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देशका विभिन्न भागमा बैशाख १२ र २९ गते आएको 

बिनाशकारी भूकम्पमा परी मिति २०७२ -०२-११ गते 

सोमबार बिहान १०:०० बजेसम्मको प्राप्त जानकारी 

अनुसार ८,६५९ जनाको ज्यान गुमेको छ भने २१,९५२ 

जना घाइते भएका छन् ।

Update till 10:00 hrs, May 25, 2015

Death- 8,659

Injured- 21,952

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"बिनम्र अनुरोध "

समर्पण बारम "आन्मोल "

यहि २०७२ साल बैशाख १२ गते सनिबारको दिन महाभुकम्पमा परि दिबंगत हुनुभएका सम्पूर्ण बरामहरु  प्रति हार्दिक स्रदान्जली तथा उहाहरुको   परिवारप्रति हार्दिक समबेदना ब्यक्त गर्दछु,  साथै उक्त दुखद घटनामा घाइते हुनु भएका बराम बन्दुहरुको सिग्र स्वास्थ्य लाभको कामना गर्दछु, यस अकल्पनीय मानबिय तथा भौतिक क्षेतिबाट माथि उठी आफ्नो दिनचर्यामा बिस्तारै फर्की, आउदो बर्सहरुमा कहिले पनि यस्तो दुखद अवस्था  झेल्न नपरोस यहि शोकाकुल चण्डीपुर्णिमाको  हार्दिक मंगल मया शुभकामान

समर्पण बराम अनमोल

चण्डीपुर्निमलाई फर्केर हेर्दा किरण कुमार बराम , सुमन बराम अनि मेरो साथमा तमाम बराम बन्दुहरु

HISTORY TAKING

Dr. DINESWAR

Importance of History Taking

Importance of History TakingImportance of History Taking

žFirst step in determining the etiology of a patient's problem.

• žA large percentage of the time ) 70%) a diagnosis made based on the history alone.

Basic Ocular Anatomy & Physiology

ASIK PRADHAN

Consultant Optometrist

Introduction

The eye is a paired organ, the organ of vision.

 The eye is made up of various components, which enable it to receive light stimuli from the environment, and deliver this stimuli to the brain in the form of an electrical signal.

The Eyeball

The eyeball 

Cystic structure

An oblate spheriod*

Anterior and posterior pole &  Equator*

Dimensions of Adult Eyeball

Anteroposterior Diameter- 24 mm

Vertical Diameter- 23mm

Volume- 6.5ml

Weight- 7 gms

Coats of the eyeball

1.Fibrous coat (Sclera & Cornea) - Outer Coat- Protection

●

2.Vascular coat (Uveal Tissue) -  Middle coat- Nutrition

●

3.Nervous Coat (Retina)- Inner Coat-  Visual Functions

●

Segments and chambers of the eyeball 

1.Anterior segment

i.Anterior Chamber

ii.Posterior Chamber

●

2.Posterior Segment

Parts of the eyeball

Conjunctiva

Cornea

Sclera

Anterior Chamber

Iris

Ciliary Body

Pupil

Posterior Chamber

Lens

Vitreous

Retina

Choroid

Optic Nerve

  conjunctiva

Mucous membrane (stratified squamous), translucent

Lines posterior surface of the eyelids and anterior aspect of the eyeball

 Contains many goblet cells which secretes mucin that keep the eye moist.

Parts-

 Palpebral

 Bulbar

 Fornix

v Nerve supply- branches of 5th Cranial nerve

conjunctiva

cornea

Transparent, avascular, watch-glass like structure

Forms anterior one-sixth of the outer fibrous coat (Type I collagen)

Functions

To act as a major refracting medium ( Refractive power of cornea is + 45 Ds )

To protect the intraocular contents

Nerve supply

Anterior ciliary nerves (Branch of ophthalmic division of 5th cranial nerve)

CORNEA 

Histologically, it has 5 layers

1.Epithelium

2.Bowman’s membrane

3.Stroma

4.Decemet’s membrane

5.Endothelium

●

●

sclera

vWhite fibrous layer

vForms the posterior opaque five-sixth part of  the outer coat

vThinnest at insersion of rectus and thickest at posterior pole.

vFunctions

vProtect the eye ball

vGive attachment to the extra ocular muscles.

vNerve supply- Long Ciliary nerve

Anterior chamber

vSmall cavity – cornea anteriorly and iris and part of ciliary body posteriorly.

vAbout 2.5mm deep in normal individuals

vShallow in Hypermetropes and Deep in myopes

vContains 0.25ml aqueous humour

vPosterior Chamber

vTraingular space bounded anteriorly by the posterior surface of iris and part of ciliary body, posteriorly by the crystalline lens

vContains about 0.06ml of aqueous humour

Anterior and posterior chamber

Uveal tract

Iris & Pupils

Most anterior part of the uveal tract.

A thin circular disc corresponding to the diaphragm of a camera.

Divides the space between the cornea and lens into anterior and posterior chambers

In its centre is an aperture of about 4mm called “PUPILS”

Regulates the amount of light reaching the retina

Muscles of the iris controls the pupils size

•SPINCHTER PUPILLAE – Parasympathetic supply

•DILATOR PUPILLAE – Sympathetic supply

Ciliary body

vForward continuation of choroid, triangular in shape

vDivided into two parts

vPars plicata: anterior, with finger-like ciliary processes

vPars plana: posterior smooth part

v3 types of Non- striated muscles in the stroma

vLongitudinal – aids in aqueous outflow

vRadial- aids in aqueous outflow

vCircular- help in accomodation

vAqueous produced by ciliary epithelium.

vOptically clear media as it is devoid of protien cells.

Choroid

Posterior most part of the vascular coat of the eyeball

Inner surface is smooth, brown and lies in contact with retina where as outer surface is rough and in contact with the sclera

Function:

Nourishes the retina

Lens

A transparent, biconvex, crystalline structure between iris and vitreous

Suspended by ciliary zonules

Refractive index is 1.39

Dioptric power is 15-16 Diopters

Function

Accomodation 

vitreous

vClear, jelly-like substance that fills the middle of the eye.

vOccupies 4/5th of volume of the globe.

vTotal volume- 4 ml

vFunction:

vMedia for light pass.

vGive shape of globe internally

vPathway for nutrients to reach the retina and the lens

retina

The innermost tunic of the eyeball

Is a thin, delicate and transparent membrane

Is the most highly developed tissue of the eye

Appears purplish-red

Divided into 3 distinct regions

Optic disc

Macula Lutea

Peripheral Retina

retina

Has 10 layers

Function:

Senses light and creates impulses to the brain through optic nerve

Visual pathway

Eyeball acts as a camera; it perceives the images and relays the signals to the brain via visual pathway

orbit

Pyramidal shape bony cavity

Each eyeball is suspended by extraocular muscles and fascial sheaths with cushion of orbital pad of fats

Extraocular muscles

4 Recti

Medial Rectus

Lateral Rectus

Superior Rectus

Inferior Rectus

2 Oblique

Superior Oblique

Inferior Oblique

Innervation

LR6  SO4  Rest3

Appendages of the eye

Beauty of each eye is enhanced by the Eyebrows

Each eye is protected anteriorly by two shutters called Eyelids & Eyelashes

Conjunctiva  joins these eyelids to the eyeball

Appendages of the eye

For smooth functioning, the cornea and conjunctiva are kept moist due to tears produced by Main & Accessory Lacrimal Gland

The tears is drained by Lacrimal passage (Punctum, Canaliculi, Lacrimal sac, Nasolacrimal duct, Inferior Meatus)

Thank you

TRACHEOSTOMY It is an operation in which the windpipe is opened from the front of neck or Surgical creation of an opening into the trachea Indications for tracheostomy 1. Upper airway obstruction: to relieve upper airway obstruction  Infection : laryngeal infection  Neoplasm: carcinoma of larynx and pharynx  Trauma: laryngo-tracheal injuries  Foreign body in larynx  Neurological : B/L vocal cord palsy 2. Respiratory insufficiency : who needs prolong ventilation  Comatose patient without cough reflex: head and chest injuries, poisoning  Neurological condition: myasthenia garvis, poliomyelitis  COPD  Pneumonia 3. Tracheobronchial toileting  Accumulation of secretion in lower respiratory tract prevent proper gas diffusion at alveoli  Tracheostomy allows frequent and adequate pulmonary aspiration  Pulmonary edema  Congestive heart failure  Chronic lung disease and infections Types of Tracheostomy  Depending upon the urgency  Emergency  acute laryngeal obstruction demanding urgent relief.  Elective  Temporary  Permanent Technique  Position / Anaesthesia Tracheostomy Tubes  Metal tubes  Non-metal tubes Types of Tracheostomy Tubes  Portex tube (with cuff)  prevent aspiration  can be used in ventilator  May get blocked- has to be removed  Metal tubes  2 tubes - inner and outer tubes  Advantage - can be used for long period and has and less chance of blockade (if inner tube is blocked, it can be removed and patient breathes through the outer tube) Metallic tube Non metallic tube It has set of outer tube, inner tube and introducer Outer tube is fastened to neck with ribbon strap Inner tube is slipped into outer tube and fused to it by locking device Made of silastic Consists of single tube Advantage Main advantage of metal tube is that , if crusts or mucous plug blocks the inner tube and patient has difficulty in breathing, inner tube can be removed while outer tube remains in trachea and maintains patency of airway allowing the patient to breathe Advantage : Have inflatable cuff and can be connected to ventilator Disadvantage Do not have cuff and cannot produce an airtight seal needed for ventilator If lower end of metal tube do not fit properly, it can cause injury and even erosion of tracheal wall Disadvantage Inflatable cuff itself can cause excess cuff pressure leading to subglottic stenosis if used more than 2-3 weeks Has single tube, so that tube can get blocked due to mucous plug or crust leading to respiratory obstruction Nursing Care of Tracheostomy  Meticulous postoperative care of tracheostomy is necessary to avoid complication  Bed should be close to nursing station  Bedside items - suction machine with sterile suction catheters, 1 extra tracheostomy tube, paper and pen for the patient to communicate  Suction: regular tracheal suction after putting 1-2 ml of sterile saline into trachea to prevent crusting  Humidification : regular humidification( done by inhalation of steam or alternately by electric humidification unit ; nebulizer)  Chest physiotherapy: regular chest physiotherapy  First change of tube The first change of tracheostomy tube is done after 72 hours of surgery . after 72 hours a tract usually form and remains patent . if removed earlier than there is likelihood of soft tissue around tracheostomy collapsing and obstructing the airway Subsequent change of tube  When a metal tube is used –inner tube is removed, cleaned and reinserted without disturbing outer tube, 2 times a day  Outer tube is similarly removed and cleaned and reinserted once a day  When single lumen silastic tube is used – this tube should be removed cleaned and reinserted everyday Deflation of cuffed tube  When a cuffed silastic tube is used, cuff should be deflated every 2 hours for a few seconds or min in order to prevent tracheal injuries- necrosis and subglottic stenosis Principles of Decanulation  Tube size reduced before decanulation  Tube is corked off for increasing periods  Self-ventilating for at least one full night  No further need for tracheal suction  Remove the tube; plug the tracheostomy site