Choosing the anaesthesia technique. Decide in advance what technique you are going to use. A retrobulbar block is more efficient in producing anaesthesia and akinesia. The right eye appears proptosed with a dilated pupil, extensive subconjunctival hemorrhage and bloody chemosis, as well evidence of periorbital swelling and hematoma. UK Vision Strategy RCGP – Royal College of General Practitioners Supported by. Advice for Floaters and Flashing Lights for primary care. Bupivacaine, marketed under the brand name Marcaine among others, is a medication used to decrease feeling in a specific area. It is used by injecting it into the. Aim: To determine outcomes of bleb excision and conjunctival advancement for leaking or hypotonous eyes after glaucoma filtering surgery. Methods: In a retrospective. Eye Health - A directory of UK health, disease, illness and related medical websites that provide patient. This article is to be published in Emergency Medicine Journal (EMJ), and is reproduced here with permission of the BMJ Group. Emergency physicians require competence. Diplopia as the Complication of Cataract Surgery. Dobry Wzrok Ophthalmological Clinic in Gdansk, Kliniczna 1. B/2, 8. 0- 4. 02 Gda. This is an open access article distributed under the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited. The authors present systematic review of aetiology and treatment of diplopia related to cataract surgery. The problem is set in the modern perspective of changing cataract surgery. Actual incidence is discussed as well as various modalities of therapeutic options. The authors provide the guidance for the contemporary cataract surgeon, when to expect potential problem in ocular motility after cataract surgery. Introduction. Cataract surgery is probably the most often performed surgical procedure in modern ophthalmology. Due to its commonness and improvement in surgical technique, the results are very spectacular, and so are patients. Most of the complications that cataract surgeon faces in his practice are connected with the course of the surgery itself and usually there is a clear explanation why such a complication has occurred. Experienced surgeon is usually capable of assessing the difficulty of the procedure and therefore he usually informs the patient about possible complications and the amount of risk. The situation is different with diplopia occurring after cataract surgery. It is not a frequent complication and usually appears as a major surprise and disappointment for both the patient and the surgeon. The purpose of our review is to assess the frequency of this complication and determine the group of patients at risk of developing diplopia after uncomplicated cataract surgery. Methodology. We conducted a search through Pub. Med for prospective and retrospective studies on aetiology and incidence of postoperative diplopia in cataract surgery. We used the following key words: cataract surgery, diplopia, and disruption of fusion. For the final analysis we chose 5. We analysed the material according to incidence, aetiology, and treatment of diplopia after cataract surgery. Incidence. Nowadays, there are not many reports in the literature that would cover the subject of postoperative diplopia in cataract patients. In this cohort of patients, only 1. The anaesthesia used during surgery was retrobulbar block ropivacaine diluted with hyaluronidase. Change in ocular alignment in 7% of patients was reported, but only one patient out of 1. Among those patients only 7 (5%) complained of diplopia; however, they did not seek the medical assistance for its treatment. The series included 2. The incidence of postoperative diplopia was 0. On average, the incidence was 0. As one can see from the above citations, the estimation of the incidence of diplopia after cataract surgery is quite difficult. Numbers given by different authors are not similar, so the only conclusion that can be made is that diplopia after cataract surgery seems to be really rare. The number of regional anaesthesia related cases of postsurgical diplopia is decreasing due to the use of topical medications so the subject of postoperative diplopia in cataract surgery is probably not in the focus of a contemporary surgeon. Interesting data are obtained from strabological clinics treating diplopia. Nayak et al. All of the patients had a form of regional anaesthesia: peribulbar or retrobulbar. Some had also superior rectus stay suture applied during the surgery. Patients with postsurgical diplopia constituted 3% of all patients with diplopia treated in the clinic during that period. Similarly, Karagiannis et al. Among them 3. 9 patients (6. Both studies go back a large span of time, when periocular anaesthesia was a rule. Presently for sure the percentage of patients treated for diplopia in orthoptic clinics after cataract surgery is much smaller, due to extensive use of solely topical anaesthesia during cataract surgery. Besides, in general, the number of patients with postoperative diplopia might be underestimated, due to their advanced age and lack of proper verbalization of this problem. Surgical Technique and Local Anaesthesia. Most of the clinical reports concerning diplopia after cataract surgery date back 1. At that time, surgical technique was evolving from extracapsular cataract extraction to phacoemulsification. The first technique involved bridal suture for stabilization of the globe, which potentially could produce trauma to superior rectus muscle. The evolution in surgical technique influenced also the type of local anaesthesia used for cataract surgery. Retrobulbar anaesthesia used widely with extracapsular extraction involved penetration of the needle towards the muscle cone and naturally bared a number of possible complications, such as direct injury to the muscle or nerves, retrobulbar haematoma, muscle paresis, or toxic reaction to the anaesthetic itself. With peribulbar anaesthesia direct trauma to the muscle is much less likely to occur so motility disturbances after cataract surgery were in such cases attributed mainly to myotoxic effect of the anaesthetic. With the advent of purely topical anaesthesia in cataract surgery, both the myotoxic effect of the anaesthetic and direct injury to the muscles are practically excluded. A few decades ago there were several reports published attributing postoperative diplopia after cataract surgery to the placement of bridal suture and subsequent injury to superior rectus or even superior oblique muscle . From a modern perspective this case does not seem to be a problem anymore, as set sutures are presently not used for regular cataract surgery. However, history gives us knowledge about this possible complication in other ophthalmic surgeries involving the use of set sutures, such as glaucoma surgery or retinal surgery. Majority of numerous reports concerning diplopia after cataract surgery published between 1. At that time majority of cataracts were operated on in retrobulbar or peribulbar anaesthesia, which was administered by the injection of the anaesthetic to the retrobulbar or peribulbar region. In both cases the needle penetrated through the skin in the immediate neighbourhood of the extraocular muscles. The placement of the injection for the retrobulbar anaesthesia was inferolateral quadrant of the orbital aperture. For peribulbar region, usually 2 injections were performed, involving inferolateral and inferomedial regions of the orbit. In both techniques inferior rectus muscle was the most exposed muscle for the direct or indirect trauma. Some authors allow the possibility of direct injury to the muscle by the needle with anaesthetic resulting in muscle paresis or significant hematoma resulting in subsequent muscle ischemia followed by fibrosis. This explanation however seems to be less probable or less frequent than myotoxic action of the anaesthetic itself. What is interesting, in some opinion, is that myotoxic effect of injection of the anaesthetic to the muscle is more likely to occur with peribulbar anaesthesia. Esswein and von Noorden report 9 cases of vertical strabismus after cataract extraction, 7 of which were consistent with the form of peribulbar injection of the anaesthetic . The usual composition of anaesthetic used in cataract surgery was 2% lidocaine and 0. Myotoxic action of the lignocaine and bupivacaine has been well documented in animal studies. Hyaluronidase is considered to have protective action against myotoxicity of the other agents . It helps spread the anaesthetic evenly through the tissues and prevents its focal high concentration, which bares the risk of toxic effect on the muscles. There are a few reports of rapid increase in the number of postcataract surgery diplopia cases when hyaluronidase became temporarily unavailable on the market in the late 9. MRI showed swelling and increase in signal intensity in affected (paretic) muscle, which was interpreted as inflammatory oedema. There was no sign of intraorbital haemorrhage. This finding supports the toxic theory of local anaesthetic. Kim and Hwang report superior rectus contracture in patient with postsurgical diplopia visible on MRI scans in case of superior rectus overaction . Animal studies showed rapid regeneration and no histological change of extraocular muscles after injection of just a simple saline solution . Presentation is hypertropia or hypotropia, depending also on the time of examination. Patients with diplopia examined promptly after cataract surgery usually had hypertropia as a result of inferior rectus paresis. With time, hypertropia might switch to hypotropia due to inferior rectus fibrosis and contracture. This kind of scenario was observed by Cap. According to the authors, myotoxicity of the anaesthetic causes transient paresis of the muscle followed by contracture or fibrosis. Mild contracture results in overaction of the affected muscle and significant contracture results in restrictive strabismus. Nayak et al. Similarly, Costa et al. Other authors report predominantly restrictive vertical strabismus with inferior rectus involvement . All these data confirm that inferior rectus is the most exposed for injury extraocular muscle during local anaesthesia. Injury to the superior rectus muscle has also been reported; however, these cases are much less frequent. There are several reports of oblique muscle injury due to anaesthesia in cataract surgery but these cases may be treated as anecdotal . Deficient motility of the affected eye was noted more often on the left side. Most of the surgeons and anaesthetists are right handed and have more difficulty in performing peribulbar or retrobulbar anaesthesia in the left eye of the patient. The needle in such cases is directed more closely to the muscle cone . The change in the technique of administering the local anaesthesia before cataract surgery resulted in significant reduction of postoperative diplopia cases .
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Stitch a Quick and Easy Crazy Nine Patch Quilt Pattern. Do you have a favorite baby quilt pattern? Mine is this Crazy Nine Patch pattern. It's quick and easy, can be made with. It's possible to put it all together and be finished in a weekend! In this example, the blocks finish at 1. Choose Your fabrics. The first step is to choose your fabrics ! I wanted to make this quilt for a baby boy, so I chose bright primary colors with lots of dots for energy. The project works best if you have a range of colors in mostly medium values (not too many very lights or very darks). I chose to use fabrics with dots, but the fabrics I used have dots in different sizes and shapes to add variety and interest to the finished quilt. The crazy nine patch pattern can be made in any size, just remember to cut your initial blocks 2. My blocks finish at 1. Can this Crazy quilt top be taken apart to make it for a full. Fabulous thank you,as a self taught patch-worker I wondered how to do crazy patchwork on a. Make the first cut and swap. Stack the nine 1. Using your rotary cutter and a ruler, make a slightly angled cut through all nine layers, making sure that the narrowest part isn't too close to the outside edge. Be careful not to make the angle too steep. Step 3. Chain piece the pairs. To start creating the pattern, take the top piece off the smaller stack and move it to the bottom of the stack. Then chain piece all nine pairs at the sewing machine without stopping in between. You'll end up with a . When you pick the stack up again, you'll have the blocks in the correct order for the next step. Step 4. Cut and swap again. Back at your cutting surface, use your rotary cutter and ruler to make another angled cut in the blocks on the opposite side of the first one. Take the top two pieces from the smaller stack and put them on the bottom. Make sure you always move pieces from the small stack, not the large one. Chain piece the smaller piece onto the larger one as before and press the seam to one side, restacking the blocks in the same order that you sewed them after pressing. Step 5. Third cut and swap. Take the blocks back to your cutting surface and turn them so the first two seams are running horizontally. Make a third angled cut through all nine blocks.
How+to+Make+Crazy+Quilt . August 2003 Crazy Block Tips & Hints. For the August block we're doing something different. We're doing crazy blocks. Be as creative as you want with them. We are making 12' blocks this year (that's 12 1/2' unfinished).This time, take the top three pieces from the smaller stack and put them on the bottom. Chain piece the smaller piece onto the larger one as before and press the seam to one side, restacking the blocks in the same order that you sewed them after pressing. Step 6. Final cut and swap. This is the last cut you'll make. Take your blocks back to your cutting surface and make an gentle angled cut on the opposite side of the block from the previous one. This last time, take the top six pieces from the smaller stack and put them on the bottom. Sew the pieces together and press as before. You should have a crazy nine patch block with one piece of each of your nine different fabrics in each angled square. Step 7. Arrange the blocks. 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