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William Mitchell
William Mitchell

Clinical Procedures For Ocular Examination Ebook Rar



This article discusses how the use of direct composites in restorations for some clinical procedures can be simpler and quicker than use of ceramics and other technologies that in recent years have often resulted in the practitioner doing too much restoring.




Clinical Procedures For Ocular Examination Ebook Rar



Used in dentistry for more than a century, electrosurgery has long been an effective soft-tissue cutting method that offers a variety of applications for clinicians. This article reviews advantages and disadvantages of electrosurgery and presents a variety of clinical examples of how it can be utilized to achieve successful outcomes in periodontal and general restorative procedures.


A case report from Rome, Italy, isolated SARS-CoV-2 by RT-PCR from conjunctival swabs in a COVID-19 patient with ocular symptoms.[17] Conjunctival swabs were collected from hospital days 3 to 27. Although conjunctivitis was clinically resolved on day 20, the patient had detectable viral SARS-CoV-2 RNA in conjunctival samples on day 21 and subsequently on day 27 after SARS-CoV-2 was negative by nasopharyngeal swab. Because SARS-CoV-2 has not been successfully cultured from human tears or conjunctival swabs, the viability and transmissibility of SARS-CoV-2 in human ocular secretions remains uncertain.[18] Limited reports suggest that tears can be both an early and late source of infection transmission, even after the patient becomes asymptomatic.[17][19]


Optical coherence tomography (OCT) showed subclinical hyperreflective lesions at the level of the inner plexiform and ganglion cell layers in 12 adults examined after systemic disease onset; cotton wool spots and microhemorrhages were found on dilated fundus examinations in 4 of these patients.[46] Invernizzi and colleagues found retinal hemorrhages (9.25%), cotton wools spots (7.4%), dilated veins (27.7%), and tortuous vessels (12.9%) in 54 patients with COVID-19 upon screening with fundus photography.[47] These authors also found that retinal vein diameter correlated directly with disease severity, suggesting that this may be a non-invasive parameter to monitor inflammatory response and/or endothelial injury in COVID-19. Lecler et al. described abnormal MRI findings in the posterior pole of 9 patients with COVID-19 consisting of one or several hyperintense nodules in the macular region on FLAIR-weighted images.[48] These lesions were postulated to be either direct inflammatory infiltration of the retina or microangiopathic disease from viral infection.


A thorough history is necessary regarding the onset, duration, and characteristics of symptoms. Anterior segment examination at the slit lamp or bedside can confirm findings of conjunctivitis or episcleritis. Measurement of visual acuity, intraocular pressure, and dilated fundus examination are warranted to rule out potentially more harmful ocular diseases. The clinician should perform a careful examination of pupils and color testing to evaluate patients for evidence of optic neuropathy. Evaluation of extraocular motility may show evidence of nystagmus or cranial neuropathies. Visual field testing can detect and confirm deficits related to stroke.


Although preliminary studies suggest that the risk of viral transmission through ocular secretions is low, large-scale research has not yet been done, and new data is emerging daily. Therefore, healthcare providers are still urged to wear proper protection of the eyes, nose, and mouth when examining patients (see below). Eye care providers and technicians may be more susceptible to infection due to the nature and proximity of the ophthalmic examination.[94] Eye care providers are encouraged to use slit lamp breath shields and should counsel patients to speak as little as possible when sitting at the slit lamp to reduce the risk of virus transmission. Disinfection and sterilization practices should be employed for shared clinic equipment such as tonometers, trial frames, pinhole occluders, B-scan probes, and contact lenses for laser procedures.[2][94] Disposable barrier protection of clinic tools should be used where possible.


  • Ocular shedding of SARS-CoV-2 via tears is a distinct possibility of which ophthalmologists should be aware.

  • Conjunctivitis or tearing can be the first presentation and even sole manifestation in a patient with the COVID-19 infection.

  • Several ocular manifestations of COVID-19 have been observed, including retinovascular disease, uveitis, optic neuropathies, and orbital fungal co-infections.

  • SARS-CoV-2 may trigger or exacerbate inflammatory/demyelinating disease.

  • Patients may present with chemosis in advanced cases (Fig 2) or follicular conjunctivitis (Fig 3).

  • The ocular examination should be performed while wearing gloves and using extension instruments (cotton swabs, etc.) to avoid direct contact with secretions.

  • As many patients who visit the ophthalmic clinic are elderly, many with comorbidities, it is important to screen the need for the visit ahead of time and only see patients who need urgent care. We continue to practice telemedicine for many of these patients.

  • As advocated in many countries, social distancing means being 6 feet away from others: this is clearly impossible in the clinical world and certainly in the small confines of ophthalmic examination lanes. One way to practice it is to have only one person in the room with the patient.

  • Anecdotally, it has been observed that physicians most at risk of becoming infected include ophthalmologists, otolaryngologists, and anesthesiologists because of the proximity of the examiners to mucosal surfaces.

  • When performing surgery under general anesthesia, it has been recommended that surgeons and other staff do not enter the room for 15 minutes after intubation or extubation. This standard is applied to all general anesthesia cases in many facilities, whether the patient is COVID-19 positive or negative.


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