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Centralchop (K aratechop)involves splitting of nucleusfrom m id-periphery by em bedding thechopperon If theim palem entisadequatethenonslighttoandfrom ovem entof theanteriorsurfaceof thenucleus muscle relaxant apo 10 buy 30pills rumalaya forte mastercard. Chopperisplacedontheanteriornucleussurface spasms cure quality rumalaya forte 30 pills,closetothe achieved in onearea muscle relaxant 5mg discount 30 pills rumalaya forte with amex,m oveto rhex ism argininahorizontalposition. N ow withtheotherhand, O neshouldcarefully selectthe phacoprobeisim paledintothenucleus. Thechopperisturnedvertical area to be im paled,try ing to and pulled towardstheU /S tip. Justbeforereaching theprobe,the rem ain within thebody of the nucleusissplitsideway s. M aintaining thefootinposi Problem sw ith peripheralchop Causesof poorholdinclude tion 3 leads to loosening of the grip. If thesiteistoo superficial, com pleteocclusionisnotachievedandthereforevacuum sealisnot effective. Thecataractgetssuckedeven withoutuseof phacoenergy anddangerof going throughandthrough ishigh. Settings forvacuum seal Therecom m endedsettingsare:D epending onm achineandex perience of thesurgeon. If thechopperisaccidentally placed overtheanteriorcapsule z thechopperhastobevery closetothephacotip otherwisethere insteadof underneathitandthechop isinitiated,itm ay leadto willberocking of thenucleus R hex isM arginTear(R M T)orzonuloly sis. A vacuum holdiscreatedby im paling thephacoprobewithaburst of energy andwithdrawing thepedaltoposition2. The verticalportion of thechopperisburied deep in thenucleusin the directionof optic nerve. Thisiseasierto accom plish by beginnerssince concentrationisonly onm ovem entsof onehand. If the fibresdonotentirely separateby thefirstm ethod,theotherhand canbem ovedtocom pleteseparation. Thebreakcanbem adefullthicknessby m oving thechopperm ore centralanddeeperandcontinuing splitting if needbe. M odification Insteadof keeping thechoppercentrally andem bedding itvertically in thehardestpartof thenucleus,chopperiskeptslightly intheperiphery (c) (d) andasy oum oveittowardsthecentre,itispusheddeeper. Blacklinedenotestheidealareatoem bedthechopperclose Problem s w ith centralchop to and to the leftof the probe. In this,afteravacuum sealhasbeen created the thechopperm ay notem bedtotherequireddepth. A lsoleathery periphery of thenucleusisbroughtoutof therhex ism argin thus fiberswhichdonotsplitcanbeeasily cutintheperipheralchop. O nehalf of nucleushasbeenrem ovedby centralchopping leaving N egotiating therhex ism arginisthem ostdifficultpartof theperipheral theotherhalf form odifiedperipheralchop. Benefitsof bothkindsof chopping areobtainedusing am odified Thisisanex trem ely usefulprocedureforhardnucleiwithleathery fibres. W ith im provem entin the fluidicsof the m achine,m ore of aspirationandlessof phaco powerisused. T heaim isto perform thesurgery in such away thatthereis m inim alkeratitisorcom plications,irrespectiveof thehardnessof thecataract,thepupilsize,anteriorcham berdepth and corneal (aa) (bb) health. A 30% reductioninpowersetting from thatkeptduring trenching,helpsinincreasing thefootgradientand thereforecontrol. Pulsem odereducestheconsum ptionof phacoenergy by half and allowsadequatetim eforvacuum buildup during theintervalwhenthe (c) phacoisoff. F orex am ple,inhy perm etropic ey ethespacein 62 A G uide to Phacoem ulsification N ucleotom y 63 A C isless. Thesituationarisesif any of thefollowing is andincreasethepossibility of keratitis. Theidealpiecetorem ovefirstisthesm allest zzzzz Hardcataractwithlow vacuum settings:Thisresultsinpoorhold, piecewhichhasbeencom pletely separatedfrom therestof thenucleus. Careshouldbe takenthroughouttheprocedureto avoidcontactof thechopperwith M anagem entof anuclearbowlrequiresphacoaspirationintheunsafe probewhenthefootpedalisinphacom ode. Phaco shouldonly beusedwhenpiecesaregrippedby phaco probe andarenotgetting suckedin,i.

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It may be associated with anterior uveitis too weak to muscle relaxer kidney pain order rumalaya forte 30pills fast delivery withstand the intraocular pressure spasms eye buy rumalaya forte with a mastercard, so that ecta and is usually a part of a systemic autoimmune disease spasms just below rib cage safe rumalaya forte 30pills. Secondary glaucoma is a Vascular sludging and occlusion, scleral thinning and com common sequel. The 5-year sometimes extend to the cornea resulting in sclerosing mortality from associated systemic disease is 25%. An opacity develops at the margin of the cornea Necrotizing scleritis without infammation is called near the affected scleral area; it is approximately triangular scleromalacia perforans (Fig. Concurrent therapy with antacids or H2-receptor blockers such as ranitidine 150 mg given twice daily orally or famotidine 20 mg twice daily orally is advisable. In patients with necrotizing scleritis, systemic steroids and immunosuppressives are recommended. Scleral patch grafting may be necessary if there is any signifcant risk of perforation. There is Local steroids tend to be ineffective and subconjunctival painless scleral thinning with melting in severe cases and injections of steroids should never be given for fear of the underlying cause is believed to be ischaemia. Posterior Scleritis Infectious causes, if identifed, are treated with appro this is an infammation with thickening of the posterior priate topical and systemic antimicrobial agents. Panoph sclera which may start primarily posteriorly or may be an thalmitis, if severe, will warrant intravenous antibiotics in extension of anterior scleritis. The clinical presentation is varied and the diagnosis is easily missed, particularly in Specifc Infammatory Diseases associated cases with no pain or no anterior segment involvement. Posterior Collagen Vascular Diseases vitiates, disc oedema, macular oedema, choroidal folds, Scleral involvement is common in this group of disorders, choroidal detachment, uveal effusion syndrome and exuda particularly in rheumatoid arthritis. The primary event of rheumatoid arthritis the chest and sacroiliac joints and, in certain patients, a full is possibly cryptogenic bacterial or viral infection in sus immunological survey for tissue antibodies. In the sclera the clinical manifestations take several 20 mg per day over the subsequent 2?3 weeks, or immuno forms. Episcleral rheumatoid nodules may appear and suppressive agents such as cyclophosphamide, methotrexate, disappear, waxing and waning with the vagaries of the cyclosporin or azathioprine. A more serious condition is necrotizing Chapter | 16 Diseases of the Sclera 229 nodular scleritis in which a violent and painful anterior eye with an incarceration of the uveal tissue. The basic scleritis, often circumferential in its extent, characterized underlying pathology is a weakening of the eye wall, which by extensive swelling and the appearance of one or more can be caused by many infammatory or degenerative yellow nodules, usually proceeds to necrosis leading diseases involving these structures. Most commonly the eventually to disintegration of the sclera and exposure diseases causing a weakening of the globe are accompanied of the underlying uvea (Fig. In scleromalacia per by a raised intraocular pressure and both contribute to the forans a similar necrosis of the sclera occurs with expo development of the staphyloma. Depending on the site affected, staphyloma can be Finally, in massive granuloma of the sclera, prolifera classifed as (i) anterior, (ii) intercalary, (iii) ciliary, tive changes are predominant. In all these Anterior Staphyloma cases, serious and often destructive extension occurs into the uveal tract, and the general prognosis is poor. This can be partial or total, depending on whether part or Systemic treatment by corticosteroids offers the only whole of the cornea is affected. Gradually the weak anterior this used to be seen in tertiary syphilis but is now surface of the eye protrudes outward leading to an anterior uncommon. Tuberculosis Intercalary Staphyloma this form of scleritis may be secondary, due to an extension this is located at the limbus and is lined by the root of from the conjunctiva, iris, ciliary body or choroid. It is also be primary, forming a localized nodule which caseates seen externally from the limbus to up to 2 mm behind and ulcerates. The usual causes are lesions that produce and the tissue examined for the organism. Treatment con weakening of the globe in this region such as perforating sists of systemic antituberculous drugs with local, lubricat injuries of the peripheral cornea, marginal corneal ulcer, ing eye drops. Suppurative Bacterial Infections Virulent organisms such as Pseudomonas causing an endo phthalmitis may spread to infect the sclera and episcleral tissue, leading to a panophthalmitis including a scleritis. Extension of such infection is clinically diagnosed by the development of painful eye movements due to infamma tion involving the muscle sheaths at the point where they are inserted onto the sclera. Treatment consists of high doses of intravenous broad-spectrum antibiotics and a care ful watch for further spread into the orbit and subsequent cavernous sinus thrombosis. Surgical measures include in travitreal injection of antibiotics, vitrectomy and, fnally, evisceration of the globe if the eye has no light perception and all measures to contain the infection fail. Here the ciliary body is incarcer ated in the region of scleral ectasia and has a bluish colour with a lobulated surface.

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