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STRABISMUS

Strabismus, also known as “crossed eyes” or “squint,” is a condition characterized by an eye misalignment.

In individuals with strabismus, the eyes do not properly align with each other, meaning they point in different directions. One eye may look straight ahead, while the other eye may turn inward, outward, upward, or downward. This misalignment can be constant or intermittent. often referred to as: cross-eyed, crossed eyes, cockeye, weak eye, wall-eyed, wandering eyes, and/or eye turn.

Strabismus can affect people of all ages, but it commonly develops in early childhood. It is estimated to affect approximately 4% of children. If left untreated, strabismus can cause several issues, including decreased depth perception, double vision (diplopia), and amblyopia (lazy eye), where the brain favors one eye over the other.

Causes of Strabismus

Childhood strabismus often has no known cause, but it tends to run in families.

A. Muscular Factors:

Imbalance in the extraocular muscles: Strabismus can occur due to a weakness or imbalance in the muscles responsible for eye movement, leading to misalignment.
Restrictive eye muscle disorders: Certain conditions, such as thyroid eye disease or orbital fractures, can restrict the movement of the eye muscles and cause strabismus.

B. Nervous System Factors:

Nerve dysfunction: Strabismus may result from abnormalities in the nerves that control eye movements, disrupting the coordination between the eyes.
Neurological disorders: Some neurological conditions, including cerebral palsy, stroke, or brain tumors, can affect the control of eye movements and lead to strabismus.
Stroke: Stroke is a leading cause of strabismus in adults

C. Refractive Errors:

Nearsightedness (myopia): Severe nearsightedness can contribute to the development of strabismus.
Farsightedness (hyperopia): Strabismus may occur in individuals with uncorrected or significantly imbalanced farsightedness.

D. Other Factors:

Congenital factors: Some individuals are born with strabismus, which may be related to genetic or developmental factors.
Eye injuries or trauma: Trauma to the eye or eye muscles can lead to strabismus.
Graves’ disease: Overproduction of thyroid hormone in Graves’ disease can cause strabismus.

Risk/Predisposing Factors for Strabismus:

Family History:

Genetic predisposition: Strabismus can run in families, suggesting a genetic component to the condition.

Age and Development:

Early childhood: Strabismus often develops during infancy or early childhood when the visual system is still developing.

Medical Conditions:

Neurological disorders: Conditions such as cerebral palsy, Down syndrome, or hydrocephalus increase the risk of strabismus.
Premature birth: Premature infants are at a higher risk of developing strabismus compared to full-term infants.

Refractive Errors:

Nearsightedness or farsightedness: Significant refractive errors can contribute to the development of strabismus.

Other Factors:

Eye muscle imbalance: An imbalance in the strength or coordination of the eye muscles can increase the likelihood of strabismus.
Visual stress: Prolonged or intense visual activities, such as excessive screen time or reading, may contribute to strabismus development in susceptible individuals.

Pathophysiology of Strabismus

The pathophysiology of strabismus involves the extraocular muscles, cranial nerves, and the visual cortex.

Extraocular Muscles: The extraocular muscles control the movement and position of the eyes. Any problem with these muscles or the nerves that control them can lead to strabismus.
Cranial Nerves: The extraocular muscles are controlled by cranial nerves III, IV, and VI. If there is an impairment of cranial nerve III, it can cause the associated eye to deviate down and out. Impairment of cranial nerve IV can cause the eye to drift up and slightly inward. Sixth nerve palsy, which affects cranial nerve VI, causes the eyes to deviate inward.
Causes of Nerve Impairment: There can be various causes of nerve impairment leading to strabismus. Increased cranial pressure can compress the nerve as it runs between the clivus and brain stem. In some cases, twisting of the baby’s neck during forceps delivery can damage cranial nerve VI.
Visual Cortex: Evidence suggests that the input provided to the visual cortex may play a role in the development of strabismus. This means that strabismus can occur without direct impairment of cranial nerves or extraocular muscles.
Amblyopia: Strabismus can cause amblyopia, also known as lazy eye. Amblyopia occurs when the brain ignores the signals from one eye, leading to reduced visual acuity. During the early years of life, the brain learns how to interpret the signals from both eyes, and this process, called visual development, can be impaired in strabismus.

Types of Strabismus

Esotropia:

Esotropia is a type of strabismus characterized by the inward turn of one or both eyes.
It can be classified into different subtypes based on the age of onset and underlying causes.
Infantile esotropia: This type of esotropia appears within the first six months of life and is often constant.
Accommodative esotropia: It occurs due to farsightedness (hyperopia) and can be corrected with glasses.
Sixth nerve palsy: Damage to the sixth cranial nerve can cause one eye to turn inward.

Exotropia:

Exotropia is a type of strabismus characterized by the outward deviation of one or both eyes.
It can be intermittent or constant and may be more noticeable when the person is tired or daydreaming.
Exotropia can be classified into different subtypes, including intermittent exotropia, sensory exotropia, and divergence excess exotropia.

Hypertropia:

Hypertropia is a type of strabismus characterized by one eye deviating upward while the other eye maintains a straight position.
It can be classified as unilateral (affecting one eye) or bilateral (affecting both eyes).
Hypertropia can be caused by various factors, including muscle imbalance, thyroid eye disease,trochlear nerve palsy, nerve palsy, or mechanical restrictions.

Hypotropia:

Hypotropia is a type of strabismus characterized by one eye deviating downward while the other eye maintains a straight position.
It can be classified as unilateral or bilateral, similar to hypertropia.
Hypotropia can be caused by muscle imbalance, nerve palsy, or mechanical restrictions.

Note; They can also be classified by whether the problem is present in all directions a person looks (comitant) or varies by direction (incomitant).

Clinical Features of Strabismus:

Misalignment of the Eyes:

The primary clinical feature of strabismus is the misalignment of the eyes, where one eye deviates from its normal position.
The misalignment can be inward (esotropia), outward (exotropia), upward (hypertropia), or downward (hypotropia).

Double Vision:

Strabismus can cause double vision, also known as diplopia.
Double vision occurs when the brain receives conflicting visual information from the misaligned eyes.

Head Tilting or Turning:

Individuals with strabismus may tilt or turn their head to compensate for the misalignment of their eyes.
This head posture helps to align the eyes and reduce the diplopia.

Eye Fatigue and Strain:

Strabismus can lead to eye fatigue and strain due to the constant effort required to align the eyes.
The misalignment can cause the eye muscles to work harder, leading to discomfort and fatigue.

Reduced Depth Perception:

Strabismus can affect depth perception, making it difficult to accurately judge distances.
The misalignment of the eyes can disrupt binocular vision, which is essential for depth perception.

Amblyopia (Lazy Eye):

Strabismus can result in amblyopia, also known as a lazy eye.
Amblyopia occurs when the brain suppresses the visual input from the misaligned eye to avoid double vision.
This can lead to reduced visual acuity and poor development of the affected eye.

Eye Fatigue and Strain:

Strabismus can lead to eye fatigue and strain due to the constant effort required to align the eyes.
The misalignment can cause the eye muscles to work harder, leading to discomfort and fatigue.

Headaches:

Some individuals with strabismus may experience headaches, particularly after prolonged visual tasks.
The strain on the eye muscles and the disruption of binocular vision can contribute to headaches.

Difficulty Reading:

Strabismus can affect reading ability, as the misalignment of the eyes can make it challenging to track lines of text smoothly.
This can result in skipping lines, losing place, or experiencing visual disturbances while reading.

Self-esteem Issues:

Strabismus can have a psychological impact, leading to self-esteem issues and social difficulties.
The visible misalignment of the eyes may cause embarrassment or self-consciousness, particularly in children.

Challenges faced by people with strabismus.

Emotional Distress: Strabismic children commonly exhibit behaviors marked by higher degrees of inhibition, anxiety, and emotional distress. The negative perception of the child by peers can lead to feelings of embarrassment, anger, and a sense of awkwardness, thereby affecting social communication in a fundamental way.
Negative Effect on Self-esteem: Strabismus can have a negative impact on self-esteem, as individuals may feel self-conscious about their appearance and worry about how others perceive them.
Limited Opportunities: Strabismus can affect employment opportunities, as individuals may face misconceptions about their ability to work hard. This can lead to career difficulties and limitations in professional growth.
Social Stigma: The cosmetic aspect of strabismus can result in social stigma, with individuals facing negative attitudes and misconceptions about their intelligence, trustworthiness, and attractiveness. This can lead to feelings of isolation and discrimination.
Vision Difficulties: Strabismus can cause vision problems such as double vision, difficulty reading, eye strain, and headaches. The misalignment of the eyes can affect depth perception and visual coordination, making it challenging to focus on objects.

COPING MECHANISM TO STRESS FROM HAVING STRABISMUS.

One study categorized coping methods into three subcategories:

Avoidance: Some individuals may cope with the stress of having strabismus by refraining from participating in activities that they feel may draw attention to their condition.
Distraction: Deflecting attention from the condition can be a coping mechanism for individuals with strabismus. This may involve focusing on other aspects of their life or engaging in activities that help take their mind off their condition.
Adjustment: Approaching activities differently can be a coping mechanism for individuals with strabismus. This may involve finding alternative ways to accomplish tasks or adapting to situations to minimize the impact of their condition.

Diagnosis of Strabismus

Diagnosing strabismus involves a combination of medical history, symptom evaluation, and specific eye examinations.

Medical History: Gather information about the patient’s medical history, including any symptoms related to strabismus, family history of eye conditions, and any underlying health conditions that may be associated with strabismus.
Symptom Evaluation: Assess the patient’s symptoms, which may include crossed eyes, double vision, decreased depth perception, and misaligned eyes with uncoordinated movements.
Visual Acuity Test: This test measures the clarity of vision at different distances using an eye chart. It helps determine any changes in vision caused by strabismus.
Cover-Uncover Test: This test involves covering one eye at a time to observe the movement and alignment of the eyes when the cover is removed. It helps detect any deviation or misalignment of the eyes.
Ocular Alignment and Focus Test: This test evaluates the movement, focus, and coordination of the eyes. It may involve using a synoptophore, a specialized device that assesses binocular vision and eye alignment.
Refraction Test: This test measures the refractive error of the eyes using a phoropter and retinoscope. It helps determine if any corrective lenses are needed to compensate for vision changes associated with strabismus.
Retinal Examination: This examination involves observing the physical structure of the eye, including the retina, to check for any other eye diseases or conditions that may be causing the strabismus symptoms.
Additional Testing: In some cases, additional tests may be required to evaluate the involvement of other related health conditions. For example, a neurological exam may be conducted to check for conditions such as cerebral palsy or Guillain-Barre syndrome.

Management of strabismus

Management of strabismus involves various treatment options depending on the severity and underlying cause of the condition.

Aims of Management.

To improve eye alignment and coordination.
To prevent complications.
To optimize visual development.

Eyeglasses: In some cases, strabismus can be corrected or improved with the use of eyeglasses. If a child has blurry vision due to nearsightedness or farsightedness, wearing glasses can help reduce the strain on the eyes and improve alignment.
Patching or eye drops: Patching or using eye drops may be recommended by an ophthalmologist to strengthen the weaker eye. This technique, known as occlusion therapy, helps to encourage the use of the weaker eye and improve its visual development.
Vision therapy: Vision therapy involves a series of exercises and activities designed to improve eye coordination and strengthen the eye muscles. It is often used in conjunction with other treatments and can be particularly beneficial for individuals with certain types of strabismus.
Prisms: Prisms are special lenses that can be prescribed to help align the eyes and reduce double vision. They work by bending light and redirecting it to the correct position on the retina, improving visual alignment.
Botulinum toxin injections: In some cases, botulinum toxin injections may be used to temporarily weaken specific eye muscles, allowing for better alignment of the eyes. The toxin is injected in the stronger muscle, causing temporary and partial paralysis. The treatment may need to be repeated three to four months later once the paralysis wears off. This treatment is reserved for certain types of strabismus or as a temporary measure before considering surgery.
Eye muscle surgery: Eye muscle surgery is often recommended for individuals with persistent or severe strabismus. During the surgery, the ophthalmologist adjusts the tension or position of the eye muscles to improve eye alignment. This procedure is usually performed under general anesthesia and may require multiple surgeries depending on the individual case.

Nursing Diagnosis.

Risk for Injury related to impaired sensory function.

The lack of coordination between the muscles around the eyes in strabismus can result in double vision, blurry vision, and poor depth perception, increasing the risk of injury.

Disturbed Sensory Perception related to structural damage.

Evidence: Strabismus causes a lack of coordination between the muscles around the eyes, leading to double vision, blurry vision, and poor depth perception, which can result in a disturbed sensory perception.

Knowledge Deficit related to impaired vision.

Evidence: Children with strabismus may have limited understanding of their condition, treatment options, and the need for early intervention. This lack of knowledge can contribute to a knowledge deficit.

Social Isolation related to limited ability to participate in activities and impaired vision

Evidence: Strabismus can affect a child’s ability to interact socially due to the limited ability to participate in activities and impaired vision, which may lead to social isolation.

Impaired Parent-Child Interaction related to the child’s visual impairment

Evidence: Strabismus can affect the parent-child interaction due to the child’s visual impairment, which may require additional support and education for parents to effectively communicate and engage with their child.

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CONGENITAL CATARACTS

Congenital cataracts are a type of cataract that occurs at birth or during a baby’s first year of life, characterized by clouding or opacity of the lens of the eye.

A lens of the eye is the transparent tissue that helps focus light onto the retina.

Congenital cataracts cover a broad spectrum of severity: whereas some lens opacities do not progress and are visually insignificant, others can produce profound visual impairment. Therefore, Congenital cataracts can be Visually significant or not, Stable or Progressive, Congenital or Acquire, Unilateral or Bilateral or else, Partial or Complete.

Classifications of Congenital Cataracts.

Congenital cataracts can be classified based on various factors such as morphology, age of onset, and etiology.

Morphology: Based on their physical appearance.

Polar Cataract: Lens opacities that involve the subcapsular cortex and lens capsule of the anterior or posterior pole of the lens. Anterior polar cataracts present as Small, bilateral, symmetric, non progressive opacities that do not impair vision. Posterior polar cataracts produce more visual impairment than anterior polar cataracts because they tend to be larger and are positioned closer to the nodal point of the eye.

Lamellar Cataract/Zonular Cataract: Lamellar cataracts are the most common type of congenital cataracts. The cataract is visible as an horseshoe- shaped opacity that surrounds a clearer center and is itself surrounded by a layer of clear cortex. Lamellar cataracts may be inherited or result from a transient toxic influence during embryonic lens development.

Sutural Cataract: Opacification of the Y-sutures of the fetal nucleus that commonly do not impair vision. They are usually bilateral, symmetric, and frequently inherited in an autosomal dominant pattern. These opacities often have branches or knobs projecting from them.

Coronary Cataract: Coronary cataracts consist of club-shaped cortical opacities arranged around the equator of the lens like a crown or corona. They cannot be seen unless the pupil is dilated, and they usually do not affect visual acuity. They are often inherited in an autosomal dominant pattern.

Cerulean Cataract/Blue-dot Cataract: Cerulean cataracts are small bluish opacities located in the lens cortex. They are nonprogressive and usually do not cause visual symptoms.

Nuclear Cataract: Opacities of either the embryonic nucleus alone or both the embryonic and fetal nuclei. They are usually bilateral, with a wide spectrum of severity. Eyes with congenital nuclear cataracts tend to be microphthalmic and have an increased risk of developing aphakic glaucoma.

Capsular Cataract: Small opacifications of the lens epithelium and anterior lens capsule that spare the cortex. They are differentiated from anterior polar cataracts by their protrusion into the anterior chamber, but generally do not affect vision.

Membranous Cataract: Membranous cataracts occur when lens proteins are resorbed, allowing the anterior and posterior lens capsules to fuse into a dense white membrane. They cause significant visual disability due to the resulting opacity and lens distortion.

Age of Onset:

Congenital/Infantile cataract: Lens opacities present at birth.
Acquired/Juvenile cataract: Onset after infancy, in childhood.

Etiology:

Genetic cataract/Hereditary: Caused by mutations in genes involved in lens structure or clarity. The affected individuals are usually perfectly well, and have no associated systemic illness. Associated with microphthalmos.
Metabolic cataract: Caused by metabolic disorders such as galactosemia, hypoglycemia, hypocalcemia. Galactosemia is a metabolic disorder in which the child’s body cannot metabolize galactose, a major component of milk and milk products. The baby develops typical ‘oil droplet’ cataracts which are easily seen by examining the red reflex. These are reversible, and the lens returns to normal on removing dairy products from the diet.
Traumatic cataract: Caused by external injuries to the eye. Trauma is the most common cause of unilateral cataract in children. Traumatic cataract is usually the result of a penetrating injury, though blunt trauma can also lead to cataract formation.
Secondary cataracts: Such as those secondary to marternal infection during pregnancy. TORCH syndrome: Toxoplasmosis, Others(Syphilis, Hepatitis B), Rubella, Cytomegalovirus (CMV), Herpes infection.. Usually bilateral, dense, and central. The most common maternal infection to cause congenital cataract in the child is Rubella. The cataracts caused by Rubella may be present at birth, or develop several months later.
Iatrogenic cataract: Caused by well-intentioned medical treatment, Such as Radiation, Drugs, Surgeries, e.t.c. latrogenic cataract is most commonly seen in children who have had Total body irradiation for leukemia, Organ transplants, On long-term systemic steroid therapy. These children are usually older children and do very well after cataract surgery.

Causes of Congenital Cataracts

The causes of congenital cataracts can vary and may include genetic factors, infections, physical trauma during pregnancy, hypoglycemia, and premature birth, It’s important to note that in many cases, the exact cause of congenital cataracts is not known.

Genetic Factors: In some cases, congenital cataracts are caused by a faulty gene that is passed from parents to their child. It is estimated that around 1 in every 5 cases of congenital cataracts have a family history of the condition.

Infections: Certain infections during pregnancy can increase the risk of congenital cataracts in babies. These infections include:

Infections during pregnancy, such as those caused by STORCH (Syphilis, Toxoplasmosis, Rubella, Cytomegalovirus, and Herpes simplex), can lead to congenital cataracts.

Other infections like influenza, measles, polio, and rubella.
Other conditions: Certain conditions like hypoparathyroidism, Conradi syndrome, aniridia, anterior segment dysgenesis, persistent fetal vasculature (PFV), posterior lenticonus, and corticosteroid use can also contribute to the development of congenital cataracts.

Physical Trauma during Pregnancy: Physical trauma to the mother’s abdomen during pregnancy, such as from a car accident, a fall, or intimate partner violence, can cause injury to the baby’s eyes in the womb and lead to congenital cataracts.

Hypoglycemia during Pregnancy: Hypoglycemia, which is low blood sugar levels, can occur in pregnant women with uncontrolled diabetes. This condition may increase the risk of congenital cataracts in the baby.

Premature Birth: Babies born prematurely, before 37 weeks of pregnancy, have a higher risk of developing congenital cataracts.

Metabolic disorders: Certain metabolic disorders, such as galactosemia and hypoglycemia, can increase the risk of developing congenital cataracts.

Syndromes: Several syndromes have been associated with congenital cataracts, including Down syndrome, Lowe syndrome, Cockayne syndrome, Marfan syndrome, Trisomy 13-15, Alport syndrome, Myotonic dystrophy, Fabry disease, and Incontinentia pigmenti.

Diagnosis and Investigations for Congenital Cataracts:

Diagnosing congenital cataracts involves a comprehensive eye examination by an ophthalmologist, who specializes in eye disorders.

There is no benefit in doing a large number of tests and investigations on all children with cataract. It is better to take a careful history.

Family History and Genetic Testing: A detailed family history is important, as congenital cataracts can have a genetic component. Genetic testing may be recommended to identify specific gene mutations associated with cataract formation.
Complete Eye Examination: This includes a thorough evaluation of the infant’s eyes, including visual acuity assessment, examination of the lens, and assessment of the red reflex. The red reflex is particularly useful in estimating the size and location of the cataract within the visual axis. The red reflex test is best performed in a darkened room and involves shining a bright direct ophthalmoscope into both eyes simultaneously from a distance of 1– 2 ft.
Slit Lamp Examination: A slit lamp is a specialized microscope that allows the ophthalmologist to examine the structures of the eye in detail. It helps in visualizing the cataract and determining its characteristics, such as size, location, and morphology.
Intraocular Pressure Measurement: This test measures the pressure inside the eye and helps in assessing or ruling out other conditions.
Ultrasound of the Posterior Pole: In cases where the cataract is not clearly visible, an ultrasound may be performed to visualize the posterior pole of the eye and assess the presence of any abnormalities.
Laboratory Tests: Depending on the clinical presentation and suspected underlying cause, various laboratory tests may be performed. These may include TORCH (toxoplasmosis, rubella, cytomegalovirus, varicella) screening, Venereal Disease Research Laboratory (VDRL) test for syphilis, blood tests for calcium, phosphorus, glucose, and galactokinase levels, and urine tests for reducing sugars.

Management of Congenital Cataracts

Management and treatment of congenital cataracts involve a multidisciplinary approach and may vary depending on the specific case and underlying cause.

Aims of Management

To remove the cloudy lens and restore clear vision in the affected eye(s).
Regaining the usual level of cognition.
Recognizing awareness of sensory needs.
Preventing injury.
Identifying potential risk factors in the environment.
Reducing anxiety to a manageable level.
Providing education on coping with altered abilities

In general, the younger the child, the greater the urgency in removing the cataract, because of the risk of amblyopia.

For optimal visual development in newborns and young infants, a visually significant unilateral congenital cataract should be detected and removed before age 6 weeks, and visually significant bilateral congenital cataracts should be removed before age 10 weeks.
Some congenital cataracts are too small to affect vision, therefore no surgery or treatment will be done. If they are superficial and small, an ophthalmologist will continue to monitor them throughout a patient’s life.
Commonly, a patient with small congenital cataracts that do not affect vision will eventually be affected later in life; generally this will take decades to occur .
Congenital cataracts are one of the most common treatable causes of visual impairment and blindness during infancy, with an estimated prevalence of 1 to 6 cases per 10,000 live births.

Nursing Assessment:

Recent medication intake: Anticoagulant therapy may be withheld to reduce the risk of retrobulbar hemorrhage.
Preoperative tests: Standard preoperative tests such as complete blood count, electrocardiogram, and urinalysis may be prescribed based on the patient’s medical history.
Vital signs: Stable vital signs are necessary before surgery. These include TPR/Bp.
Visual acuity test results: Assessment of visual acuity using tests like Snellen’s chart is important.
Patient’s medical history: Assessing the patient’s medical history helps determine the required preoperative tests.

Nursing Diagnosis:

Disturbed visual sensory perception related to altered sensory reception or status of sense organs as evidenced by the patient using hand to locate environment.
Risk for trauma related to poor vision and reduced hand-eye coordination.
Anxiety related to the threat of permanent loss of vision/independence as evidenced by the patients restlessness.

Medical Management: Pharmacologic Therapy:

Dilating drops: These are administered pre and postoperatively to dilate the pupil and facilitate surgery.
Antibiotic drugs: Prophylactic administration of antibiotics helps prevent postoperative infection and inflammation.
Intravenous sedation: Sedation may be used to minimize anxiety and discomfort before surgery.

Surgical Intervention:

Surgery is the mainstay of treatment for congenital cataracts.
Pediatric ophthalmologists who specialize in congenital cataract surgery perform the procedure.
During surgery, a small incision is made in the eye, and the cloudy lens is removed.
In some cases, additional surgical procedures may be required, such as intraocular lens implantation or capsulotomy.

Lens Replacement:

Phacoemulsification: This procedure involves removing a portion of the anterior capsule, extracting the lens nucleus and cortex, and leaving the posterior capsule and zonular support intact. Different lens replacement options include aphakic glasses, contact lenses, and intraocular lens (IOL) implants.
Extracapsular cataract extraction (ECCE): This procedure removes the anterior lens and cortex, leaving the posterior capsule intact.
Intracapsular cataract extraction: This procedure removes the entire lens within the intact capsule.

Timing of Surgery:

The timing of surgery depends on various factors, including the age of the child, the severity of the cataract, and the presence of any associated eye conditions.
Early surgery is generally recommended to prevent visual deprivation and promote normal visual development.
In some cases, surgery may be delayed if there are other medical conditions that need to be addressed first.

Correction of Refractive Errors:

After cataract surgery, children may develop refractive errors, such as nearsightedness or farsightedness.
Corrective measures, such as glasses or contact lenses, may be prescribed to optimize visual acuity.

Amblyopia Management:

Amblyopia, also known as lazy eye, is a common complication of congenital cataracts.
Amblyopia occurs when the brain favors one eye over the other due to visual deprivation.
Treatment may involve patching or blurring the stronger eye to encourage the use and development of the weaker eye.

Regular Follow-up and Monitoring:

Children with congenital cataracts require long-term follow-up and monitoring by a pediatric ophthalmologist.
Regular eye examinations are essential to assess visual acuity, monitor for any complications, and adjust treatment as needed.

Complications of congenital cataracts

Cloudy Vision: After cataract surgery, a condition called posterior capsule opacification (PCO) can occur. This is when part of the lens capsule thickens and causes cloudy vision. PCO is not the cataract returning, but rather the growth of cells over the artificial lens. It usually develops within 4 to 12 months after surgery and may require another operation to correct it.
Lazy Eye: Lazy eye, also known as amblyopia, can occur if there is weaker vision in one eye. The brain may ignore the visual signals from the weaker eye, leading to improper development of vision. Treatment for lazy eye usually involves wearing a patch over the stronger eye.
Glaucoma: Increased pressure inside the eye, known as glaucoma, can affect vision. Children who have had cataract surgery are at a lifelong risk of developing glaucoma and will need regular eye pressure measurements by an optician.
Squint: A squint, also called strabismus, is a condition where the eyes look in different directions. It can occur as a complication after cataract surgery.
Pupil Abnormalities: Pupil abnormalities, such as the pupil becoming a more oval shape, can occur but usually do not affect vision significantly.
Retinal Detachment: Retinal detachment is a condition where the retina becomes separated from the inner wall of the eye, leading to vision impairment. It can be a complication after cataract surgery.
Cystoid Macular Edema: Cystoid macular edema is the buildup of fluid between layers of the retina, which can affect vision.
Infection: In rare cases, an infection called endophthalmitis can occur after cataract surgery. It may require medication or further surgery for treatment

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VISUAL IMPAIRMENT

Visual impairment also known as vision impairment or vision loss , is a decreased ability to see to a degree that causes problems not fixable by usual means, such as glasses.

Visual impairment refers to any kind of vision loss, ranging from partial vision loss to complete blindness.

Visual impairment is often defined as a best corrected visual acuity of worse than either 20/40 or 20/60.

To understand Visual Acuity numbers,

Visual acuity numbers are used to measure the clarity or sharpness of a person’s vision. They are expressed as a fraction, such as 20/20 or 20/40. The interpretation of these numbers is as follows:

The Top Number: The top number in the visual acuity measurement represents the distance at which the person is standing from the eye chart during the test. For example, if the top number is 20, it means the person is standing 20 feet away from the chart.
The Bottom Number: The bottom number indicates the distance at which a person with normal vision can read the same line on the chart that the individual being tested can read. For instance, if the bottom number is 20, it means a person with normal vision can read that line from a distance of 20 feet.

Causes of Visual Impairement

The most common causes of visual impairment globally are uncorrected refractive errors (43%), cataracts (33%), and glaucoma (2%). Visual impairment can be caused by various factors, including genetic conditions, eye injuries, infections, and age-related diseases.

Genetic Conditions:

Retinitis pigmentosa: A genetic disorder that causes the breakdown and loss of cells in the retina, leading to progressive vision loss.
Congenital cataracts: Clouding of the lens present at birth, which can cause visual impairment if not treated.
Glaucoma: A group of eye conditions that damage the optic nerve, often caused by genetic factors.

Eye Injuries:

Trauma: Injuries to the eye, such as from accidents, sports-related incidents, or workplace hazards, can result in vision loss or impairment.
Corneal injuries: Damage to the cornea, the clear front part of the eye, can lead to vision problems.
Corneal Opacification: Corneal opacification, which refers to the clouding or scarring of the cornea, corneal abrasion can be a cause of corneal opacity. In some cases, eye swelling can also cause damage to the cornea that results in opacity.

Infections:

Ocular infections: Infections of the eye, such as conjunctivitis, uveitis, or keratitis, can cause visual impairment if left untreated.
Infections during pregnancy: Certain infections, like German measles (rubella), can be transmitted from the mother to the fetus and result in visual impairment in the baby.
Trachoma: Trachoma is a disease of the eye caused by infection with the bacterium Chlamydia trachomatis. It is a public health problem in 42 countries, and is responsible for the blindness or visual impairment of about 1.9 million people.

Age-Related Diseases:

Cataracts: Clouding of the lens in the eye, commonly associated with aging, can cause blurry vision and visual impairment.
Age-related macular degeneration (AMD): A progressive condition that affects the macula, the central part of the retina, leading to loss of central vision.
Glaucoma: Increased pressure within the eye can damage the optic nerve and result in vision loss.
Childhood Blindness: Various conditions, including genetic disorders, infections, and developmental abnormalities, can cause visual impairment in children

Other Causes:

Diabetic retinopathy: Damage to the blood vessels in the retina due to diabetes, which can lead to vision impairment or blindness.
Amblyopia (lazy eye): Reduced vision in one eye due to abnormal visual development during childhood.
Medications: Certain medications, such as those used in chemotherapy or for treating autoimmune diseases, can have side effects that affect vision.
Undercorrected refractive error: Refractive errors, such as nearsightedness, farsightedness, and astigmatism, can cause visual impairment if not corrected with glasses or contact lenses.
Undetermined: A significant percentage of visual impairment cases were categorized as undetermined, indicating that the cause could not be identified

Signs and Symptoms of Visual Impairment

Blurred Vision: Objects may appear fuzzy or out of focus.
Double Vision: Seeing two images instead of one.
Floaters: Seeing spots, specks, or cobweb-like shapes drifting across your field of vision.
Flashes of Light: Seeing sudden flashes of light, especially in peripheral vision.
Halos: Seeing circles of light around objects, particularly when looking at bright lights.
Changes in Iris Color: Noticing a change in the color of the iris, such as a darkening or lightening.
Eye Pain: Experiencing sudden or recurrent pain in or around the eye.
Sensitivity to Light: Feeling discomfort or pain when exposed to bright lights.
Difficulty Seeing at Night: Struggling to see clearly in low-light conditions.
Loss of Peripheral Vision: Having a reduced ability to see objects or movement in the outer edges of your visual field.
Inability to see shapes: An inability to see shapes refers to the difficulty in perceiving and recognizing the outlines and forms of objects.
Cloud vision: Cloudy vision refers to a hazy or blurred visual perception, which can make it difficult to see objects clearly.
Seeing only shadows: Seeing only shadows means that a person can perceive the presence of light and darkness but cannot distinguish detailed visual information.
Tunnel vision: Tunnel vision is a condition where a person’s peripheral vision is significantly reduced, resulting in a narrowed field of view.

Visual impairments can also impact daily activities which include:

Reading: Holding reading material closer to the face, difficulty reading in low light, or experiencing a decrease in reading speed.
Mobility: Bumping into objects, having trouble navigating stairs or uneven surfaces, or experiencing a loss of depth perception.
Recognizing Faces and Objects: Difficulty identifying faces or objects, especially from a distance.
Color Perception: Trouble distinguishing between colors or selecting clothing with appropriate color combinations.
Eye Strain: Experiencing eye fatigue, headaches, or discomfort after prolonged visual tasks.

Diagnosis, Tests, and Investigations for Ruling Out Visual Impairment

These assessments help in evaluating the visual functions and identifying any abnormalities or impairments.

History and External Examination:

A complete history, including family history of visual impairment, is taken.
External examination of the eye is conducted, which includes assessing the lids, conjunctiva, cornea, iris, lens, etc..

Visual Acuity Test:

The Snellen test, also known as the visual acuity test, is commonly used.
The patient reads progressively shortening random letters and numbers from a chart placed at a distance of 6 meters.
The ability to read the letters at each size determines the visual acuity.
The test provides a score, represented by two numbers, indicating the patient’s ability to read compared to a person with healthy vision.

Visual Field Test:

Perimetry and visual field testing are used to assess the integrity of the field of view.
This test evaluates vision outside the macula and measures the range of peripheral vision.
The patient’s field of vision is assessed by flashing lights in their peripheral vision, and they are asked to respond when they see the lights.
Any gaps or abnormalities in the field of vision can be detected through this test.

Tonometry Test:

Tonometry is performed to evaluate the fluid pressure inside the eye, which helps in detecting glaucoma.

Ocular Motility Assessment:

This test assesses the movement of the eyeballs and checks for any squint or other problems.

Additional Tests:

In certain cases, additional tests may be prescribed, such as Visually Evoked Potential (VEP), Electroretinogram (ERG), and Electro-oculogram (EOG).
These tests evaluate the transmission of signals from the eye to the brain and can be helpful in diagnosing visual impairment, especially in young patients or those with multiple handicaps

Classification of Visual Impairement

The International Classification of Diseases 11 (2018) provides a classification system for vision impairment, categorizing it into two groups: distance vision impairment and near vision impairment. It is assessed by reading an eye chart from a specific distance.

Distance Vision Impairment:

Mild: Presenting visual acuity worse than 6/12 – This means that a person with mild distance vision impairment can see at 6 meters what a person with normal vision can see at 12 meters.
Moderate: Presenting visual acuity worse than 6/18 – Individuals with moderate distance vision impairment can see at 6 meters what a person with normal vision can see at 18 meters.
Severe: Presenting visual acuity worse than 6/60 – People with severe distance vision impairment can see at 6 meters what a person with normal vision can see at 60 meters.
Blindness: Presenting visual acuity worse than 3/60 – This category includes individuals with very limited or no ability to perceive visual information.

Near Vision Impairment:

Presenting near visual acuity worse than N6 or M.08 with existing correction – This refers to difficulties in seeing objects up close, even with corrective measures.

N6: N6 refers to the near visual acuity measurement. It indicates the level of visual clarity or sharpness at a close distance. The “N” stands for “near,” and the number represents the visual acuity scale. N6 refers to the ability to see at a distance of 40 cm (16 inches) with existing correction. In the International Classification of Diseases 11 (2018), N6 is used to classify near vision impairment.

40 cm: 40 cm (or 16 inches) is the standard working distance used to measure near visual acuity. It represents the distance at which a person is tested for their ability to see objects up close. This measurement is commonly used in vision assessments and is considered the standard distance for near vision testing

M.08 refers to presenting near visual acuity worse than N6 or M.08 at 40 cm. This means that individuals with M.08 near vision impairment have difficulty seeing objects clearly at close distances, even with existing correction such as glasses or contact lenses.

Note; Blindness in combination with hearing loss is known as deafblindness .

Management of Visual Impairment

Management ranges from Surgery, Pharmacological, Rehabilitation and Prevention.

Patient Reception:

Greet the patient and their caretaker with empathy and understanding.
Collect relevant medical history, including information about the visual impairment and any existing assistive devices.
Provide a comfortable waiting area with appropriate lighting and signage to assist visually impaired individuals.

Medical Assessment and Diagnosis:

Conduct a thorough examination by an ophthalmologist to determine the cause and severity of the visual impairment.
Perform necessary tests, such as visual acuity measurements, visual field tests, and imaging studies.
Discuss the diagnosis with the patient and their caretaker, explaining the implications and available treatment options.

Treatment and Management:

On return of the results, Prescribe appropriate corrective lenses, such as eyeglasses or contact lenses, if applicable.
Recommend assistive devices and technology based on the patient’s needs, such as magnification systems, visual aids, and adaptive technology.
Refer the patient to low vision rehabilitation programs for specialized training and support.
Provide information about available support services, such as counseling, support groups, and registration as visually impaired if necessary.

Rehabilitation and Training:

Arrange orientation and mobility training to help the patient navigate their environment safely and independently.
Offer daily living skills training to enhance independence in activities of daily living.
Provide access to Braille literacy programs for those interested in learning Braille. Braille is a tactile writing system used by people who are blind or visually impaired. It consists of raised dots arranged in cells, which can be read by touch.
Facilitate low vision rehabilitation programs to maximize the patient’s remaining vision through training and adaptive strategies.

Emotional and Psychological Support:

Offer counseling services to address emotional and psychological challenges associated with visual impairment.
Connect the patient and their caretaker with support groups to share experiences and receive peer support.
Collaborate with mental health professionals to address any psychological issues related to visual impairment.

Ongoing Monitoring and Follow-up:

Schedule regular follow-up appointments to monitor the patient’s visual health and adjust the management plan as needed.
Provide educational resources and information to the patient and their caretaker for continued self-care and support.

Discharge:

Ensure that the patient and their caretaker understand the management plan and have access to necessary resources and support services.
Provide written instructions, including medication details, follow-up appointments, and contact information for further assistance.
Coordinate with other healthcare professionals involved in the patient’s care to ensure a smooth transition post-discharge.

Surgical Management:

Surgical management is crucial according to the cause of the visual impairement.

Cataract Surgery:

Cataract surgery is a common surgical procedure to treat visual impairment caused by cataracts.
During the surgery, the clouded natural lens of the eye is removed and replaced with an artificial lens called an intraocular lens (IOL).
This procedure is usually highly successful in restoring vision and improving visual acuity.

Corneal Transplant:

In cases where visual impairment is caused by a scarred or damaged cornea, a corneal transplant may be considered.
During the procedure, the damaged cornea is replaced with a healthy cornea from a donor.
Corneal transplants can help improve vision and restore clarity to the cornea.

Retinal Surgery:

Retinal surgery may be performed to address visual impairment caused by retinal conditions such as retinal detachment or macular holes.
The specific surgical techniques used depend on the underlying condition and may involve repairing or reattaching the retina.
Laser surgery may also be used to treat certain retinal conditions, such as diabetic retinopathy or retinal tears.

Glaucoma Surgery:

In cases where visual impairment is caused by glaucoma, surgical interventions may be necessary to manage the condition.
Different types of glaucoma surgeries are available, including trabeculectomy, tube shunt surgery, and laser trabeculoplasty.
These procedures aim to reduce intraocular pressure and prevent further damage to the optic nerve, thus preserving vision.

Prevention

Eat a Nutritious Diet: Consuming a balanced diet rich in fruits, vegetables, and omega-3 fatty acids can help maintain good eye health.
Get Regular Eye Exams: Regular eye exams are crucial for early detection and treatment of vision problems. The frequency of eye exams may vary depending on age and risk factors.
Know Your Family’s Eye History: Understanding your family’s history of eye problems can help identify potential risks and take preventive measures.
Follow a Healthy Lifestyle: Maintaining a healthy lifestyle, including regular exercise and not smoking, can contribute to overall eye health.
Protect Your Eyes from Trauma: When engaging in activities that pose a risk to your vision, such as sports or working with hazardous materials, wear durable eye protection to prevent injuries.
Avoid Harmful Substances: Avoid smoking, as it is a major risk factor for vision problems such as macular degeneration and cataracts. Additionally, minimize exposure to harsh chemicals and protect the eyes from harmful substances.
Protect Your Eyes from UV Radiation: Wear sunglasses that provide 99-100% protection against UVA and UVB rays to shield your eyes from the harmful effects of UV radiation.
Practice Good Eye Hygiene: Take breaks when using digital devices or performing concentrated activities to prevent eyestrain. Blink regularly to keep your eyes lubricated and use artificial tears if needed.
Manage Chronic Conditions: Properly manage chronic conditions like diabetes and high blood pressure, as they can contribute to vision problems.
Genetic testing: Genetic testing can be helpful in prevention of genic eye disorders such as Retinitis pigmentosa.

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STINGS AND BITES

STINGS AND BITES.

Stings and bites refer to injuries caused by animals, insects, or plants that break the skin surface and can result in various reactions, ranging from minor irritation to severe medical conditions.

The terms “sting” and “bite” are used to differentiate between the type of injury and the mechanism by which it occurs.

Insect bites occur when insects like mosquitoes, fleas, or bedbugs use their mouthparts to break the skin and feed on blood. These bites usually cause itching.
Insect stings occur when insects, such as bees, wasps, or hornets, use a barbed stinger or another body part to pierce the skin and inject venom as a defense mechanism.

Other Animal Bites and Stings:

Animal bites, such as dog bites, occur when an animal uses its teeth to break the skin.
Animal stings, like those from jellyfish or scorpions, occur when an animal uses a specialized body part to inject venom into the skin.
Plant Stings: Some plants have tiny needles or hairs on their leaves that can break off and lodge into the skin, causing discomfort. These are known as stinging plants

INSECTS STINGS AND BITES

Causes of Insect Stings and Bites:

Insects: Insects such as bees, wasps, hornets, mosquitoes, and ants are common causes of stings and bites.
Arachnids: Arachnids like spiders and ticks can also cause stings and bites.
Environmental Factors: Spending time outdoors in areas where insects are prevalent, such as forests, gardens, or fields, increases the risk of being stung or bitten.
Provocation: Insects may sting or bite if they feel threatened or provoked. For example, bees and wasps may sting if they perceive a threat to their nest or hive.
Attractants: Certain scents, perfumes, bright colors, and sweet foods can attract insects and increase the likelihood of being stung or bitten.
Seasonal Factors: Insect activity tends to be higher during warmer months, increasing the chances of encountering stinging or biting insects.
Geographic Location: The prevalence of specific insects varies by region, so the risk of stings and bites may be higher in certain areas.

Pathophysiology of Insect Stings and Bites:

Exposure: When an insect stings or bites, it injects venom or saliva into the skin through its mouthparts or stinger.
Venom/Saliva: The venom or saliva contains various substances that can trigger an immune response and cause local and systemic effects.
Immune Response: The immune system recognizes the foreign substances in the venom or saliva and releases chemicals, such as histamine, to defend against them.
Local Effects: The release of histamine and other chemicals leads to local inflammation, causing redness, swelling, pain, and itching at the site of the sting or bite.
Systemic Effects: In some cases, the venom or saliva can cause systemic effects, affecting other parts of the body. This can occur due to an allergic reaction or a toxic reaction to the venom.

Signs and Symptoms of Insect Stings and Bites:

When it comes to insect stings and bites, there are several signs and symptoms that can occur. These can range from mild irritation to more severe allergic reactions.

Localized Reactions:

Localized redness and swelling at the site of the sting or bite.
Itching and irritation.
Pain or tenderness.
Formation of a small blister or weal.
Development of a rash or hives.
In some cases, a visible puncture mark or stinger may be present.

Systemic Reactions:

Dizziness.
Weakness.
Nausea.
Headache.

Signs and Symptoms of Anaphylaxis:

Anaphylaxis is a severe allergic reaction that can occur in response to an insect sting or bite. It is a medical emergency and requires immediate attention. The signs and symptoms of anaphylaxis may include:

Difficulty breathing or wheezing.
Swelling of the face, lips, tongue, or throat.
Rapid heartbeat or palpitations.
Severe itching or hives over a large area of the body.
Nausea, vomiting, or abdominal pain.
Feeling of impending doom or anxiety.
Loss of consciousness or collapse.

Management of Insect bites and stings.

Reassure the casualty and keep them calm.
Apply constant firm pressure to the sting area using the edge of a blunt object or your fingernail. Scrape or brush off the sting. Avoid using tweezers as they may squeeze the venom sac and increase venom release.
If the sting is on the fingers or hands, remove any rings or watches in case of swelling.
Remove the sting by scraping with a straight-edged object across the stinger. Do not use tweezers – these may squeeze the venom sac and increase the amount of venom released.
Wash the site thoroughly with soap and water. Then, follow these steps:
Place ice (wrapped in a washcloth) on the site of the sting for 10 minutes and then off for 10 minutes. Repeat this process. Avoid direct contact with the skin to prevent frostbite.
If necessary, take an antihistamine or apply creams that reduce itching.
Over the next several days, watch for signs of infection (such as increasing redness, swelling, or pain).
Advise the casualty to see a doctor if the pain and swelling persist.
DO NOT apply a tourniquet or give the person stimulants, aspirin, or other pain medicine unless prescribed.

Diagnosis.

History of a bite or stung by an insect
Physical exam-view of the swollen site.
Skin allergic test

Medical management.

In mild cases, insect stings and bites may be managed without drug therapy. However, in more severe cases, the following drug therapies may be used:

Anti-histamines: These can help relieve itching and reduce allergic reactions.
Steroids: Systemic steroids may be prescribed to reduce inflammation and allergic responses.
Epinephrine: In cases of anaphylaxis, epinephrine (adrenaline) may be administered to reverse severe allergic reactions.
Prophylactic antibiotics: In certain cases, antibiotics may be prescribed to prevent infection.

Safety precautions to consider:

Use insect repellents to help prevent insect stings.
Wear long pants and a T-shirt to minimize exposed skin.
If you encounter an attack, cover your face and run in a straight line as quickly as possible.
Grab a net, coat, towel, or any object that can provide temporary protection.
Seek shelter in a house, tent, or car with windows and doors closed.
Avoid other people as they may also come under attack.
Be aware that bees can pursue for up to 400 meters.
Bees are slow fliers, and most people can outrun them.
Stay alert for bees entering or exiting through cracks in walls.
Once you notice a bee colony, do not provoke it and keep a safe distance.

When to Seek Emergency Care:

Trouble breathing, wheezing, or experiencing shortness of breath.
Swelling anywhere on the face or in the mouth.
Throat tightness or difficulty swallowing.
Feeling weak or experiencing a sudden drop in blood pressure.
Turning blue or experiencing a loss of consciousness.

Prevention of Insect stings and bites.

Avoid rapid, jerky movements around insect hives or nests.
Avoid wearing perfumes and clothing with floral patterns or dark colors, as they can attract insects.
Use appropriate insect repellents and wear protective clothing, such as long sleeves and pants.
Exercise caution when eating outdoors, especially around garbage cans or sweetened beverages that may attract bees.
If you have severe allergies to insect bites or stings, it is important to have an emergency kit and an EpiPen. Ensure that your friends and family know how to use it in case of a reaction.

ANIMAL BITES

Animal bites, especially in children, are a common occurrence and can result in puncture wounds. It is important to properly manage these bites to prevent complications such as infection and the transmission of diseases like rabies.

General Wound Care:

Rinse the wound with saline water or sterile water under pressure to remove any dirt or debris.
Wash the surrounding skin with soap and water to reduce the risk of infection.
Apply a clean dressing to protect the wound and promote healing.
If possible, elevate the affected body part to help control bleeding.

Medical Interventions:

Tetanus toxoid should be administered if the person has not been adequately vaccinated against tetanus.
Prophylactic antibiotics may be prescribed to prevent infection, especially in high-risk wounds or individuals with immune deficiencies.
Debridement of lacerations may be necessary to remove damaged tissue and promote healing.

Suspected Rabies Infection:

If there is a suspicion of rabies infection, immediate medical attention is crucial.
Anti-rabies immunoglobulins, such as inactivated rabies vaccines, may be administered to induce an active immune response.
Rabies Ig (preformed antibodies) may also be given to provide immediate protection against the virus.

Animal Safety:

Teach children how to prevent interactions with unfamiliar animals.
Vaccinate your pets regularly to protect them against diseases and reduce the risk of bites.
Avoid teasing or provoking animals, as this can lead to aggressive behavior.
Do not make direct eye contact with a threatened animal, as it may perceive it as a challenge.
Never pull an animal’s tail or take away its food, as this can agitate them.
Approach restrained animals with caution and respect their space.
Avoid running in front of a dog, as it may trigger their instinct to chase.
Do not allow inexperienced individuals to feed dogs, as they may not understand proper handling techniques.
Alert animals to your presence before approaching them to avoid surprising or startling them.
Consider spraying your pets with appropriate insect repellents to prevent bites from insects like fleas and ticks.
Socialize your animals to ensure they are comfortable and well-behaved around people.
Do not allow children to lead dogs, as they may not have the necessary control or understanding of the animal’s behavior.

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PLANT ALLERGIES

Plant allergies, also known as pollen allergies or hay fever, refer to allergic reactions that occur when a person’s immune system overreacts to certain plant substances, such as pollen, plant proteins, or other allergens released by plants.

These allergies are a common type of allergic rhinitis, which is characterized by symptoms such as sneezing, runny or stuffy nose, itchy or watery eyes, and nasal congestion.

Causes and Triggers of Plant Allergies:

Pollen: Pollen is a common trigger for plant allergies. It is a fine powder produced by trees, flowers, grasses, and weeds to fertilize other plants of the same species. When people with pollen allergies breathe in pollen, their immune system mistakenly identifies it as a harmful intruder and produces chemicals, such as histamine, leading to allergic reactions.
Trees: Certain trees can trigger plant allergies due to the release of pollen. Common ones include Pine trees, Palm trees, Cypress, sycamore and oak trees. Oak pollen stays in the air for longer periods, causing severe allergic reactions in some individuals.
Grass: Grass pollen is a primary trigger for allergies such as perennial rye, Bermuda grass, and bluegrass are capable of triggering allergies.
Weeds: Weeds, particularly ragweed plants, are known to cause allergies. Ragweed can produce a large number of pollen grains. Other weeds include Amaranth (pigweed)
Other Plants: While pollen is the most common trigger for plant allergies, other plants can also cause allergic reactions. Some individuals may be allergic to specific plants such as juniper, nettle, sagebrush, tumbleweed, lamb’s quarters, walnut, English plantain, pine, cottonwood, and ordinary sunflowers.

Classification of Plant Allergens

Plant allergens can be classified into different categories based on the route of exposure and the symptoms they cause. The main categories of plant allergens include inhalant allergens, ingestant allergens, injectant allergens, contactant allergens, and infectant allergens.

Inhalant Allergens:

Inhalant allergens are substances that are distributed in the atmosphere and come into contact with the nasal or buccal mucosa during respiration. These allergens can cause symptoms such as sneezing, runny or clogged nose, coughing, itching eyes, nose, and throat, sinusitis, hay fever, and asthma.
Seasonal Hay Fever or Pollinosis: This type of hay fever is related to the release of pollen grains from certain plants during specific seasons of the year.
Non-seasonal Hay Fever or Perennial Rhinitis: In this case, the allergic symptoms can occur throughout the year without regularity and are caused by inhalant allergens other than pollen grains, such as fungus spores and dust.
Examples of responsible plant allergens: Pollens of oak, walnut, ragweed, Russian thistle, Bermuda grass, Parthenium grass, fungal spores, old plant parts, volatile oils, alfalfa, lemon, strong perfumes, and cotton pillowcases.

Ingestant Allergens:

Ingestant allergens are substances found in food that are swallowed and can stimulate an allergic response. These allergens can cause symptoms such as gastrointestinal disturbances, vomiting, nausea, migraine pains, dermatitis, puffed lips and tongue, rhinitis, bronchial asthma, and severe cases of eczema of hands.
Examples of ingestant allergens: Cow’s milk, orange juice, cod liver oil, coffee, flavoring agents, and preservatives.

Injectant Allergens:

Injectant allergens refer to substances that cause allergy in hypersensitive individuals through injection. Common examples include antibiotics like penicillin and cephalosporin.
Symptoms of injectant allergy: Itching of the hands and soles of the feet, erythema (redness of the skin) with severe pain, and peeling of the skin.

Contactant Allergens:

Contactant allergens are substances that come into direct contact with the epithelium, causing allergic symptoms. These symptoms can include watery blisters and dermatitis.
Examples of contactant allergens: Poison ivy, poison oak, grasses like parthenium and asparagus, buckwheat, gingko, lobelia tobacco, podophyllum, perfumes, soaps, detergents, nail polishes, hair dyes, and wool in clothing.

Infectant Allergens:

Infectant allergens are bacterial metabolic wastes or products released by living organisms during their metabolism in the human body. These allergens can cause chronic illnesses and allergic reactions.
Examples of infectant allergens: Certain types of bacteria, protozoans, molds, helminths, and other parasitic forms.

Signs and Symptoms of Plant Allergies:

Plant allergies can cause a range of symptoms, both when there is direct skin contact with the plant and when the allergens are inhaled.

Skin Contact Symptoms:

Red rash: A red rash may develop on the skin within a few days of contact with a plant allergen.
Bumps, red patches, or streaking: These may appear on the skin and can be accompanied by weeping blisters. It’s important to note that the fluids in the blisters will not cause the blisters to spread on you or to others.
Swelling: Swelling of the affected area may occur.
Itching: Itching is a common symptom associated with plant allergies.

Respiratory Symptoms:

Sneezing: Frequent sneezing may occur as a result of inhaling plant allergens.
Stuffy or runny nose: The nose may become congested or produce excessive mucus.
Watery or itchy eyes: Allergens can cause the eyes to water or become itchy.
Coughing: A persistent cough may develop.
Wheezing or shortness of breath: Some individuals may experience wheezing or difficulty breathing.
Chest tightness: A feeling of tightness or discomfort in the chest may be present.

General Symptoms:

Fatigue: Allergies can cause fatigue or a feeling of low energy.
Headache: Headaches may occur as a result of the allergic reaction.
Sinus pressure: Pressure or pain in the sinuses can be a symptom of plant allergies.
Postnasal drip: Excess mucus can drip down the back of the throat, causing irritation.
Sore throat: A sore throat may develop due to postnasal drip or inflammation.

Seek immediate medical attention:

You have symptoms of a severe reaction, such as severe swelling and/or difficulty breathing.
The rash covers more than one quarter of your body.
The rash occurs on the face, lips, eyes, or genitals.
The initial treatment does not relieve symptoms.
You develop a fever and/or the rash shows signs of infection, such as increased tenderness, pus or yellow fluid oozing from the blisters, and an odor coming from the blister

Diagnosis and Investigations

Personal and Medical History:

Through assessment about your symptoms, their duration, and any potential triggers, exposure to plants, such as gardening or outdoor activities.
Family history of allergies and any previous allergic reactions will also be considered.

Physical Examination:

Close examination of the ears, eyes, nose, throat, chest, and skin.
A lung function test may be performed to assess the respiratory function.
In some cases, an X-ray of the lungs or sinuses may be necessary.

Skin Tests:

Skin tests are the most common and reliable method for diagnosing plant allergies.
Skin prick tests involve placing a small amount of allergen extract on your skin and then pricking or scratching the area.
If you are allergic to the specific plant allergen, you will develop a raised bump or hive at the test site within 15 minutes.
Intradermal tests may also be performed, where a small amount of allergen is injected just under the skin. This type of testing is more sensitive than skin prick tests.

Blood Tests:

Blood tests, such as the RAST (radioallergosorbent test) or ELISA (enzyme-linked immunosorbent assay), measure the presence of specific IgE antibodies to plant allergens in your blood.
The tests are used when skin testing cannot be performed, such as in cases of severe skin conditions or recent severe allergic reactions.
Blood tests may take longer to get results and may be more expensive than skin testing.

Challenge Tests:

Challenge tests involve supervised exposure to a small amount of the suspected allergen, either by ingestion or inhalation.
This test is closely monitored by an allergist to observe any allergic reactions.
Challenge tests are used for diagnosing food or medication allergies when the risk of a severe reaction is low.

Management of Plant Allergies

Plant allergies, such as pollen allergies, can cause symptoms like sneezing, runny nose, itchy eyes, and congestion. Managing plant allergies involves a combination of first aid measures, medical treatments, nursing care, and general measures to minimize exposure to allergens.

First Aid Measures:

Remove yourself from the source of allergens, if possible.
Rinse your nasal passages with a saline (saltwater) nose rinse to flush out allergens.
Use over-the-counter antihistamine eye drops to relieve eye allergy symptoms.
Apply cold compresses to reduce eye swelling and itching.
Remove your clothes and wash all exposed areas with cool running water using soap and water.
Wash clothing and all gardening tools, camping gear, sports equipment, and other objects that came into contact with the plants.
Bathe pets exposed to the plants.

Medical Treatments:

Antihistamines: Take oral antihistamines to relieve sneezing, itching, and runny nose.
Nasal Sprays: Corticosteroid nasal sprays can reduce nasal inflammation and congestion.
Decongestants: Short-term use of decongestants can help relieve nasal stuffiness.
Leukotriene Modifiers: These medications can block chemicals released during an allergic reaction.
Topical preparations such as calamine or topical steroids are helpful in treating a poison ivy rash.
Allergy Shots (Immunotherapy): In severe cases, allergy shots are used to desensitize the immune system to specific allergens. It’s good for longterm management.

Nursing Care:

Educate patients about their specific allergens and how to avoid them.
Teach proper use of nasal sprays and eye drops.
Monitor and document symptoms and response to treatment.
Provide emotional support and reassurance to patients experiencing allergy symptoms.

General Measures to Minimize Exposure:

Stay indoors during peak pollen times, usually early morning and evening.
Keep windows closed and use air conditioning with HEPA filters.
Avoid outdoor activities on windy days when pollen counts are high.
Wear sunglasses to protect your eyes from pollen.
Wash your hands and face after being outdoors to remove pollen.
Dry clothes indoors to prevent pollen from sticking to them.
Avoid mowing lawns or being around freshly cut grass.
Consider using a pollen mask when working outdoors.

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SKIN ALLERGIES

Skin allergy, also known as allergic dermatitis, is a condition in which the immune system has an abnormal reaction to a harmless substance, known as an allergen, that comes into contact with the skin.

Skin allergy is an abnormal reaction of the skin following an irritant that continues as long as there is an exposure to that irritant.

Skin allergies frequently cause rashes, or swelling and inflammation within the skin, in what is known as a “weal and flare” reaction characteristic of hives and angioedema.

Causes and Triggers of Skin Allergies

Contact Allergens: Substances that directly touch the skin and trigger an allergic reaction, such as nickel, latex, fragrances, and certain plants (e.g., poison ivy).
Food Allergies: Allergic reactions to certain foods, such as peanuts, shellfish, dairy, and eggs, that can manifest as skin rashes or hives.
Insect Bites and Stings: Bites or stings from insects, such as bees, wasps, and mosquitoes, can release allergens that cause allergic reactions.
Medications: Certain medications, such as antibiotics (e.g., penicillin), nonsteroidal anti-inflammatory drugs (NSAIDs), and chemotherapy drugs, can cause allergic skin reactions.
Environmental Irritants: Exposure to environmental irritants, such as dust mites, pollen, and pet dander, can trigger allergic reactions in susceptible individuals.
Skin Conditions: Certain skin conditions, such as eczema and psoriasis, can make the skin more sensitive and prone to allergic reactions.
Metals: Exposure to certain metals, such as nickel, cobalt, and chromium, can cause allergic reactions in some people, like some who react to necklaces and rings.
Rubber and Latex: Some individuals are allergic to rubber or latex, which can be found in gloves, condoms, and certain clothing items.
Cosmetics and Personal Care Products: Ingredients in cosmetics, skincare products, and hair dyes can cause allergic reactions in some people.
Genetics: Some individuals are genetically predisposed to developing skin allergies, increasing their risk of developing reactions to various triggers.

Pathophysiology of Skin Allergies

Contact with Allergen:

Skin allergies occur when the skin comes into contact with an allergen, which is a substance that triggers an immune response in the body.
Common allergens include chemicals, metals (such as nickel), fragrances, plants (like poison ivy), medications, and certain fabrics.

Sensitization:

When the allergen comes into contact with the skin, it can penetrate the outermost layer of the skin called the stratum corneum.
Langerhans cells, a type of immune cell in the skin, capture and process the allergen.
The allergen is then presented on the surface of Langerhans cells, activating the immune response.

Activation of the Immune Response:

The immune system recognizes the allergen as a threat and triggers an immune response.
Immune cells, such as T cells and B cells, are activated and release chemical mediators, including histamine.
Histamine causes blood vessels to dilate and become leaky, leading to redness, swelling, and itching.

Inflammatory Response:

The release of histamine and other chemical mediators leads to inflammation in the skin.
Inflammatory cells, such as mast cells and eosinophils, are recruited to the site of allergen contact.
These cells release additional inflammatory substances, increasing the allergic reaction.

Symptoms:

The immune response and inflammation in the skin result in various symptoms, including redness, itching, swelling, and the formation of a rash.
The specific symptoms and their severity can vary depending on the individual and the allergen involved.

Forms of Skin Allergies

Atopic Dermatitis (Eczema):

Atopic dermatitis, also known as eczema, is a common skin condition that primarily affects children but can also occur in adults.
It is characterized by dry and itchy skin due to a “leakiness” of the skin barrier, making it more susceptible to irritation and inflammation from environmental factors.
In some cases, eczema symptoms can be worsened by food sensitivities.
Severe atopic dermatitis can be caused by a genetic mutation in the skin called filaggrin.
Eczema is often associated with asthma, allergic rhinitis (hay fever), or food allergies, and this progression is known as the atopic march.

Allergic Contact Dermatitis:

Allergic contact dermatitis occurs when the skin comes into direct contact with an allergen.
Common allergens include nickel, certain plants like poison ivy, poison oak, and poison sumac, as well as various chemicals found in everyday products.
Symptoms of allergic contact dermatitis can include redness, bumps, scales, itching, or swelling at the point of contact .

Urticaria (Hives):

Urticaria, commonly known as hives, is an inflammatory skin condition triggered by the release of histamine by the immune system.
It causes small blood vessels to leak, resulting in swelling of the skin.
Acute urticaria can be caused by allergic reactions to certain foods, medications, insect bites, or non-allergic triggers like heat or exercise.
Chronic urticaria, on the other hand, lasts for a longer period and is often not caused by specific triggers.

Angioedema:

Angioedema is swelling that occurs in the deeper layers of the skin, often accompanying hives .
It commonly affects soft tissues such as the eyelids, mouth, or genitals .
Acute angioedema is usually caused by allergic reactions to medications or foods.
Chronic recurrent angioedema is characterized by the return of symptoms over a long period without an identifiable cause .

Signs and Symptoms of Skin Allergies

Skin allergies can manifest in various ways and may differ depending on the specific allergic reaction.

Rash: Skin allergies often result in the development of a rash, which can appear as red, inflamed patches on the skin.
Itching: Itchy skin is a common symptom of skin allergies. The urge to scratch the affected area may be intense.
Redness: Allergic reactions can cause redness in the affected area, making the skin appear flushed or irritated.
Swelling: Skin allergies can lead to swelling, which may be localized or affect a larger area of the body.
Raised bumps: Allergic reactions can cause the formation of raised bumps on the skin, known as hives or wheals.
Scaling: Scaling refers to the flaking of the skin, which can occur as a result of an allergic reaction.
Cracked skin: In some cases, skin allergies can cause the skin to become dry and cracked, leading to discomfort.
Dry skin: Eczema, a common skin condition associated with allergies, can cause itchy, red, or dry skin. The affected skin may also weep or leak fluid when scratched.
Excessive little lines on the skin of the palms: Individuals with a faulty filaggrin gene may develop hand eczema with excessive little lines on the skin of their palms.
Swelling without itch: Angioedema is a deeper layer of swelling that often appears on the face, particularly around the eyes, cheeks, or lips. It can also occur on the hands, feet, genitals, or inside the bowels or throat. Unlike hives, angioedema does not cause itching.

Prevention of Skin Allergies

Identify and avoid allergens: The first step in preventing skin allergies is to identify the specific allergens that trigger your reactions. Common allergens include certain metals (like nickel), fragrances, chemicals, latex, and certain plants.
Read product labels: When purchasing skincare products, cosmetics, detergents, or any other products that come into contact with your skin, carefully read the labels. Look for products that are labeled hypoallergenic, fragrance-free, and free of known allergens.
Patch testing: This test involves applying small amounts of potential allergens to your skin to determine which substances you are allergic to.
Protect your skin: Use protective measures to minimize contact with potential allergens. For example, wear gloves when handling chemicals or irritants, and use barrier creams or ointments to protect your skin from potential allergens.
Moisturize regularly: Keeping your skin moisturized can help maintain its natural barrier function and reduce the risk of skin allergies. Choose moisturizers that are gentle and free of potential allergens.
Practice good hygiene: Maintain good hygiene practices to prevent skin allergies. This includes regular bathing with mild, fragrance-free soaps and shampoos. After bathing, pat your skin dry instead of rubbing it.
Avoid hot water and harsh soaps: Hot water and harsh soaps can strip your skin of its natural oils and disrupt its protective barrier. Instead use lukewarm water and mild, fragrance-free soaps to minimize the risk of skin allergies.
Wear appropriate clothing: Choose clothing made from natural, breathable fabrics like cotton or silk. Avoid clothing with rough textures or tight-fitting garments that can irritate the skin. Wash new clothes before wearing them to remove any potential irritants.
Manage stress: Stress can exacerbate skin conditions and increase the risk of allergic reactions. Practice stress management techniques such as exercise, meditation, or engaging in hobbies to reduce stress levels.

Diagnosis and Investigations for Skin Allergies:

Medical History: Taking a detailed medical history through assessment about symptoms, their duration, and any potential triggers or exposures that may be related to skin allergies.
Physical Examination: A thorough physical examination of the affected skin to assess the nature and severity of the allergic reaction. Look for specific signs such as redness, swelling, rash, or other characteristic skin changes.
Allergy Skin Tests: Allergy skin tests, such as a skin prick test or scratch test, are used to identify specific allergens causing skin allergies. During these tests, small amounts of potential allergens are applied to the skin, like on the forearm or back. If you are allergic to any of the substances, a small raised bump or redness, known as a wheal, will appear at the test site.
Intradermal Test: This involves injecting a small amount of allergen just under the skin to check for a more sensitive reaction. Intradermal tests are more sensitive but may also have a higher risk of false-positive results.
Blood Tests: Blood tests, such as the radioallergosorbent test (RAST) or enzyme-linked immunosorbent assay (ELISA), may be used to measure the levels of specific IgE antibodies in the blood. These tests can help identify allergens that may be causing skin allergies. Blood tests are used when skin tests cannot be performed, or as a follow-up to confirm the results of skin tests.
Patch Testing: Patch testing is commonly used to diagnose allergic contact dermatitis, a type of skin allergy caused by direct contact with allergens. During this test, small amounts of potential allergens are applied to patches, which are then placed on the skin for a specific period. The patches are then removed, and the skin is evaluated for any allergic reactions.

Management of Skin Allergies

Initial Assessment:

Obtain a detailed medical history, including the onset, duration, and progression of symptoms, previous allergic reactions, and any known triggers.
Perform a physical examination to assess the extent and severity of the skin allergy, including the appearance of the rash, presence of swelling or blistering, and any associated symptoms.

Identification of Allergen:

Conduct a thorough evaluation to identify the specific allergen causing the skin allergy. This may involve a detailed history, physical examination, and potentially allergy testing such as patch testing or skin prick tests.
Collection of blood samples where necessary can also be done.

Allergic Reaction:

Anyone having an allergic reaction should be watched closely for changes
Remember that allergy reactions are unpredictable
The way that your body reacts to an allergen one time cannot predict how it will react the next time
Stay with the child and alert his or her parents or emergency contacts
Symptoms can also worsen quickly, progressing to the life-threatening condition anaphylaxis
Epinephrine is the only treatment for anaphylaxis!

Symptomatic Treatment:

Provide immediate relief for symptoms such as itching and inflammation.
Prescribe and administer antihistamines to alleviate itching and reduce allergic reactions.
Advise the patient to avoid scratching the affected area to prevent further irritation and potential infection.
Suggest the use of cool compresses or topical corticosteroid creams to reduce inflammation and soothe the skin.

Avoidance of Allergen:

Educate the patient about the identified allergen and provide guidance on how to avoid exposure.
Advise the patient to read product labels carefully and avoid using products that contain the allergen.
Provide information on alternative products or ingredients that can be used instead.

Medical Management:

An Action Plan may include these medications

Topical Antihistamine
Inhaler (if allergy triggers asthma symptoms)
Nebulizer (if allergy triggers asthma symptoms)
Epinephrine

Refer to the Action Plan!

Antihistamines are appropriate for mild to moderate symptoms. The antihistamines cannot control a severe reaction and are not a substitute for epinephrine. If symptoms multiply or worsen, give epinephrine.
Antihistamines, known as H1 blockers, reduce or block histamines/ chemicals the body releases when it comes into contact with an allergen
Examples of Antihistamines include diphenhydramine (Benadryl®) and cetirizine (Zyrtec®)
Antihistamines may be topical or oral.
Prescribe topical corticosteroids for moderate to severe skin allergies to reduce inflammation and relieve symptoms. Consider prescribing oral corticosteroids for severe cases or when topical treatment is not sufficient.
In cases of allergic contact dermatitis, recommend the use of barrier creams or ointments to protect the skin from further exposure to the allergen.

Pediatric Care:

Ensure appropriate dosing of medications based on age and weight.
Provide education to parents or caregivers on how to manage the child’s skin allergies, including avoidance of allergens and proper application of topical medications.
Monitor pediatric patients closely for any signs of worsening symptoms or adverse reactions to medications and should report these changes immediately.

Follow-up and Referral:

Schedule a follow-up appointment to assess the patient’s response to treatment and make any necessary adjustments.
Consider referral to an allergist or dermatologist for further evaluation and management, especially in complex or severe cases.

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ECZEMA

Eczema, also known as atopic dermatitis, or atopic eczema, is a dermatologic problem where patches of skin become inflamed, itchy, red, cracked, and rough. Blisters may sometimes occur.

It is commonly seen in children. It is a relapsing skin problem that is manifested as pruritus, accompanied with swelling, redness, and dryness of the skin. Flaking, cracking, oozing, blistering or bleeding may occur as a result of excessive scratching of the skin.

Several factors are linked with this disease such as genetic mutation, and family history. Eczema cannot be cured, but it is not contagious. This is usually associated with allergy.

Causes of Eczema

The specific cause of eczema remains unknown, but it is believed to develop due to a combination of genetic and environmental factors.

Genetic Factors:

Family History: Children with relatives affected by eczema or other atopic diseases, such as asthma or hay fever, have a higher likelihood of developing the condition.
Inherited Gene Mutations: Genetic mutations can disrupt the skin’s natural barrier function, increasing vulnerability to irritants and allergens.

Environmental Factors:

Irritants: Exposure to harsh soaps, detergents, shampoos, disinfectants, and even juices from fresh fruits, meats, or vegetables can trigger eczema. Certain fabrics like wool or synthetic materials may also contribute to irritation.
Allergens: Eczema can be aggravated by exposure to common allergens, including dust mites, pet dander, pollen, mold, and dandruff.
Microbes: Presence of microbes like bacteria (e.g., Staphylococcus aureus), viruses, and fungi can play a role in eczema development.
Environmental Conditions: Extreme temperatures, whether hot or cold, and fluctuations in humidity levels can impact eczema.

Dietary Factors:

Common Food Triggers: Consumption of certain foods, including dairy products, eggs, nuts, seeds, soy products, and wheat, can be associated with eczema development.

Other Factors:

Stress: Psychological stress can exacerbate eczema symptoms.
Hormonal Changes: Hormonal fluctuations, such as those occurring during pregnancy or the menstrual cycle, may influence the severity of eczema symptoms.
Age: Eczema is more common in children and infants, although it can affect individuals of all ages.
Skin Dryness: Dry skin can worsen eczema symptoms, emphasizing the importance of maintaining proper skin hydration.

Classification of Eczema

The National Eczema Association has categorized eczema into various types.

Table 1. More Common Types of Eczema.

Classification	Description
Atopic eczema	Presented as xerosis and pruritus.
Contact dermatitis	Skin lesions attributed to any allergens or irritants.
Seborrhoeic dermatitis	Papulosquamous dermatologic disease with greasy scales on the scalp

Table 2. Lesser Common Types of Eczema.

Classification	Description
Dyshidrosis (Dyshidrotic Eczema/ Housewife’s Eczema)	Presents as pruritic vesicles with thickening and cracks on palms, soles, and lateral borders of fingers and toes.
Nummular Dermatitis (Discoid Eczema)	Well-demarcated round, oozing lesions mainly on lower extremities with an unknown etiology.
Stasis Dermatitis (Varicose eczema/Venous eczema)	Commonly found in ankles of individuals aged 50 and above with blood circulation problems; may lead to leg ulcers.
Dermatitis herpetiformis	Often associated with celiac disease, featuring a symmetrical, pruritic rash on arms, knees, back, and thigh.
Neurodermatitis(Lichen Simplex Chronicus)	Thickened, hyperpigmented, pruritic patch.
Autoeczematization (Autosensitization)	Skin reaction to microorganisms, manifesting at a distance from the original site of infection.

Symptoms of atopic eczema vary across different age groups:

Infants (Under 2 Years Old):

Rashes commonly appear on the scalp and cheeks.
Rashes typically bubble up before leaking fluid.
Extreme itchiness may interfere with sleep, and continuous rubbing can lead to skin infections.

Children (2 Years Until Puberty):

Rashes commonly appear behind the creases of elbows or knees, as well as on the neck, wrists, ankles, and buttock- leg creases.
Over time, rashes can become bumpy, change in color, thicken (lichenification), develop knots, and lead to permanent itching.

Adults:

Rashes commonly appear in creases
of the elbows or knees, the nape of the neck, and cover much of the body.
Prominent rashes on the neck, face, and around the eyes may occur.
Skin can become very dry, and rashes can be perma
nently itchy.
Rashes in adults may be more scaly than those in children.
Skin infections can result from scratching.
Adults who had atopic dermatitis as children may still experience dry or easily-irritated skin, hand eczema, and eye problems, even if the condition has resolved.

Diagnosis of Eczema.

Assessment:

Eczema is a skin condition and the main characteristic of this disease is itching.
Acute refers to the initial stage, where the skin may have crusted, oozing, eroded vesicles (small blisters), erythematous plaques (red, raised areas of skin), or papules (small, raised bumps).
Subacute is the stage that comes after the acute stage, where the skin may have erythematous scaly plaques (red, flaky areas of skin) or papules.
Chronic is the stage that comes after the subacute stage, where the skin may have slightly pigmented (discolored), lichenified (thickened and hardened) plaques or excoriations (areas where the skin has been scraped or scratched).

Skin Allergy Test:

Conducting a skin allergy test helps identify specific allergens that may be contributing to eczema flare-ups.
Skin Prick Testing: Involves introducing small amounts of allergens into the skin to identify specific triggers.
Patch Testing: Identifies delayed hypersensitivity reactions by applying small amounts of potential allergens to the skin and observing reactions over time.
Food Allergy Testing: Helps identify food triggers contributing to eczema symptoms.

Skin Biopsy:

In some cases, a skin biopsy may be recommended, involving the collection of a small skin sample for laboratory examination. This procedure helps in confirming the diagnosis and ruling out other skin disorders.

Blood Tests – IgE Level:

An elevated IgE level can be associated with eczema and may be measured through blood tests.

Treatment and Management of Eczema

There is no cure for eczema. Treatment for the condition aims to heal the affected skin and prevent flare-ups of symptoms.

Treatment based on an individual’s age, symptoms, and current state of health.

For some people, eczema goes away over time. For others, it remains a lifelong condition.

Home Care

Lukewarm baths: Avoid hot water, which can dry out the skin.
Moisturizing: Apply moisturizer within 3 minutes of bathing to “lock in” moisture. Moisturize daily, especially after bathing.
Clothing: Wear loose-fitting, soft fabrics like cotton. Avoid rough, scratchy fibers and tight clothing.
Cleansing: Use a mild soap or non-soap cleanser when washing.
Drying: Air dry or gently pat skin dry with a towel. Avoid rubbing.
Temperature control: Avoid rapid temperature changes and activities that cause sweating.
Trigger avoidance: Identify and avoid individual eczema triggers.
Humidifiers: Use a humidifier in dry or cold weather.
Nail care: Keep fingernails short to prevent scratching.

Medications

Topical corticosteroids: Anti-inflammatory creams or ointments applied directly to the skin to reduce inflammation and itching.
Systemic corticosteroids: Injected or oral corticosteroids for severe cases. Used for short periods only.
Antibiotics: Prescribed if eczema is accompanied by a bacterial skin infection.
Antiviral and antifungal medications: Treat fungal and viral infections.
Antihistamines: Reduce nighttime scratching by causing drowsiness.
Topical calcineurin inhibitors: Suppress immune system activity, reducing inflammation and preventing flare-ups.Calcineurin works by suppressing the activity of the immune system, specifically by inhibiting the production of certain inflammatory chemicals called cytokines.
Barrier repair moisturizers: Reduce water loss and repair the skin’s barrier.

Other Therapies

Phototherapy: Exposure to ultraviolet light to treat moderate eczema. Skin is monitored closely.

Ongoing Care

Even after skin has healed, it is important to continue caring for it to prevent irritation. Regular moisturizing and trigger avoidance are helpful for long term care.

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ATOPIC DERMATITIS

ATOPIC DERMATITIS.

Atopic dermatitis (AD) also known as atopic eczema is a common type of eczema that causes the skin to become itchy, dry, and cracked.

It results in itchy, red, swollen, and cracked skin. Clear fluid may come from the affected areas, which often thicken over time.

Other names include “infantile eczema“, “flexural eczema“, “prurigo Besnier“, “allergic eczema“, and “neurodermatitis“.

While the condition may occur at any age, it commonly starts in childhood with changing severity over the years. In children under one year of age much of the body may be affected.

As children get older , the back of the knees and front of the elbows are the most common areas affected.

In adults the hands and feet are the most commonly affected areas.

Scratching worsens symptoms and affected people have an increased risk of skin infections.

Many people with atopic dermatitis develop hay fever or asthma.

Causes and Predisposing Factors of Atopic Dermatitis

The exact cause of atopic dermatitis (AD) is unknown, but several factors are believed to contribute to its development, including genetics, immune system dysfunction, environmental exposures, and difficulties with the permeability of the skin.

Genetics: AD is strongly influenced by genetics. If one identical twin has AD, there is an 85% chance that the other twin will also have the condition. Many people with AD have a family history of atopy. Atopy is an immediate-onset allergic reaction (type 1 hypersensitivity reaction) that manifests as asthma, food allergies, AD or hay fever.
Immune system dysfunction: People with AD have an overactive immune system that reacts to allergens and irritants in the environment. This leads to the production of inflammatory chemicals that cause the skin to become red, itchy, and inflamed.
Environmental exposures: Exposure to certain environmental factors can trigger or worsen AD symptoms. These factors include: Dust mites, Pollen, Pet dander, Smoke, Chemicals, Dry air, Stress. Exposure to certain chemicals or frequent hand washing makes symptoms worse. Those who live in cities and dry climates are more commonly affected.
Skin barrier defects: People with AD have a defective skin barrier that allows allergens and irritants to penetrate the skin more easily. This leads to inflammation and the development of AD symptoms. Studies have found that abnormalities in the skin barrier of persons with AD are exploited by S. aureus to trigger cytokine expression, thus aggravating the condition.
Staphylococcus aureus (S. aureus) colonization: S. aureus is a type of bacteria that is commonly found on the skin. In people with AD, S. aureus can colonize the skin and produce toxins that worsen the inflammation and symptoms of AD.
Calcium carbonate in household water: Studies have found that children who live in areas with high levels of calcium carbonate in their household water are more likely to develop AD. Atopic dermatitis in children may be linked to the level of calcium carbonate or “hardness” of household water.
Hygiene Hypothesis: According to the hygiene hypothesis , when children are brought up exposed to allergens in the environment at a young age, their immune system is more likely to tolerate them, while children brought up in a modern “sanitary” environment are less likely to be exposed to those allergens at a young age, and, when they are finally exposed, develop allergies. There is some support for this hypothesis with respect to AD.

Triggers of Atopic Dermatitis:

There are several factors that can trigger or worsen symptoms, including:

Food allergies
Stress
Heat and humidity
Certain fabrics, such as wool and synthetic fibers
Harsh soaps and detergents
Perfumes and other fragrances

Pathophysiology of Atopic Dermatitis

The disorder is not contagious. The pathophysiology may involve a mixture of type I and type IV -like hypersensitivity reactions.

After a Genetic Predisposition or any other predisposing factor, it leads to Skin Barrier Dysfunction hence a compromised skin barrier allowing irritants to penetrate more easily.

The immune system, especially the T-cells, responds exaggeratedly to these triggers leading to the release of inflammatory chemicals like histamines.

Inflammation occurs in the skin layers, causing redness, swelling, and itching. Scratching the itchy skin worsens the inflammation, leading to a cycle of itching and scratching leading to an imbalance of the skin’s normal flora like Staphylococcus aureus (S. aureus) with an overgrowth of S. aureus, further contributing to inflammation.

Chronic inflammation and persistent scratching can lead to a thinning of the skin layers which makes the skin more susceptible to infections and environmental damage.

Immune cells release cytokines like Interleukins, in particular, leading to even more inflammation. The combined effects of inflammation, scratching, and immune response result in characteristic eczematous lesions. These include red, dry, and scaly patches of skin. Triggers like allergens, stress, and environmental factors can exacerbate symptoms, leading to flare ups.

Signs and symptoms of Atopic Dermatitis

Dry and scaly skin that spans the entire body, except perhaps the diaper area: Atopic dermatitis can cause dry, scaly skin that affects most of the body, except for areas that are usually covered by a diaper.
Intensely itchy red, splotchy, raised lesions in the bends of the arms or legs, face, and neck: These lesions are a hallmark symptom of atopic dermatitis and can be extremely itchy. They often appear in the creases of the elbows, knees, and neck.
Dennie-Morgan infraorbital fold, infra-auricular fissure, and periorbital pigmentation on the eyelids: These are subtle signs of atopic dermatitis that can appear on the eyelids. The Dennie-Morgan infraorbital fold is a crease below the lower eyelid, the infra-auricular fissure is a groove in front of the ear, and periorbital pigmentation is darkening of the skin around the eyes.
Post-inflammatory hyperpigmentation on the neck, giving it a classic ‘dirty neck’ appearance: This is a darkening of the skin on the neck that can occur after inflammation from atopic dermatitis.
Lichenification, excoriation, erosion, or crusting on the trunk, indicating secondary infection: Lichenification is a thickening and hardening of the skin, excoriation is scratching of the skin, erosion is a loss of the top layer of skin, and crusting is a buildup of dried fluid on the skin. These signs can indicate that a secondary infection has developed on the skin.
Flexural distribution with ill-defined edges with or without hyperlinearity on the wrist, finger knuckles, ankle, feet, and hand: Flexural distribution means that the rash appears in the creases of the body, such as the elbows, knees, and wrists. Ill-defined edges means that the rash does not have a clear border. Hyperlinearity is an increase in the lines on the palms of the hands and soles of the feet.

Additionally;

Dry, itchy skin: Intense itching is a hallmark symptom.
Redness and inflammation: Skin appears red and inflamed, often with small bumps or blisters.
Eczema: Dry, scaly patches of skin that can become crusty or oozing.
Oozing or crusting: Blisters or lesions may break open and release fluid that crusts over.
Lichenification: Thickening and hardening of the skin due to chronic scratching.

Skin infections: Due to compromised skin barrier, infections such as staph or yeast can occur.
Allergic reactions: Atopic dermatitis can be triggered by allergens, leading to flare-ups with symptoms such as hives, swelling, and itching.

Diagnosis of Atopic Dermatitis

Atopic dermatitis is diagnosed clinically, meaning that it is diagnosed based on signs and symptoms alone, without special testing. However, several different forms of criteria developed for research have also been validated to aid in diagnosis.

Assessment: This involves a physical examination and a review of the patient’s medical history. The physical examination will focus on the skin, and the doctor will look for signs of atopic dermatitis, such as:

Dry, itchy skin
Redness and swelling
Scaling and crusting
Lichenification (thickening and leathery appearance of the skin)

They will also ask about the patient’s family history of atopic dermatitis and other allergic conditions. A diagnostic criteria such as the UK Diagnostic Criteria can be used.

UK Diagnostic Criteria

The UK diagnostic criteria for atopic dermatitis are as follows:

People must have itchy skin, or evidence of rubbing or scratching, plus 3 or more of the following:

Skin creases are involved.
Flexural dermatitis of fronts of ankles, antecubital fossae, popliteal fossae, skin around eyes, or neck, (or cheeks for children under 10 years old).
History of asthma or allergic rhinitis (or family history of these conditions if patient is a child ≤4 years old).
Symptoms began before age 2 (can only be applied to patients ≥4 years old).
History of dry skin (within the past year).
Dermatitis is visible on flexural surfaces (patients ≥age 4) or on the cheeks, forehead, and extensor surfaces (patients<age 4).

Explanation of the Criteria:

Itchy skin or evidence of rubbing or scratching: This is a hallmark symptom of atopic dermatitis.
Skin creases are involved: Atopic dermatitis often affects the creases of the body, such as the elbows, knees, and neck.
Flexural dermatitis: This refers to a rash that appears in the creases of the body.
History of asthma or allergic rhinitis: Atopic dermatitis is often associated with other allergic conditions, such as asthma and allergic rhinitis.
Symptoms began before age 2: Atopic dermatitis typically begins in childhood.
History of dry skin: Dry skin is a common symptom of atopic dermatitis.
Dermatitis is visible on flexural surfaces or on the cheeks, forehead, and extensor surfaces: The location of the rash can help to distinguish atopic dermatitis from other skin conditions.

Other Investigations

In some cases, the doctor may order other investigations to help confirm the diagnosis of atopic dermatitis. These investigations may include:

Allergy testing: Allergy testing can be used to identify the allergens that are triggering the atopic dermatitis. This testing can be done through skin prick tests or blood tests.
Patch testing: Patch testing is a type of allergy test that is used to identify the allergens that are causing contact dermatitis. This test involves applying small amounts of different allergens to the skin and then observing the skin for signs of a reaction.

Differential Diagnosis

Atopic dermatitis can sometimes be confused with other skin conditions, such as:

Contact dermatitis
Seborrheic dermatitis
Psoriasis
Eczema

Treatment of Atopic Dermatitis

There is no known cure for atopic dermatitis (AD), but treatments can help to reduce the severity and frequency of flares. Treatment involves both preventive measures and medications.

Preventive Measures

Avoiding triggers: Identifying and avoiding triggers that make the condition worse is an important part of managing AD. Common triggers include wool clothing, soaps, perfumes, chlorine, dust, and cigarette smoke.
Daily bathing and moisturizing: Bathing daily with lukewarm water and applying a fragrance-free, hypoallergenic moisturizer afterwards can help to keep the skin hydrated and reduce the need for other medications.
Using mild soaps and detergents: Harsh soaps and detergents can irritate the skin and worsen AD. It is important to use mild, fragrance-free soaps and detergents that are designed for sensitive skin.
Wearing loose, cotton clothing: Loose, cotton clothing allows the skin to breathe and helps to prevent irritation.
Managing stress: Stress can trigger AD flares. Finding healthy ways to manage stress, such as exercise, music, or meditation, can help to reduce the frequency and severity of flares.

Medications

Topical corticosteroids: Topical corticosteroids, such as hydrocortisone, are effective in reducing inflammation and itching. They are typically applied to the affected areas of skin once or twice daily.
Topical calcineurin inhibitors: Topical calcineurin inhibitors, such as tacrolimus and pimecrolimus, are non-steroidal medications that can be used to treat AD. They are typically used for short periods of time, as they can cause side effects such as skin irritation and burning.
Systemic immunosuppressants: Systemic immunosuppressants, such as cyclosporine, methotrexate, and azathioprine, are used to suppress the immune system and reduce inflammation. They are typically used for severe AD that does not respond to other treatments.
Antidepressants and naltrexone: Antidepressants and naltrexone can be used to control pruritus (itchiness).
Antibiotics: Antibiotics may be used to treat bacterial infections that can develop on the skin of people with AD.
Phototherapy: Phototherapy involves exposing the skin to ultraviolet (UV) light. This can help to reduce inflammation and improve the skin’s appearance.

Other Treatments

Moisturizers: Applying moisturizers regularly can help to keep the skin hydrated and reduce the need for other medications.
Salt water baths: Bathing in salt water can help to soothe the skin and reduce inflammation.
Dilute bleach baths: Dilute bleach baths have been shown to be effective in managing AD.
Vitamin D supplementation: There is some evidence that vitamin D supplementation may improve AD symptoms.
Dietary changes: This is only effective if allergens have been identified in certain foods hence avoiding them.

Complications of Atopic Dermatitis

Skin infections: People with AD are more likely to develop skin infections, such as eczema herpeticum (a viral infection) and impetigo (a bacterial infection).
Allergic contact dermatitis: AD can increase the risk of developing allergic contact dermatitis, which is a type of skin irritation caused by contact with an allergen.
Hand eczema: AD can lead to hand eczema, which is a type of eczema that affects the hands. Hand eczema can be difficult to treat and can interfere with daily activities.
Sleep problems: The itching and discomfort of AD can make it difficult to sleep.
Psychological problems: AD can lead to psychological problems, such as anxiety, depression, and low self-esteem.
Increased risk of asthma and hay fever: People with AD are more likely to develop asthma and hay fever.
Poor quality of life: AD can have a significant impact on quality of life, affecting work, school, and social activities.
Erythroderma: Erythroderma is a rare but serious complication of AD that causes the skin to become red, swollen, and itchy. Erythroderma can be life-threatening if not treated promptly.
Lymphoma: People with severe AD are at an increased risk of developing lymphoma, a type of cancer that affects the lymph nodes.

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Inguinal Buboes Syndrome

Inguinal buboes refer to localized swellings or enlarged lymph glands in the groin and femoral area.

They are often locally described as “grenades.”

Case Definition:

Inguinal Buboes Syndrome is characterized by the clinical manifestation of localized swellings or enlarged lymph glands in the groin and femoral area.

Aetiology

It is crucial to differentiate sexually transmitted causes, specifically LGV and chancroid, from non-sexually transmitted local and systemic infections, such as lower limb or gluteal region infections. Exclusion of these non-STI causes is essential for accurate diagnosis. Other causes inclide;

Chlamydia strains: lymphogranuloma venereum (LGV).
Haemophilus ducreyi: chancroid.
Treponema pallidum: syphilis.

Clinical features

These swellings may present with pain and fluctuation and are commonly associated with Lymphogranuloma venereum (LGV) and chancroid. In the case of chancroid, an observable ulcer may accompany the buboes.

Excessively swollen inguinal glands.
Pain, tenderness.
Swellings may become fluctuant if pus forms.

Treatment Protocol: Inguinal Buboes Syndrome

Examination and Differential Diagnosis to rule out Non-STI Causes:

Thorough clinical examination to rule out non-sexually transmitted infections causing inguinal swellings.
Rule out infections in the foot, leg, or buttock.
Exclude the possibility of an inguinal hernia.
Differential diagnosis to consider both STI-related and non-STI-related etiologies.

Follow the Management Flow Chart:

Adhere to the syndromic management flow chart for inguinal buboes.
Treatment options may include antibiotics and other therapeutic measures based on the underlying cause.
If a genital ulcer is present, initiate treatment following the established protocol.
Administer doxycycline 100 mg orally every 12 hours for a duration of 14 days.
Ensure treatment for both the patient and their partner.

Pregnant Partner Consideration:

In cases involving a pregnant partner, substitute doxycycline with erythromycin.
Administer erythromycin 500 mg orally every 6 hours for a period of 14 days.

Aspiration of Fluctuant Swellings:

Fluctuant swellings, indicative of fluid accumulation, should be aspirated daily.
Do not incise the bubo; instead, aspirate through normal skin using a large bore needle (gauge <20) every 2 days until resolution.
As an alternative to doxycycline, azithromycin 1 g as a single dose can be considered.
Caution: Never incise fluctuant swellings, as this may lead to sinus formation.

Address Underlying STI:

If LGV or chancroid is diagnosed, initiate appropriate antibiotic therapy as per established guidelines.
Consider partner notification and treatment to prevent further transmission.

Monitoring and Follow-up:

Regular monitoring of the swelling’s progression and response to treatment.
Follow-up examinations to assess resolution and ensure the absence of complications.

Persistent Bubo Treatment:

If the inguinal bubo persists and the partner was not treated, continue the prescribed treatment for an additional 14 days.

Referral for Specialist Management:

In cases where the condition does not show improvement, consider referral for specialist management.

Lower Abdominal Pain Syndrome

Lower abdominal pain syndrome stands out as one of the most prevalent and serious STI syndromes among women, bearing significant reproductive health and socio-economic consequences.

Its presentation can be acute or chronic, posing diagnostic challenges due to numerous potential differential diagnoses.

Patients usually present with

abdominal pain,
Bleeding,
dyspareunia,
meno-metrorrhagia,
fever, and occasional vomiting.

Comprehensive evaluation involves assessing

abdominal tenderness,
cervical motion,
adnexal tenderness,
uterine tube enlargement, and pelvic masses.
Elevated temperature may be indicative, requiring thorough bimanual vaginal examination.

Case Definition:

Symptoms of lower abdominal pain and pain during sexual intercourse, coupled with examination findings such as vaginal discharge, lower abdominal tenderness on palpation, or a temperature > 38 degrees Celsius.

Aetiology:

This syndrome strongly suggests pelvic inflammatory disease (PID), encompassing salpingitis and/or endometritis. Causative agents may include gonococcal, chlamydial, or anaerobic infections.

Management:

Referral for Surgical Emergencies:

Patients presenting with symptoms of other surgical emergencies resembling lower abdominal pain syndrome should be promptly referred for inpatient admission and management.

Syndromic Antibiotic Treatment:

Ciprofloxacin, metronidazole, and ceftriaxone are prescribed, targeting the likely causative agents due to the challenge of specific diagnosis.
Outpatient treatment is extended due to the chronic nature of the condition.

Intrauterine Contraceptive Devices (IUCD):

Patients with IUCDs, predisposing factors for PID, should have the device removed after initiating treatment for at least 2 days.
Contraceptive counseling is essential for these patients.

Comprehensive STI Case Management:

Include other components such as partner notification and treatment, education on treatment compliance, and promotion of preventive measures.
Continuous monitoring and evaluation to address potential complications and ensure treatment effectiveness.

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