Mitchell Colllins Black, MD

• Assistant Professor of Medicine

https://medicine.duke.edu/faculty/mitchell-colllins-black-md

Marcus Gunn jaw winking phenomenon-There is unilateral ptosis on movements of the jaw as a result of misdirected 3rd nerve muscle relaxant ratings imitrex 25 mg low cost. In complete paralysis of 3rd nerve operation is usually contraindicated due to intolerable postoperative diplopia muscle relaxant zolpidem imitrex 50 mg fast delivery. In cases of incurable paralysis spasms versus spasticity cheap imitrex 50 mg mastercard, congenital and mechanical ptosis muscle relaxant pakistan imitrex 100mg without a prescription, the deformity can be relieved by suitable operation. The ideal age for surgery is 4-5 years but it can be done early in cases of complete bilateral ptosis. Principle There are three main techniques available for the correction of ptosis: i. If the levator muscle is paralysed, the superior rectus muscle is used to lift the lid. If both levator and superior rectus muscles are paralysed, the action of frontalis muscle is utilized. Resection of levator muscle-If the levator muscle is not completely paralysed, the levator muscle may be shortened by the resection of the muscle. Fasanella-Servat operation-The levator muscle is shortened along with excision of 4-5 mm of the tarsal plate. Motais operation-If the levator muscle is paralysed, the superior rectus is pressed into service to elevate the lid. Fascia lata sling operation-Three incisions are made in the upper lid about 4 mm from the lid margin. Xanthoma these are often bilateral, symmetrical, slightly raised yellow plaques situated near the inner canthus. The lid may be affected along with the facial angioma as in Sturge-Weber syndrome. It is seen at the edge of the lid (transition zone) where the characteristic of epithelium changes. Basal cell carcinoma (Rodent ulcer) It is the most common malignant tumour of the lid. Distichiasis It is a rare condition where one or more extra rows of eyelashes are present at the opening of meibomian glands. Coloboma There is a triangular notch in the upper lid margin near the nasal side usually. A semilunar fold of skin, situated above and sometimes covering the inner canthus is known as a. Surgery of choice in cases where multiple ptosis operations have failed and levator action is poor a. Lacrimal Glands these are serous glands situated at the upper and outer angle of the orbit, in a depression known as the fossa for the lacrimal gland. Anteriorly the gland is divided into two parts-the upper orbital part and the lower palpebral part. The ducts of the lacrimal gland which are about 12 in number open in the fornix of the upper lid. The glands secrete tears composed of water, salt and lysozyme, a bactericidal enzyme. Accessory Lacrimal Glands these are very small glands of exactly the same structure as the lacrimal glands. Glands of Krause-These are about 20 in number in the upper lid and about 8 in the lower lid situated within the stroma of the conjunctiva mainly near the fornix. Glands of Wolfring-These are few in number situated near the upper border of tarsal plate. Lacrimal Puncta these are two small openings situated on a small elevation called lacrimal papilla, about 6 mm from the inner canthus on each lid margin. Lacrimal Canaliculi these are narrow tubular passages which lie one above the other being separated by a small body, the caruncle. The two canaliculi may open separately in the lacrimal sac or may join to form a common canaliculi. The Lacrimal Apparatus 425 Lacrimal Sac It is a cystic structure lined with columnar epithelium. It is situated in the lacrimal fossa formed by the lacrimal bone and the frontal process of the maxilla. The portion of the sac above the opening of the canaliculi is known as the fundus. Nasolacrimal Duct It is a membranous canal approximately 2 cm long extending from lower part of the sac to the inferior meatus of the nose. Blood Supply of the Lacrimal Gland the arterial supply is by the lacrimal branch of the ophthalmic artery and infraorbital branch of the maxillary artery. The venous drainage is by the lacrimal vein which opens into the superior ophthalmic vein. Lymphatic Drainage the lymph vessels join the conjunctival and palpebral lymphatics and pass to the preauricular nodes. Secretomotor fibres-These are derived from the facial nerve via the sphenopalatine ganglion. It is slightly alkaline and consists mainly of water, small quantities of salts, such as sodium chloride, sugar, urea, protein and lysozyme, a bactericidal enzyme. The Tear Film the fluid which fills the conjunctival sac consists of 3 layers namely: 1. Mucous layer-A hydrated layer of mucoproteins secreted by the goblet cells, crypts of Henle and glands of Manz. Aqueous layer-It consists of tears secreted by the lacrimal gland and accessory lacrimal glands. Lipid layer-It consists mainly of cholesterol, esters and lipid being secreted by the meibomian glands and Zeis glands. Functions the surface of the eyeball must remain wet for comfort and normal functioning. The tear film spreads over the surface of corneal epithelium by gravity, capillary action and blinking of the eyelids. It contains protective substances such as lysozyme, immunoglobulin, lactoferrin, compliments. The oiliness of this mixed fluid delays evaporation and prevents drying of the conjunctiva and cornea. When a foreign body or other irritant enters the eye, the secretion of tears is greatly increased and the conjunctival vessels dilate. Etiology It is a rare condition occurring in association with mumps, influenza, infectious mononucleosis, etc. Symptom There is marked pain, redness and swelling in the upper and outer angle of the orbit along with excessive watering of the eye. A tender swelling is present at the outer part of the upper lid spreading towards the temple and cheeks. There is epiphora or continuous watering of the eyes usually evident in 2nd week of life. This constitutes the treatment of congenital nasolacrimal duct block up to 6-8 weeks of age. Then bring the thumb Massage with thumb downward pressing towards the ala of the nose. Massage increases the hydrostatic pressure in the sac and helps to open up the membranous occlusions. It should be carried out at least 3 times a day to be followed by instillation of antibiotic drops. Broad-spectrum antibiotic eyedrops are instilled frequently after expressing the contents of the sac by pressure over the sac area. Intubation with silicone tube-This may be performed if repeated probing is a failure. Probing of Nasolacrimal Duct If there is no improvement after three months, probing of the nasolacrimal duct is performed through the upper punctum under general anesthesia. Great care is taken to avoid injury to the walls of the duct as it may cause fibrosis or infection.

Numerous bronchiolar epithelial cells spasms after gallbladder surgery cheap 100mg imitrex with visa, bronchiolar epithelial syncytia muscle relaxant non prescription generic imitrex 25mg on line, pneumocytes muscle relaxant youtube order imitrex 25 mg line, endothelial cells and macrophages contain prominent glassy eosinophilic intranuclear viral inclusions spasms under xiphoid process buy generic imitrex 50mg on-line. Several vessels have perivascular hemorrhage, edema, mural fibrinous necrosis, vasculitis and thrombosis. However, the disease was experimentally reproduced in meat-type rabbits using one of the isolates. In the summer of 2006, a commercial pet and agricultural rabbitry in Alaska also reported high morbidity and mortality associated with systemic herpesvirus infection. Snowshoe hares were present in the surrounding area and feral domestic rabbits had been in close proximity to the hutches earlier in the spring. In the following spring and summer, several rabbits from this same rabbitry developed conjunctivitis and skin lesions; and one breeding rabbit that had recovered from clinical infection in the previous year experienced perinatal mortality. Lung, rabbit: Within areas of necrosis, numerous cells of various lineage contain eosinophilic intranuclear viral inclusions. Leporid herpesvirus 2 is also a gammaherpesvirus, but is capable of inducing encephalitis. Additionally, natural infections of Human herpesvirus 1 (herpes simplex) have been reported in rabbits causing a fatal encephalitis. Acute hemorrhagic and necrotizing pneumonia, splenitis, and dermatitis in a pet rabbit caused by a novel herpesvirus (l e p o r i d h e r p e s v i r u s - 4). Characterization of a novel alphaherpesvirus associated with fatal infections of domestic rabbits. Experimental infection of New Zealand White rabbits (Oryctolagus cuniculi) with Leporid herpesvirus 4. Naturally occurring herpes simplex encephalitis in a domestic rabbit (Oryctolagus cuniculus). History: There is a ten-day history of increasing bloody discharge from the vulva. Uterine horns are enlarged and filled with brown to black watery fluid and blood clots. In one section, the thrombus is adhered to the wall of the vessel (will vary with section). There are hemosiderin laden macrophages focally in the adjacent endometrium (in some sections). In rabbits, at necropsy, clotted blood may be found within the uterine Histopathologic Description: Uterus: A blood vessel in the endometrium is markedly dilated and filled with blood, laminated fibrin, and neutrophils mixed with karyorrhectic debris (thrombus). The endometrium overlying this area is thin with only 1 layer of low cuboidal cells and 2 to 3 layers of collagen separating it from the 3-1. Uterus, rabbit: A large distended vein in the uterine wall contains a lamellated thrombus. Uterus, rabbit: the wall of the aneurysmal vein is endothelial- lined (small arrows). Aneurysms should be contrasted with false aneurysms or dissections, which are a defect in the vascular wall leading to an extravascular hematoma. Uterus, rabbit: At one edge of the thrombus, the proliferation of fibroblasts and immature collagen represents the nascent organization of this thrombus. Conference Comment: In rare sections in this case, the origin of the venous aneurysm is visible within the vessel wall. By definition, an aneurysm is a localized dilatation of a vessel due to widening of the lumen which causes an abnormal attenuated vascular wall. In normal branching vessels, the elastic fibers contract but are continuous when the area of branching is cut into histologic section. Adult male chinchilla, Chinchilla History: the chinchilla was found dead with no reported premonitory signs. This animal was one of seven chinchillas submitted for necropsy during an approximately 3-week period that were either noted to exhibit respiratory distress and tachypnea or found dead without premonitory signs. Gross Pathology: the caudal portion of the right cranial lung lobe was firm and mottled red to tan. Small amounts of soft to gelatinous, pale tan material were adhered to the pleural surface of the affected lung lobe. Laboratory Results: Aerobic bacterial culture of the lung yielded the growth of many Bordetella bronchiseptica; B. Histopathologic Description: In the most severely affected sections, 50-75% of airways and alveolar spaces are multifocally obscured and expanded by large numbers of heterophils that are often degenerate with poorly demarcated, round to streaming nuclei (oat cells), macrophages, small numbers of lymphocytes and plasma cells, aggregates of homogenous, eosinophilic material (fibrin), wispy to granular eosinophilic material (fibrin and proteinaceous fluid), and variable amounts of cellular and karyorrhectic debris (necrosis). Bronchial and bronchiolar epithelial cells are often hypertrophic (reactive) with occasional areas of attenuation and infrequent piling of cells (hyperplasia). The adventitia surrounding pulmonary vessels and airways is often expanded by clear space with wispy, eosinophilic material and small numbers of heterophils, macrophages, lymphocytes and plasma cells. The alveolar spaces surrounding areas of intense inflammation contain copious amounts of wispy, eosinophilic material (edema) and moderate numbers of macrophages with foamy cytoplasm and fewer heterophils and lymphocytes. Moderate amounts of fibrin with small numbers of associated heterophils, macrophages and lymphocytes are adhered to the pleural surface multifocally; the underlying pleura is lined by plump, reactive mesothelial cells. In less severely affected sections, small to moderate numbers of heterophils infiltrate the bronchial and bronchiolar mucosa and are associated with small amounts of fibrin and edema. Alveolar septa are multifocally fragmented with the formation of large alveolar spaces (emphysema). Small numbers of lymphocytes, plasma cells and heterophils mildly expand perivascular spaces. Lung, chinchilla: the filling of airways with exuberant suppurative exudate clearly defines this pattern as a bronchopneumonia. Lung, chinchilla: Airways are filled with degenerate neutrophils which erupt through the ulcerated bronchiolar wall into surrounding alveolae. Lung, chinchilla: Throughout the lung, in areas adjacent to airways, there are extensive areas of septal necrosis. Nasal cavity (tissue not submitted): Rhinitis, mucopurulent, diffuse, moderate, subacute with intralesional, intra- and extracellular coccobacilli colonies and multifocal, mild mucosal erosion and ulceration. Bordetella bronchiseptica was isolated from samples of lung for all chinchillas (n=4) that were submitted for aerobic bacterial culture, and all 7 chinchillas showed similar gross and histologic features. Other significant associated findings in the affected chinchillas included rhinitis (n=3), tracheitis (n=2) and otitis media (n=1). In small mammals, respiratory bordetellosis is most commonly reported in guinea pigs and rabbits; however, outbreaks in commercial chinchilla operations have been documented. Lung, chinchilla: the pleura is multifocally expanded by abundant fibrin, few degenerate neutrophils, and small amounts of cellular debris. Bordetella bronchiseptica has an array of virulence factors as explained by the contributor, yet in many domestic animal species it is a known commensal organism of the upper respiratory tract. Its presence is not typically equitable with clinical disease unless an immune compromising event takes place in the host. History: this was one of several ferrets in this colony suffering from debilitation due to watery diarrhea. The animal died despite supportive care and a necropsy was performed by the overseeing clinical veterinarian. Gross Pathologic Findings: No gross lesions were reported in the gastrointestinal tract. Lungs appeared collapsed and atelectatic, with multifocal pale, plaque like areas of discoloration noted throughout all lobes. Lung, ferret: Numerous variably-sized white plaques are present within all lung lobes but are most concentrated in cranial lobes. Lung, ferret: Cross sections of lung tissue demonstrate the pleural location of the inflammatory nodules. Lung, ferret: Multiple 2-3mm inflammatory nodules are scattered throughout the lung parenchyma. Lung, ferret: Smaller subpleural inflammatory nodules are composed of foamy, lipid laden histiocytes admixed with fewer lymphocytes and plasma cells. These are often (correlative to the gross distribution of lesions seen) present in subpleural locations, although foci deep within pulmonary parenchyma are often noted. Some areas consist solely of homogeneous alveolar aggregates of foamy macrophages. Others are comprised of more dense mixed inflammatory infiltrates including histiocytes, lymphocytes, scattered neutrophils and occasional multinucleated giant cells. Cholesterol clefts and crystals are often seen in association with these latter areas.

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Sustained action capsules of acetazolamide 250-500 mg (substitute) are given once or twice daily Side effects of acetazolamide iii spasms quadriplegia cheap 25mg imitrex free shipping. Mode of action-There is decreased formation of bicarbonates which causes less secretion of aqueous from the ciliary epithelium (diuretic effect is not a factor in the reduction of intraocular pressure) spasms symptoms discount 50 mg imitrex with amex. Pilocarpine 1% spasms right side of body imitrex 100mg free shipping, 2% muscle relaxant for stiff neck discount 25 mg imitrex free shipping, 4% 3-4 times daily Ciliary muscle contraction, miosis, opens spaces in trabecular meshwork Miosis and spasm, induced myopia, hyperaemia, risk of retinal detachment, cataract, iris cyst 2. Irritation, conjunctival congestion, cystoid macular oedema Hyperaemia, foreign body sensation, allergy Same as Brimonidine Twice daily Twice daily Twice daily 2-3 times daily 3. Brinzolamide 1% Once daily Once daily Once daily Hyperaemia, iris pigmentation, allergy, risk of cystoid macular oedema Conjunctival hyperaemia More conjunctival hypercaemia but fewer headache and less iris hyperpigmentation Allergy, superficial punctate keratitis, blurring dryness Similar to dorzolamide but lower incidence of stinging and local allergy 5. Hyperosmotic Agents Mode of action-These agents increased the plasma tonicity or osmolality to draw water out of the eyes. Surgical Treatment Trabeculectomy, a filtering operation is done when the miotics and -blockers fail to control the tension and the field defects progress. Mode of action-Discrete laser beam causes a shrinkage of the collagen on the inner surface of the trabecular ring, thereby, opening the intertrabecular spaces. Open angle glaucoma Patients with insufficient response to topical treatment Poor compliance to the medical treatment by patients Elderly patients in whom laser therapy may postpone surgery to beyond life expectancy. Extent-180o Viewing power-The slit-lamp is utilised with a gonioscopic lens with 25-fold ocular viewing power. Glaucoma 277 Placement of the argon-laser beam focus Direction-The beam is to be focused at the junction between the pigmented and non-pigmented trabeculum. Laser filtration-It is done with virtually any laser coupled to a fiberoptic delivery system. The advantage over routine filtering operations are fewer complications by use of smaller or no incision. Seton valves-These include filtration devices such as the Molteno (silicon tube) and Krupin (supramid tube) implants. It is a subconjunctival implant connected to a tube that enters the anterior chamber. Aqueous is shunted through the implant and diffuses away in the subconjunctival tissue. Non-penetrating surgery-The anterior chamber is not entered and the internal trabecular meshwork preserved. There is no bleb formation which means the aqueous does not drain into the subconjunctival space. This view is supported by presence of: Nocturnal systemic hypotension and overtreated systemic hypertension Migraine Reduced blood flow velocity in the ophthalmic artery and posterior ciliary arteries (as shown by transcranial Doppler imaging) Raynaud phenomenon-There is peripheral vascular spasm on cooling. Optic nerve head It is usually larger than open angle glaucoma Glaucomatous cupping and parapapillary changes are identical Splinter haemorrhages and optic disc pits are more frequent than open angle glaucoma 4. Glaucoma 279 Investigation Perimetry should be done at 4-6 monthly interval to demonstrate progression before starting medical treatment. Treatment the risk factors necessary for treatment include: Progression of visual field loss Presence of disc haemorrhages Female patients Associated migraine. If nocturnal drop of blood pressure is present, avoid high dose of antihypertensive medication. Relative pupil block-Normally pupillary margin just touches the anterior surface of the lens. Physiological iris bombe-On dilatation of the pupil there is crowding of the iris in the angle of anterior chamber causing obsruction to the flow of aqueous from the posterior to the anterior chamber at the level of the pupil. Irido-trabecular contact-It totally cuts off the drainage channel by forming a false angle. It precipitates an attack of raised intraocular pressure (acute congestive attack). Irido-trabecular contact Stages the clinical course of the disease has been divided into five stages. The condition however does not necessarily progress from one stage to the other in an orderly sequence. Absolute primary angle-closure glaucoma Mechanism of closed angle glaucoma Glaucoma 281 1. The pigmented trabecular meshwork is not visible (Shaffer grade 1 or 0) without indentation or manipulation in at least three quadrants. The patient is asked to lie down in a dark room, in the prone (face downwards) position for 1 hour without sleeping. It is confirmed in one eye during an attack of acute congestive angle closure in the other eye usually. An optical section of the peripheral cornea and anterior chamber is made with the illumination and viewing arms at 60 degrees to each other. It is a corneal topography mapping system which combines scanning slit with placido disc technology. Treatment Prophylactic peripheral laser iridotomy in both eyes will prevent an acute attack. If untreated, the risk of acute pressure rise during the next 5 years is approximately 50%. The normal diurnal variation Intermittent angle closure occurs in an anatomically predisposed eye in which physiological factors such as reading in dim illumination or watching television in a dark room precipitates a pupillary block due to mydriasis. This causes a sharp rise in intraocular pressure for a short period of time followed by a spontaneous resolution of the pupillary block possibly due to: i. Sleep (As the pupil becomes constricted) Emotional stress may also be a precipitating factor. Coloured halos around lights-There is accumulation of fluid in the corneal epithelium and corneal lamellae which alters the refractive conditions of the cornea. As halos are seen as coloured rings around lighted bulb, they are observed only after dark. The colours are distributed as in the spectrum of rainbow with red colour being outside and violet inner most. Course Some eyes may develop an acute attack or may progress into chronic primary angle-closure glaucoma. Diagnosis Diagnosis in the early stages (angle-closure suspect and intermittent or subacute angle-closure) is important since adequate treatment at this stage is easy and certain to prevent the loss of vision. If the patient gives a vague history, the halo can be demonstrated by him on looking through a thin layer of lycopodiun powder enclosed between two glass plates made up as a trial lens. Gonioscopy Presence of narrow angle of the anterior chamber is seen There is narrow angle recess with clumping of pigments in the angle Occasional peripheral anterior synechiae may be present. Provocative tests- Rise in tension can be tested by the provocative tests even if the tension is normal. Dark room test-The patient lies awake in the prone (with face downward) position in a dark room for 1 hour. The pupil dilates and if the rise in tension is more than 8 mm Hg (Schiotz), it is pathological. Full miosis is achieved after the test by the instillation of pilocarpine eyedrops as precaution. Lenticular halos-These are typically seen in early cataractous changes in the lens. Lenticular halo-It is broken up into segments which revolve as the slit is moved. It is typically seen in the case of incipient cataract due to the prismatic effect of the wedge-shaped peripheral cortical opacities where the halos "make and brake". Halo in conjunctivitis-This is due to the sticking of conjunctival discharge on the cornea. The stenopaeic test (Fincham test) Treatment Prophylactic peripheral laser iridotomy is performed in both eyes of all the patients because if untreated the risk of acute pressure rise during the next 5 years is very high (50% approximately). Glaucoma 285 Mechanism of the rise in intraocular pressure in angle-closure glaucoma Pathogenesis the crisis is due to acute ischaemia associated with liberation of prostaglandin-like substances. If the attack lasts for several hours or days, irreversible damage may occur to the ocular tissues. Severe unilateral headache, nausea, vomiting and prostration are often associated. There is sudden onset of intense unbearable pain in the eye due to stretching of the sensory nerves.

Hypersensitivity reaction-It occurs due to hypersensitivity reaction to autologous tissue components (autoimmune reaction) muscle relaxant pregnancy safe order imitrex 25 mg fast delivery. Allergic (exudative or non-granulomatous)-It is of acute onset and short duration muscle relaxant images generic imitrex 50 mg without a prescription. It is characterized by the presence of fine keratic precipitates which are composed of lymphoid cells and polymorphs muscle relaxant depression generic 25mg imitrex with visa. Keratic precipitate Aqueous flare Iris nodule Posterior synechiae Posterior segment Slow and insidious Chronic course with remissions and exacerbations Features of low grade inflammation Mutton fat kp Mild with few cells Common Marked and organised Commonly involved 1 knee spasms pain discount 50 mg imitrex mastercard. There is severe neuralgic pain referred to forehead, scalp, cheek, malar bone, nose and teeth (as the iris is richly supplied by sensory nerves from the ophthalmic division of 5th nerve). Lacrimation and photophobia may be present (without any mucopurulent discharge) due to associated keratitis. Impaired vision-It is mainly due to hazy plasmoid aqueous and opacity in the media. Photophobia is due to pain induced by pupillary constriction and ciliary spasm because of inflammation. Circumciliary congestion-There is hyperaemia around the limbus which is dull purple-red in colour. There is plasmoid aqueous containing leucocytes, minute flakes of coagulated proteins and fibrinous network. Aqueous flare grading +1 Faint +2 Moderate +3 Marked +4 Intense Slit-lamp examination in acute iridocyclitis - - - - Just detectable Iris details clear Iris details hazy With severe fibrinous exudate b. Keratic precipitates (kp)-The exudate tends to stick to the damaged endothelium in the lower part of cornea in a triangular pattern due to the convection currents in anterior chamber and effect of gravity. They are characteristic of granulomatous uveitis with predominance of macrophages. Hypopyon-In severe cases of iritis polymorphonuclear leucocytes are poured out which sink to the bottom of the anterior chamber forming hypopyon. Hyphaema-Blood in the anterior chamber rarely occurs due to spontaneous haemorrhage. It reacts sluggishly to light due to irritation of the third nerve endings in iris. Ectropion of uveal pigment is due to the contraction of exudates upon the iris so that the posterior surface of iris folds anteriorly. Anterior peripheral synechiae-The iris gets attached to the periphery of the cornea. Intraocular pressure may rise when 3/4 circumference or more of the angle of anterior chamber is blocked. Annular or ring synechiae (seclusio-pupillae) Whole pupillary margin is tied to the lens capsule by exudates therefore anterior chamber becomes funnel-shaped. Occlusio-pupillae or blocked pupil-Exudates organize across the pupillary area therefore the vision is impaired and there is associated raised tension. Total posterior synechiae-In severe cyclitis, the posterior chamber is filled with exudates which may organize tying down the iris to the lens capsule. Cyclitic membrane-In worst cases of plastic iridocyclitis, a cyclitic membrane may form behind the lens. Complicated cataract-There is typical posterior cortical cataract with bread crumb appearance and polychromatic lustre. Vitreous-Vitreous opacities due to leucocytes, coagulated fibrin and exudates may be present in severe cases. Hypertensive iridocyclitis may be present due to increase pressure in dilated capillaries and outpouring of leucocytes. The sticky albuminous aqueous drains Acute iridocyclitiswith difficulty thus raising the tension. Secondary glaucoma-It may occur as an early or late complication of iridocyclitis. Early glaucoma (Inflammatory glaucoma)-In active phase of the disease, presence of exudates and inflammatory cells in the anterior chamber may block the trabedular meshwork resulting in decreased aqueous drainage and thus a rise in intraocular pressure (hypertensive uveitis). Late glaucoma (postinflammatory glaucoma) is the results of pupil block (seclusio-pupillae due to ring synechiae formation or occlusio-pupillae due to organised exudates) not allowing the aqueous to flow from anterior to posterior chamber. Cyclitic membrane-It results due to fibrosis of exudates present behind the lens. Choroiditis-It may develop in prolonged cases of iridocyclitis owing to their anatomical continuity. Retinal complications-These include cystoid macular oedema, macular degeneration, exudative retinal detachment and secondary periphlebitis retinae. Investigations Series of tests should be done because of varied etiology of uveitis. Radiological investigations include X-rays of chest, paranasal sinuses, sacroiliac joints and lumbar spine. Modern broad-spectrum antibiotics which cross the blood-aqueous barrier are given in cases of infections. Atropine It is the most powerful, longest acting (2 weeks) and commonly used mydriatic and cycloplegic. Pupil Gradual Mild discomfort Mucopurulent May be present Absent Usually gradual Moderate Watery Absent Mild Sudden Severe Watery Present Prostration and vomiting Deep ciliary Marked Corneal oedema Shallow Large, oval Poor Raised Corneal oedema and anterior synechiae 2. Superficial conjunctival Absent Clear Normal Normal Good Normal Normal Deep ciliary Marked Opacities may be seen May be deep Small, irregular Fair Normal or low Aqueous flare and kp 3. Thus, it also relaxes the ciliary muscle spasm which is always associated with iritis. It prevents formation of posterior synechiae and breaks down recently formed synechiae which are not firmly attached by dilating the pupil. In case of atropine allergy, other mydriatics like phenylephrine, cyclopentolate or tropicamide may be used. In milder cases weaker, short-acting agents such as cyclopentolate 1% or homatropine 2% thrice daily may be used. Dark glasses or an eyeshade may also be used to avoid glare, discomfort and lacrimation specially in sunlight. Heat Application Heat application in the form of hot fomentation or local dry heat is very soothing. Due to their anti-allergic and anti-fibrotic activity they reduce fibrosis and thus prevent disorganisation and destruction of tissues. It is better to use full strength topical steroids for 6 weeks to make sure that patient is not having side effects such as raised intraocular pressure. It is indicated for Severe acute anterior uveitis As an adjunct to topical or systemic therapy in resistant chronic anterior uveitis In cases of poor patient compliance with topical or systemic medication. It is indicated in cases of Severe uveitis When there is no improvement on maximal topical and periocular steroids v. Rimexolone (Vexol 1%)-A new drug is being used in United States of America for anterior uveitis. Analgesics and Anti-inflammatory these are useful in relieving pain and discomfort. Antibiotics the modern broad-spectrum third generation antibiotics are of immense value particularly in fulminant cases of purulent uveitis. Although these are of not much use in allergic iridocyclitis, they provide an umbrella cover. These are safer as prolonged use of steroids may produce open angle glaucoma by reducing outflow facility, cataract and secondary infection with bacteria or fungi. These agents should be administered with great caution under the supervision of haematologist or an oncologist as they have adverse side effects or kidney, liver and cause bone marrow depression. Recently azathioprine, mycophenolate, mofetil, tacrolimus are used in unresponsive or intolerant patients. Specific Treatment Specific treatment of the underlying disease should be added if the etiology is identified. Secondary glaucoma (hypertensive uveitis)-Drugs to lower intraocular pressure such as 0. Post-inflammatory glaucoma due to ring synechiae and iris bombe demand an iridectomy in all cases so that communication can be restored between anterior and posterior chambers. Complicated cataract requires lens extraction with guarded prognosis in a quiet eye under cover of steroids.