appropriate migraine type or subtype(s) only.

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Elderly patients administered without ruling out the pres (2) Glycerin ence of an intracranial hematoma, in the Nonproprietary name event of transient hemostasis due to Glycerin intracranial pressure, bleeding may Action resume when intracranial pressure Decreases vitreous volume decreases, so the drug should not be Dosage and administration administered until the bleeding source 50% glycerin p. Patients with urinary retention or renal Headache, dizziness, thirst, nausea, diar function disorders rhea, rigor, diuresis, and for the intrave 3. Methods of observing the fundus oculi red-free light is recommended for the detection As a rule, in observation of the optic disc and of tiny defects in the retinal nerve fiber layer. In observation should be conducted with sufficient the case of a fundus camera not having a red-free light. Observation points for the optic disc and reti to sufficiently magnify the fundus image, and in nal nerve fiber layer this sense, observation using a direct ophthalmo the four methods for observing the fundus scope is recommended. Except when the ocular oculi discussed above are used as appropriate in medium is highly opaque, which makes observa order to evaluate whether or not there are any tion with a direct ophthalmoscope difficult, indi abnormalities due to glaucoma in the optic disc rect ophthalmoscopy using a lens with a low and retinal nerve fiber layer. Observation meth magnification, such as 14 or 20 D, is unsuitable ods can roughly be divided into (1) qualitative for observation because the optic disc image will assessment and (2) quantitative assessment. In •Shape of optic disc this case, a lens for observing the fundus oculi is •Shape of the cup of the optic disc (referred to used in slit-lamp microscopy. Using a slit beam, the width •Hemorrhaging of the optic disc (referred to and depth of the cup can be observed with strong in the following as disc hemorrhage) magnification. Caution is •Defects in the retinal nerve fiber layer required in this case, as the image is inverted. A stereoscopic camera speaking, in myopic eyes of 8 D or below, provides optimum results. The shape of the angle of 45 degrees or more in recording the reti optic disc is unrelated to age, sex, body nal nerve fiber layer. It varies widely from approximately methods mentioned above can be used to a suffi 0. The size of the optic disc shows no 55 correlation with age from the age of around 10 camera, it stands out as an indicator of cup on. The depth of the cup can be height, body weight, and refraction defects, roughly estimated based on whether or not reports differ, and no consensus has been one can see the pores of the lamina cribrosa of reached. If the lation with refraction within a range of at least pores can be seen, the cup can be considered ± 5 D. Enlargement of this cup times observed in the case of physiological is one of the major characteristics of glau excavations. Stereoscopic general tendency, and there may also be observation is the optimum method for numerous differences in rim size resulting observing the extent of this cup, but in cases from individual differences such as the num where this technique cannot be used, diagno ber of nerve fibers, nerve fiber density, struc ses are made based on the course of the blood ture of the lamina cribrosa, and number of vessels in the optic disc. The areas showing a curved course of the is usually somewhat transversely elongated, so blood vessels on planar observations are taken the rim shape undergoes a variety of changes as the outer rim of the cup. In glaucoma, when the cup increases in Ordinarily, the widest part of the rim is the size, 2-dimensional enlargement and 3 inferior region of the disc, followed in dimensional increases in depth occur in paral descending order by the superior region and lel. Specifically, while the existing cup nasal side of the disc, with the thinnest area becomes deeper, new excavations appear. When the cup rapidly increases in size, the Because of this, the visibility of the nerve fiber small blood vessels originally running along layer of temporal-inferior region to the disc is the inside of the rim of the cup do not follow ordinarily high. If the optic disc is large, how this expansion, but remain exposed on the ever, this trend is not very pronounced, and floor of the enlarged cup or on its slope. If such vessels are present, this eyes, the rim on the temporal side of the disc constitutes an important finding indicating is the thinnest, with the nasal area of the disc progressive expansion of the cup. As this the enlargement of the cup is more predomi change is relatively pronounced, when the nant either in the superior or inferior areas of disc cup is observed over time using a fundus the disc. Accompanying this, progressive 56 thinning of the rim takes place at the superior, hemorrhaging are known to show a higher inferior, or both poles of the optic disc. With rate of visual field progression than patients in further progression, the shallow cup region whom such hemorrhaging is not observed, so increases in depth, the border between the this is a finding of great clinical significance. This change is with a high degree of frequency in glaucoma a significant finding indicating the presence of tous eyes compared to normal eyes, and the optic nerve fiber defects. At this point, visual impairment is char increase with the progression of visual field acterized by superior and inferior arcuate damage. It is rare in healthy persons (6) Presence or absence of retinal nerve fiber (0-0. Defects of the retinal nerve fiber layer fre Compared to the glaucomatous eyes, the fre quently occur prior to enlargement of the quency of disc hemorrhaging is high in eyes optic disc cup and visual field defects, which with normal-tension glaucoma. Moreover, it can be said to be the earliest change in the tends to occur in the same areas where notch glaucomatous fundus oculi, and this finding is ing of the rim and defects in the retinal nerve therefore significant. In ophthalmoscopic fiber layer are present, and approximately examination of normal eyes, the retinal nerve 80% of disc hemorrhaging is observed either fiber layer shows the highest visibility in the corresponding to the area of defects in the inferior-temporal region, followed in order by nerve fiber layer or in the vicinity thereof. Identification by oph disc hemorrhaging and local disc damage, but thalmoscopic examination becomes difficult they do not necessarily constitute characteris directly superior and inferior to the disc, on tic findings in eyes with normal-tension glau the temporal side, and on the nasal side. In any case, disc hemorrhaging, at the visibility of the retinal nerve fiber layer stage when it can be observed, indicates the decreases with age, and this is consistent with presence of rim notching and nerve fiber the finding that almost 1. In a 57 clinical setting, slit-lamp microscopy is ordi the case of image analysis instruments developed narily carried out using a 78 or 90 D fundus in recent years. The nerve fiber bundle ing as C/D ratio) is seen as a whitish/silver-colored line. When • Rim-to-disc diameter ratio (abbreviated in one moves away from the optic disc by a dis the following as R/D ratio) tance approximately 2 times the diameter of (1) Definition of the outer edge of the optic the disc, the optic nerve fiber layer appears disc thin, taking on a brushlike appearance and the outer edge of the optic disc is defined then gradually disappearing. In large vessels, it is highly likely that these are glau optic discs, physiological concavities are also comatous. In such a case, the retina in the large, and there are also cases in which a defected area appears with dark band-like small disc does not show a clear cup. In cases in which retinal nerve the optic disc cup is glaucomatous, it is impor fiber layer defects are detected and accompa tant to conduct this evaluation bearing in nied by glaucomatous changes in the optic mind disc size. The approximate size can disc, the presence of glaucomatous visual field even be assessed using a slit-lamp microscope damage is virtually certain. In such cases, the length of hand, when the retinal nerve fiber layer is get the slit being set to 1 mm, the observation axis ting thinner, the optic nerve fibers above the and the light axis are aligned, the slit lamp is retinal blood vessels becomes thin, and the placed over the disc, and an assessment is vascular walls are more clearly visible, made as to the rough vertical diameter of the appearing to rise up above the nerve fibers. On the other hand, because the distance Such changes are also considered to be signifi from the center of the optic disc to the macu cant findings indicating a retinal nerve fiber lar fovea centralis is largely uniform, by taking layer defect. This hemorrhaging may be seen in an area close to ratio is ordinarily in the range of 2. However, it is defined as the outermost area at which the the parameters mentioned here are defined cup begins. Following the course of fine according to the definition established in clinical blood vessels in the optic disc, the apex show observation, and this differs from the definition in ing a curved course of the blood vessels 58 (4) Definition of C/D ratio1) the ratio of the maximum vertical diameter of the optic disc cup to the maximum vertical optic disc diameter is referred to as vertical C/ D ratio, and the ratio of the horizontal diame ter of the cup to the horizontal optic disc diameter is referred to as the horizontal C/D ratio (Fig. In assessing whether or not there are glaucomatous changes, the vertical diame ter is more useful. With respect to C/D ratio, there are also methods involving assessment of disc diameter and cup diameter along the same line, but in the present Guideline, we Fig. However, in stereoscopic evaluation, the C/D ratio is in normal distribution and has been reported to average 0. The optic disc cup is defined quantitative assessment of the optic disc as the inside of the area demarcated by the In the following, based on evaluation outer edge of the cup. Ordinarily, the bluish results for vertical C/D ratio and R/D ratio, we white discoloration of the disc referred to as show glaucoma diagnostic criteria prepared pallor is seen on the floor of the cup, and the based on the diagnostic criteria proposed by disc cup should not be assessed by observing Foster et al. Using diagnosed as glaucoma based on optic disc these diagnostic devices, one can carry out quan findings (however, this does not apply to cases titative evaluations of the optic disc or retinal in which reliable visual field tests show a visu nerve fiber layer thickness, and they have been al field within the normal range or the pres reported to be useful in glaucoma diagnosis. Criteria in cases of suspected glaucoma3): ments in which automatic diagnostic programs Cases where one or more of the following have been installed, it has been reported that the findings are present: (1) the vertical C/D ratio specificity and sensitivity of glaucoma diagnosis ranges from 0. At the present time, such vertical C/D ratios between the two eyes rang instruments can only be used on an auxiliary es from 0. Acta Soc Ophthalmol Jpn 107: configuration or retinal nerve fiber layer 126-157, 2003. Significance of glaucoma diagnosis using —————————————————————————————————————————————————— computerized image analysis techniques Explanation of attached figures When persons who are experienced in the use Fig. Vincent Road Kochi 682 018, Kerala, Phones: +91-484-4036109, +91-484-2395739, +91-484-2395740 e-mail: kochi@jaypeebrothers. This book has been published in good faith that the material provided by author is original. Every effort is made to ensure accuracy of material, but the publisher, printer and author will not be held responsible for any inadvertent error(s). The Bible the need for a textbook for undergraduate medical students in ophthalmology dealing with the basic concepts and recent advances has been felt for a long-time. Keeping in mind the changed curriculum this book is intended primarily as a first step in commencing and continuing the study for the fundamentals of ophthalmology which like all other branches of medical sciences, has taken giant strides in the recent past. While teaching the subject I have been struck by the avalanche of queries from the ever inquisitive students and my effort therefore has been to let them find the answers to all their interrogatories. In the competitive market of medical text publishing, only successful books survive. Any textbook, more so, a medical one such as this, needs to be updated and revised from time to time. Yet the very task of revising Basic Ophthalmology presents a dilemma: how does one preserve the fundamental simplicity of the work while incorporating crucial but complex material lucubrated from recent research, investigations and inquiries in this ever expanding field. In essence, Basic Ophthalmology is both a ‘textbook’ and a ‘notebook’ that might as well have been written in the student’s own hand. The idea is for the student to relate to the material; and not merely to memorize it mechanically for reproducing it during an examination. It is something I wish was available to me when I was an undergraduate student not too long ago. The past few years have witnessed not only an alarming multiplication of information in the field of ophthalmology, but more significantly, a definite paradigmatic shift in the focus and direction of ophthalmic research and study. The dominant causes of visual disabilities are no longer pathological or even genetic in nature, but instead a direct derivative and manifestation of contemporary changes in predominantly modern urban lifestyles. With posterior chamber intraocular lenses establishing themselves as the primary modality in the optical rehabilitation of patients undergoing cataract surgery, the emphasis has shifted from just visual rehabilitation to an early, perfect optical, occupational and psychological rehabilitation. When I initiated this project I scarcely realized that it only had toil, sweat and hard work to offer. Whenever anyone reminded me that I was working hard, my answer always was; I am trying to create something very enduring. In truth, it is a vivid reflection of my long lasting concern and affection for my students. All books are collaborative efforts and I would like to take this opportunity to thank all the people who have advised and encouraged me in this project: specially my husband Shri Ajit Jogi, my son Aishwarya, Amit and Dr Nidhi Pandey. By the grace of the Almighty God and with the continuing support of the teachers, I am happy to present the fourth updated edition of my book. A thickening appears on either side of the neural tube in its anterior part, known as the optic plate. The two eyes develop from these optic vesicles and the ectoderm and mesoderm coming in contact with the optic vesicles. The hyaloid artery enters through the fissure to provide nutrition to the developing structures.

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