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Maternal infections Morphological Classification Depending on the location and configuration of opacities symptoms 1dp5dt order cyclophosphamide 50 mg with amex, cataract can be classified as: 1 medicine 7767 discount 50mg cyclophosphamide with amex. Cataract associated with systemic diseases Developmental Cataract Developmental cataracts are usually present at birth (congenital) or may manifest after birth. However, following factors play important role in the formation of developmental cataract. Heredity: A strong hereditary predisposition is found in about 25% of all developmental cataracts. Other infections such as cytomegalic inclusion disease, toxoplasmosis and syphilis can also lead to cataract formation. Toxic agents: Administration of corticosteroids or thalidomide during pregnancy has cataractogenic effect. Nutritional deficiency: Deficiency states are often incriminated in the causation of zonular cataract. Miscellaneous causes: Birth trauma, placental hemorrhage, endocrine dysfunction, and inborn errors of metabolism have been associated with developmental cataract. The effects of infection, noxious agents, deficiency states or gene upon the developing lens are indistinguishable and mainly depend on the time of the insult. The most critical period in the development of the lens lies between 5th and 8th weeks of intrauterine life, when the cellular activity is maximal. Interference in the normal development during this period results in the formation of abnormal primary lens fibers leading to the development of central cataract. The involvement of secondary lens fibers during 8th to 16th weeks produces developmental cataract. Slight aberration in the development of lens fibers is common and, therefore, the lenses of most people show minute opacities especially when examined on slit-lamp under full mydriasis. It is advisable not 253 to alarm such patients about their lens opacities as they rarely interfere with vision. Developmental or congenital cataracts are broadly classified into two groups: capsulolenticular cataract wherein the capsule or the subcapsular region of the lens is involved, and lenticular cataract implicating the substance of the lens itself. Several forms of developmental cataracts are found, the relatively common ones are described below. Punctate Cataract Punctate cataract is very frequent in occurrence and manifests as multiple, small opaque dots, scattered throughout the substance of the lens. On slit-lamp examination they appear as blue dots hence known as blue-dot cataract or cataracta cerulea. Anterior Polar Cataract the anterior polar cataract commonly occurs as a single or multiple opacities in the anterior part of the lens. The acquired form of anterior polar cataract occurs after perforation of a central corneal ulcer wherein part of the lens capsule comes in contact with perforated edges of the cornea. Occasionally the opaque lens capsule projects forwards into the anterior chamber like a pyramid, anterior pyramidal cataract. Later, normal transparent lens fibers grow between the capsular and cortical opacities, thus giving rise to a reduplicated cataract. Central Nuclear Cataract In the central nuclear cataract, the opacities are mostly confined to the embryonic nucleus. It is due to the inhibition of development of the lens during the first three months of gestation. The opacity is heterogenous, either dense in the center and rare in the periphery or vice versa. A progressive form of nuclear cataract is associated with the rubella (German measles) infection in the mother in which the entire lens may be opacified as the virus causes necrosis of the embryonic nucleus. Besides cataractous lens, other ocular changes Posterior Polar Cataract the posterior polar cataract is characterized by the presence of an opacity or opacities at the central posterior part of the lens and its capsule. Slit-lamp examination reveals concentric rings around the central opacity (onionpeel appearance). The posterior polar cataract is usually associated with a thin posterior capsule or an occult posterior capsular defect. The posterior polar cataract may be associated with persistence of the anterior tunica vasculosa lentis. Mittendorf dot (also known as hyaloid corpuscle as it represents the attachment of hyaloid vessel to the posterior capsule) is a small white dot attached to the lens capsule inferonasally. It is usually stationary but the progressive form may appear which shows diffuse cortical opacities.

The ability of an organ to control its own blood flow according to need is called autoregulation medicine 003 buy cyclophosphamide with a visa. Some organs symptoms 8dpo generic cyclophosphamide 50 mg without prescription, including the central nervous system, liver and kidneys receive proportionately higher blood flow as a matter of course. Other tissues, such as resting skeletal muscle, receive much less, but their blood supply can increase by as much as 20-fold during heavy exercise. Other examples include blood flow through the gastrointestinal tract increasing after a meal to allow for increased activity in the tract, and adjustments to blood flow through the skin in the control of body temperature (p. Blood flow is increased through individual organs by vasodilation of the vessels supplying it, and decreased through vasoconstriction. The main mechanisms associated with this local control of blood flow include: release of metabolic waste products. An active tissue releases more wastes than a resting one, and increased levels of waste increase blood flow into the area tissue temperature: a rise in metabolic activity increases tissue temperature, which in turn causes vasodilation release of vasodilator chemicals. Inflamed and metabolically active tissues release a number of vasodilators, which increase blood supply to the area. One important vasodilator is nitric oxide, which is very short lived, but which is important in opening up the larger arteries supplying an organ. Other agents include substances released in the inflammatory response, such as histamine and bradykinin (p. The sympathetic hormone adrenaline (epinephrine), released from the adrenal medulla, is a powerful vasoconstrictor. Oxygen is carried from the lungs to the tissues in combination with haemoglobin as oxyhaemoglobin. Exchange in the tissues takes place between blood at the arterial end of the capillaries and the tissue fluid and then between the tissue fluid and the cells. Oxygen diffuses down its concentration gradient, from the oxygen-rich arterial blood, into the tissues, where oxygen levels are lower because of constant tissue consumption. Oxyhaemoglobin is an unstable compound and breaks up (dissociates) easily to liberate oxygen. Carbon dioxide is one of the waste products of cell metabolism and, towards the venous end of the capillary, it diffuses into the blood down the concentration gradient. Exchange of other substances the nutrients required by the cells of the body are transported round the body in the blood plasma. In passing from the blood to the cells, the nutrients pass through the semipermeable capillary walls into the tissue fluid bathing the cells, then through the cell membrane into the cell. The mechanism of the transfer of water and other substances from the blood capillaries depends mainly upon diffusion and osmosis. Diffusible substances include dissolved oxygen and carbon dioxide, glucose, amino acids, fatty acids, glycerol, vitamins, mineral salts and water. The force of the osmotic pressure depends on the number of non-diffusible particles in the solutions separated by the membrane. The main substances responsible for the osmotic pressure between blood and tissue fluid are the plasma proteins, especially albumin. Capillary fluid dynamics the two main forces determining overall fluid movement across the capillary wall are the hydrostatic pressure (blood pressure), which tends to push fluid out of the bloodstream, and the osmotic pressure of the blood, which tends to pull it back in, and is due mainly to the presence of plasma proteins. At the arterial end, the hydrostatic pressure is about 5 kPa (35 mmHg), and the opposing osmotic pressure of the blood is only 3 kPa (25 mmHg). The overall force at the arterial end of the capillary therefore drives fluid out of the capillary and into the tissue. Blood flow is slower than at the arterial end because the hydrostatic pressure drops along the capillary to only 2 kPa (15 mmHg). The osmotic pressure remains unchanged at 3 kPa (25 mmHg) and, because this now exceeds hydrostatic pressure, fluid moves back into the capillary. This transfer of substances, including water, to the tissue spaces is a dynamic process. As blood flows slowly through the large network of capillaries from the arterial to the venous end, there is constant change. Of the 24 litres or so of fluid that moves out of the blood across capillary walls every day, only about 21 litres returns to the bloodstream at the venous end of the capillary bed.

When a small non-metallic foreign body perforates the cornea and the lens capsule and gets lodged within the lens treatment brown recluse spider bite buy cyclophosphamide 50mg on-line, intralenticular foreign body medicine 1950 cheap cyclophosphamide 50mg online, it may cause a focal cortical cataract without much reaction. The intraocular metallic foreign bodies composed of iron or copper often cause cataract and ocular tissue discoloration. Ionising radiation: Actively growing lens cells are extremely sensitive to ionizing radiation. An early radiation induced cataract is characterized by punctate opacities within the posterior capsule and feathery anterior subcapsular opacities radiating towards the lens equator. Ultraviolet radiation: Ultraviolet radiation in the range of 290-320 nm is considered as a risk factor for the development of cortical and posterior subcapsular cataracts. Microwave radiation: There is an inconclusive evidence to suggest that the microwave radiation causes cataract in human beings. Electrical Injury A powerful electrical shock can cause coagulation of lens proteins and cataract formation. Diabetic cataracts can be of two types: true diabetic cataract (snowflake cataract) and senescent cataract. In diabetic patients, significant amount of sorbitol and fructose get accumulated in the lens which in turn increase the intralenticular osmolarity and draw water into the lens. In the early stage, a number of fluid vacuoles appear under the capsule, but later snowflake opacities develop all over the cortex giving a milky-white appearance to the lens. The control of diabetes may partially resolve the opacities, but more often they become confluent to make the entire lens opaque. Senescent cataract occurs earlier, rapidly and more frequently in diabetics than in non-diabetics. Galactose is reduced to dulcitol within the lens, the accumulation of which causes lens opacities. The dust-like lenticular opacities manifest soon after birth (within 2 months) and the nucleus and deep cortex become opaque causing a classical "oil droplet" appearance on retrolumination. Besides bilateral cataract, other clinical manifestations include mental retardation, splenohepatomegaly, jaundice and ascites. Dietary exclusion of milk and food containing galactose and lactose during first 3 years of life usually prevents galactosemic cataract. The syndrome is characterized by mental retardation, renal dwarfism, muscular hypotonia, osteomalacia, congenital cataract and glaucoma. Tetanic Cataract Inadvertent removal of parathyroid gland during thyroidectomy leads to the deficiency of parathyroid hormone and calcium (idiopathic hypocalcemia) resulting in cataract formation. The cataract is marked by the appearance of small discrete opacities in the cortex which are separated from the capsule of the lens by a clear zone. Galactosemic Cataract Galactosemia is an inborn error of carbohydrate metabolism characterized by inability to metabolize 266 Textbook of Ophthalmology in approximately 50% of fetuses. The classical manifestations of rubella infection are congenital heart defects, deafness and cataract (rubella triad). Other ocular features of rubella include diffuse pigmentary retinopathy, glaucoma, microphthalmos and corneal clouding. Dermatogenic Cataract Dermatogenic cataracts are bilateral and occur in young age. Atopic Dermatitis Atopic dermatitis is a chronic erythematous skin disorder associated with increased level of IgE. The opacities are anterior subcapsular involving the pupillary area and resemble a shield-like plaque that may gradually involve the entire lens. The disease is characterized by eruptive and exudative skin lesions beginning in the first year of life, bony defects, sparse hair growth, hypogonadism and bilateral zonular cataract. Drug Induced Cataract (Toxic Cataract) Long-term administration of corticosteroids, phenothiazine and miotics may induce lens changes. Corticosteroid Cataract Posterior subcapsular opacities may occur following topical, subconjunctival and systemic long-term use of corticosteroids.

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The sort of thin medicine hat weather discount cyclophosphamide 50 mg on line, ruthless exuberance that glowed in the boy screened an underlying stratum of personal insecurity probably common to all mankind and sometimes particularly disturbing at this age medicine you can overdose on purchase cyclophosphamide 50mg with mastercard. He did not try to account for the triumphant feeling or to ask if it sprang chiefly from ideas of debasing the female or, perhaps even more, from the scornfully superior position he thus attained in fantasy to the other male. By no means given to violence in action, this boy would not have inflicted physical injury on another. In imagination, as in the comic strips, all sorts of fatalities occur without anyone really getting hurt. Then they began to interchange a sort of chuckling that was half laughter and half teasing, designed to provoke curiosity in their companion. Each of the other boys gave a detailed account of his own experiences, including one success by Jack in the storage room at school. These experiences were quite recent and until now had not been widely discussed by either Butch or Jack. The untouchable priestess, once disclosed as an impostor, must be thoroughly defiled. Thus man sometimes seeks protection from confusion through which he himself risks the defilement of personally enshrining one who will make his virility (honor) the laughingstock of the group. All of the boys found a special pleasure in talking together about their achievements. Soon a friend of these three was told about their source of pleasure, then another friend, and still another. At first each boy had gone alone, but as time passed it became more practical for several to visit Anna together. Anna, under the pretext of taking a walk or going to visit a friend would, without detection, make her way to a building situated on the other side of the large garden behind her house. Now used as a storehouse and garage, the building was originally a stable, and its former hayloft afforded reasonable privacy. The boys, by coming from another street through a hedge back of the garage, could make their way unnoticed to the rendezvous. Safe opportunities, though fairly frequent, were limited because the chauffeur was sometimes in the garage. Of even more importance, perhaps, was a specific satisfaction found by some in entering upon the venture together. The closely shared experience seemed to enhance the pleasures of club conversation when they gathered later to talk over what happened. After chapel in the morning it was customary for the captain of the baseball team, the chairman of the debating club, and others interested in extracurricular activities occasionally to announce plans for meetings of their various groups. Among the older boys who had been attracted by Anna was one who had apparently turned to her in the utmost seriousness. All accessible information indicates that this boy fell in love with Anna not by a trivial attraction but with all the vividness and life shaking stir that the first complete and genuine experience of this sort can bring to an earnest young man almost ready for college. The younger girl, suddenly having become mature in body, loomed like something never seen before upon his awareness. There is reason to believe that he was determined to marry her and resolved to be scrupulously faithful through all the years he must wait for this. There is nothing to suggest he did not seek her with strongly passionate physical desire, but apparently his idealization of her and fear of arousing even further impulses, which it would have been for him a desecration to fulfill under these conditions, caused him to treat her, if not like an untouchable goddess, at least with extraordinary restraint. Anna, it seems, behaved in such a way that he was sure she reciprocated his feelings not only in kind but also in degree. Reports as to how he discovered the relations of Anna with the club are somewhat conflicting. It is almost impossible to believe that fortune was so unkind as to have him blunder upon an actual meeting of this group with the customary activities in progress. At any rate, he received enlightenment in such a convincing way that the impact was sudden and trenchant. In his immediately subsequent state, rumored to be a "nervous breakdown" at the time, his family physician, after considerable difficulty, seems to have obtained some idea of what he had experienced.