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Prevalence of serious eye disease and visual impairment in a north London population: population based discount kamagra polo generic impotence tumblr, cross sectional study order kamagra polo 100 mg visa erectile dysfunction treatment herbal remedy. The deficit in cataract surgery in England and Wales and the escalating problem of visual impairment: epidemiological modelling of the population dynamics of cataract buy kamagra polo with amex new erectile dysfunction drugs 2013. Genetic and environmental factors in age-related nuclear cataracts in monozygotic and dizygotic twins. The Cataract National Dataset electronic multi-centre audit of 55,567 operations: updating benchmark standards of care in the United Kingdom and internationally. Time trends and geographical variation in cataract surgery rates in England: study of surgical workload. Catquest questionnaire for use in cataract surgery care: description, validity, and reliability. The ultimate responsibility for diagnosis and management of the patient lies with the ophthalmologist in charge. The decision on whether to proceed to surgery should be made by the patient in discussion with an ophthalmologist. Cataract surgery should be performed by an ophthalmic surgeon although much of the process may be undertaken by the non-medical members of the team provided that they are properly trained and supervised. Action on Cataracts suggested direct optometrist referral according to locally agreed protocols and there are now many such projects with audited outcomes and high conversion rates from referral to surgery. The Department of Health in the National 2 Eye Care Plan proposes this as the preferred referral method. Whatever method of referral is used there are important underlying principles:  the patient should have sufficient cataract to account for the visual symptoms  the cataract should affect the patient’s lifestyle  the risks and benefits of surgery should be discussed with the patient and relevant written information supplied  the patient should wish to undergo cataract surgery  this information together with a report from a recent sight test should form the minimum data on the referral form. Patients with co-morbidity who might appreciate only slight benefit from surgery may wish to consult with an ophthalmologist to discuss their case. Patients with lifestyle impairment due to cataract who do not complain should, if necessary, be encouraged to consider cataract surgery, particularly those who live alone or act as carers. Other indications for cataract surgery include facilitating treatment and / or monitoring posterior segment disease e. Following referral the patient should be sent clear instructions on what they will be required to take to  their out-patient visit and what to expect at the visit. Additionally a comprehensive document outlining the pros and cons of cataract surgery and the complications that may result should be included to form the background to obtaining informed consent. If surgery is to take place on the same day this plan should be made very clear in the appointment letter. An experienced cataract surgeon should perform a one-eyed patient’s cataract operation. Second eye surgery confers significant additional gains in visual function in everyday activities and quality of life above 2 and beyond those achieved after surgery to the first eye. Functional improvement in visual symptoms after 3,4 second eye surgery has been demonstrated. These benefits of surgery are recognised clinically 2,3,4,6 and its value should not be overlooked in the management of cataract. The purpose of the out-patient appointment is to:  confirm the diagnosis of visually significant cataract  ensure the cataract is the cause of the visual symptoms  determine if there is co-existing ocular pathology  ensure the patient wishes to undergo surgery and understands the risks and benefits of surgery 9,10,11  formulate a surgical care plan including stratification of surgical risk  choose the type and power of the intraocular lens and discuss and plan any refractive surgical procedure that may be required, in some cases this may be part of the pre-operative assessment if held separately the aims of the pre-operative assessment are to:  ensure the patient is fit for surgery  put a care plan in place (this can be helped by the use of an integrated care pathway). B-scan ultrasonography will establish that the retina is attached and identify any intraocular masses. Electrodiagnostic tests may sometimes be useful in the assessment of retinal or visual pathway dysfunction. No special tests of visual function, other than visual acuity with best spectacle correction, are required prior to referral for cataract surgery. Following history taking and examination:  discussion should take place with the patient about  the risks and benefits of cataract surgery including any risks specific to them  preferred refractive aim and the need for refractive balance between the two eyes  the type of anaesthesia  if the patient wishes to proceed to surgery the patient should be given a date for surgery  Informed consent for the surgery should be obtained, unless this is routinely done a pre-op assessment visit. The patient should be provided with a written sheet detailing the reasons for, benefits of and possible complications of cataract surgery. These features will allow the risk of the operation to be determined and the level of surgical experience required. The vast majority of patients are suitable for day surgery under local anaesthesia and this is the accepted model of care. Patients having surgery to their only seeing eye may need an overnight stay if the local anaesthetic reduces their vision post-operatively, and they do not have a relative or carer to look after them. The patient should leave the combined out-patient appointment and pre-operative assessment with a good understanding of the procedure, a date for surgery and a contact number in case of need. The patient should be encouraged to contact the hospital in the week prior to surgery if there has been a change in the patient’s ocular or general health. The pre-operative checks (carried out as part of an integrated care pathway) should include identification of the patient and the eye for surgery together with external eye examination to ensure there is no ocular infection. Changes in general or ocular health since the patient was last examined must be noted and re- examination by an ophthalmologist should take place if indicated. Adequate pupillary dilatation is essential for cataract surgery and is usually achieved by short acting mydriatics (G. Phenylephrine 10% due to its systemic side effects but it is useful in dark eyed patients. Routine pre-operative antibiotics have not been shown to be effective but surgery should be delayed if there is concurrent infection. As yet the literature does not allow an exact regimen to be determined 17,18 however. If the surgeon carrying out the operation has not assessed the patient him or herself pre-operatively then they should ensure they are familiar with the patient and the nature of the cataract and any other co-morbidity before the start of the operation. Cataract surgery should include:  minimal trauma to ocular tissues  capsular fixation of the intraocular lens  watertight incision closure with reduction of astigmatism where appropriate. This will include the siting of the incision and consideration of limbal relaxing incisions if appropriate. The study was criticised on two counts, firstly that the endophthalmitis rate in the patients not receiving the intracameral antibiotic was higher than in previous reports, and secondly that it did not compare the intracameral route to the more conventional subconjunctival route of antibiotic administration in cataract surgery. A subsequent paper has shown superiority of intracameral cefuroxime over 21 subconjunctival administration. However, this latter paper was retrospective and may have had a 22 number of confounding factors affecting the results. An additional report found lower baseline rates of endophthalmitis without the use of intracameral cefuroxime. If the use of intracameral cefuroxime is considered there are potential problems that must be addressed: 24  the drug is heat labile, it cannot be heat sterilised and must be produced aseptically. Commercial preparations of the drug for intracameral use are available, and their use will prevent the possibly significant risks associated with the preparation of a suitable intracameral dose of the drug in the operating theatre. In summary, reaching a decision on whether or not to give the drug intra-camerally, may involve a comparison of the local rate of endophthalmitis with that in the studies mentioned. Additionally the exact dose and best antibiotic prophylaxis (for example the possible use of two different antibiotics) has not yet been determined. Following surgery and return to the day-care unit the patient should be discharged by an appropriately trained member of staff who ensures that:  the patient is comfortable and pain free  if not the eye is examined and if there are any problems e.

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Moreover generic 100mg kamagra polo otc erectile dysfunction natural supplements, it takes three and until the proliferative phase months for an aponeurosis to of healing begins buy cheap kamagra polo do herbal erectile dysfunction pills work, wound strength recover 70% of its strength and is low order 100mg kamagra polo with amex erectile dysfunction hotline. Macrophages peak at 24 it probably never regains its full hours and produce lactate. Postmenopausal length, direction and position of women having vaginal surgery the incision in such a way as to are therefore advised to use provide maximal exposure and pre-operative topical oestrogen. Maintenance of a sterile feld and With regard to infection, the aseptic technique. Laparoscopic or clean/contaminated when the surgery affords a favorable vagina is incised (2-5% rate of environment to prevent infection). Other surgical factors in contamination by extraneous infection include local trauma from debris and airborne infection. Avoid careless ripping of tissue planes and extensive cautery Foreign bodies burns. Atraumatic tissue handling Avoid strangulating tissue with is the hallmark of a good surgeon. These Pressure from retractors devitalizes represent a signifcant foreign structures, causes necrosis and body challenge and reduce tissue traumatizes tissue and this oxygen tension. Swabs are such as chromic gut, provoke more remarkably abrasive, and if used to infammatory reaction than others, pack off bowel, must be soaked in for example nylon. Haemostasis Wound closure Good haemostasis allows greater surgical accuracy of dissection, Choice of material prevents haematomas and the appropriate needle and suture promotes better healing. When combination allows atraumatic clamping, tying or cauterizing tension, free tissue approximation, vessels, prevent excessive tissue with minimal reaction, and damage. Avoid tissue dessication Elimination of dead space Long procedures may result in Separation of wound edges the tissue surface drying out, permits the collection of fuid with fbrinogen deposition and which promotes infection and ultimately adhesion formation. Stress on wounds Postoperative activity may Removal of surgical debris stress the wound during the Debride devitalised tissue, and healing phase. Coughing stresses remove blood clots, necrotic debris, abdominal fascia, and careful foreign material, and charred wound closure prevents disruption. The capillary the length of the suture for action of braided material promotes infec- wound closure should be six times tion, as opposed to non-braided sutures length of the incision to prevent Resistant to shrinkage and contraction excessive suture tension. Complete absorption after predictable interval Choice Of Suture Available in desired diameters and lenghth Many surgeons have a personal Available with desired needle sizes preference for sutures both as a result of profciency in a particular technique and the suitable In general terms, the thinnest handling characteristics of a suture to support the healing suture and needle. This limits trauma of the physical characteristics of and, as a minimum of foreign suture material, the requirements material is used, reduces local of wound support, and the type tissue reaction and speeds re- of tissue involved, is important absorption. The tensile strength of to ensure a suture used which the material need not exceed that will retain its strength until of the tissue. The properties and characteristics of the “ideal” suture are listed in Because of its composition Table I monoflament material may have a “memory” and care should be Table I: the Ideal Suture taken when handling and tying monoflament sutures – perhaps Good handling and knotting characteristics a few extra throws on a proper High tensile strength surgical knot would prevent unravelling. Nylon sutures Multiflament sutures consist of have high tensile strength and very several flaments braided together, low tissue reactivity and degrade in affording greater tensile strength, vivo at 15% per year by hydrolysis. They 205 must be coated to reduce tissue Specifc Sutures And resistance and improve handling Applications characteristics. Because of their inherent capillarity they are Surgical gut more susceptible to harbouring Absorbable surgical gut may be organisms than monoflament plain or chromic, and spun from sutures. Ribbons of collagen are Absorbable sutures are prepared spun into polished strands, but from the collagen of animals or most protein-based absorbable from synthetic polymers. Surgical gut may be submucosa or bovine serosa and used in the presence of infection, may be treated with chromium but will then be more rapidly salts to prolong absorption time. Surfaces may be Enzymes degrade the suture, with irregular and so traumatise tissue an infammatory response. The loss of tensile strength and the rate of absorption are separate Plain surgical gut is absorbed phenomena. A suture can lose within 70 days, but tensile strength tensile strength rapidly and yet is maintained for only 7-10 days be absorbed slowly. Chromic gut is febrile or has a protein defciency, collagen fber tanned with chrome the suture absorption process may tanning solution before being accelerate, with a rapid loss of spun into strands. Chromic sutures produce processed from single or multiple less tissue reaction than plain gut flaments of synthetic or organic during the early stages of wound fbers rendered into a strand by healing, but are unsuitable for spinning, twisting or braiding. Recently, the use of sutures of 206 animal origin has been abandoned approximation where short-term in many countries because of the support is desired, for example for theoretical possibility of prion episiotomy repair. It has developed to counter the suture high tensile strength initially, antigenicity of surgical gut, with but all strength is lost after one its excess tissue reaction and month. Synthetic a lubricant to facilitate better absorbable monoflament sutures handling properties of the are useful for subcutaneous skin material. Absorption is minimal closure since they do not require until day 40, completed about 2 removal. This suture is suitable for months after suture placement, sheath closure at laparotomy. Non absorbable sutures Occasionally it is desirable to have Surgical silk consists of flaments a rapid-absorbing synthetic suture, spun by silkworms, braided into a such as Vicryl Rapide™. The suture suture which is dyed then coated retains 50% of tensile strength with wax or silicone. It loses most at 5 days, and since the knot its strength after a year, and “falls off” in 7 to 10 days, suture disappears after about 2 years. It is only Although it has superior handling suitable for superfcial soft tissue qualities, it elicits considerable 207 tissue reaction, so is seldom used in minimal tissue reactivity, and gynaecology nowadays. Prolene*, for example, has better Synthetic non absorbable suture handling properties sutures than nylon, and may be used in Nylon sutures consist of a contaminated or infected wounds polyamide monoflament with very to minimize sinus formation and low tissue reactivity. They do not degrades at 20% per year, and the adhere to tissue and are easily sutures are absorbed after several removed. Because of the «memory» of nylon, more throws of the knot are Topical skin adhesions required to secure a monoflament Where skin edges appose under suture than braided sutures. Nylon low tension, it is possible to glue sutures in fne gauges are suitable edges together with glue, such for micro-surgery because of the as Dermabond™. It is a sterile properties of high tensile strength liquid, and when applied onto and low tissue reactivity. It protects Polyester sutures are composed of and seals out common bacteria, braided fbers in a multiflament commonly associated with wound strand. They are stronger than infections, and promotes a natural fbres and exhibit less favourable, moist, wound healing tissue reaction. Mersilene* environment, speeding the rate synthetic braided sutures last of epithelialisation. The adhesive indefnitely, and Ethibond* is gradually peels off after 5 – 10 coated with an inert covering days with a good cosmetic result. They if topical skin adhesions are to are unsuitable for suturing vaginal be used. It may especially be epithelium, as they are non- used in cases of Laparoscopy to absorbable. Skin adhesive use are not degraded or weakened eliminates the pain occasionally by tissue enzymes.

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