Your cycle starts on the first day you have your period. If you have a 28-day cycle, start using the test on day 11 and use it for six days, or however many days the manufacturer recommends. If your cycle runs between 27 and 34 days, your ovulation may range between days 13 and 20. Start testing on day 11 and continue until day 20 or so. If you have an irregular cycle, you may find that this is the least satisfying way for you to detect your ovulation, because some of the kits — which range in price from $20 to $50 — provide only five to nine days’ worth of tests. You may need to buy more than one kit a month.

Charting Your Menstrual Cycle

Many women choose to chart their menstrual cycle in order to determine when they are ovulating. Ovulation charting is also useful for predicting when your next period will be. All you need is a calendar that marks all the days in each month. When your period comes, mark that day on the calendar. This is known as Day 1. Next month, you will also record the first day of your period on the calendar. Count the number of days in between to find out the length of your cycle. To determine when you ovulate, count back 14 days from Day 1 of your cycle. This method will not be completely accurate it may be a few days off but it should give you a good idea as to when you are ovulating.

Also, some women get ovulation symptoms when their ovulation day is approaching or when ovulation is actually occurring. I will talk about three of the most common ovulation symptoms next to help make ovulation prediction simpler for you.

* Cervical mucus during ovulation and approaching ovulation is one of the signs of ovulation and a great way to know that your most fertile days have arrived. One of the purposes of cervical mucus during ovulation is to sustain the sperm in a healthy medium and to allow it to move freely through the cervix. Logically, as your cycle progresses, your cervical mucus increases in volume and changes texture. The changes reflect your body’s rising levels of estrogen. You are considered most fertile when the mucus becomes clear, slippery, and stretchy. Many women compare mucus at this stage to raw egg whites.

Normally the mucous is a protective barrier, but during the most fertile time of your cycle, it allows sperm to get through the cervix, up to the uterus, and then to the fallopian tubes for a rendezvous with your egg. Using clean fingers, or if you prefer, toilet paper, you can examine your cervical fluid. Prior to ovulation, during non-fertile periods, you will experience a dryness (or lack of cervical mucus). Gradually, as you approach ovulation, the cervical mucus will increase, though the consistency will be “sticky” and the color will be white, yellow, or cloudy in nature.

Directly prior to ovulation, cervical fluid will increase greatly, and now the mucus will be semi-transparent, slippery, with the consistency of “raw egg white”. This is your most fertile period and ovulation will take place at about this time.

Keep track of this and other ovulation symptoms on your ovulation calendar and/or basal body temperature (BBT) chart. The more you track, the clearer you will understand when your most fertile days are and the easier time you will have determining ovulation date. You should begin to see patterns after tracking for a couple months. If you find that your cervical mucus is not reaching the “raw egg white” stage, you may want to try a lubricant like Pre-Seed. Pre-Seed is the only truly sperm friendly lubricant currently on the market at this time, and many people have found success in getting pregnant while using it.

Mittleschmerz

* Another ovulation symptom some women experience is cramping during ovulation or ovulation pain. About one-fifth of women actually feel ovulatory activity, which can range from mild achiness to twinges of pain. This is called mittelschmerz, which means “middle pain” in German, and may last a few minutes to a few hours. Many women experience a cramping-type sensation during ovulation. Sometimes this cramping sensation has felt like trapped stomach gas.

* Many times women will also have light spotting along with the cramping during ovulation. The bleeding during ovulation could be caused by a couple different things. One theory is that the egg bursting forth from the follicle caused the bleeding. Another theory is that the estrogen rise during ovulation caused the uterine lining to shed a bit and cause a little spotting. This along with the cramping sensation is apparently an excellent fertility sign and means you are ovulating good and strong.

First, let’s discuss what ovulation is.

“What is ovulation?”

Track your cycle using basal termometer

Ovulation is the period of the menstrual cycle when the mature egg is released from its follicle in the ovary. This happens about midway (day 14 of a 28-day cycle) through the menstrual cycle, but varies from woman to woman, especially those with irregular cycles.

“Do you have irregular cycles? How can you know?”

Well, the best way to tell if you have irregular cycles is to begin to track your cycles. The more tools you use to track your monthly cycles, the better you will be at determining ovulation date. This is absolutely crucial to timing baby-making sex, especially if you ovulate irregularly.

How does ovulation determine when I can get pregnant?

Credits to : Encyclopedia Brittanic

To be fruitful and multiply, you must have sexual intercourse during the period spanning one to two days before ovulation to about 24 hours afterward. The reason: Sperm cells can live for two or three days, but an egg survives no more than 24 hours after ovulation — unless, of course, fertilization occurs.

If you have sex near the time of ovulation, you’ll increase your chances of getting pregnant. And you’ll be happy to know that the odds are with you: In normally fertile couples, there is a 20 percent chance of getting pregnant each cycle. About 85 percent of women who have sex without using birth control will get pregnant within one year. You can try to boost your likelihood of getting pregnant by learning to pinpoint exactly when you ovulate and by familiarizing yourself with the cyclic hormonal and physical changes that take place in your body each month. You can also use this knowledge to attempt birth control by avoiding intercourse near the time of ovulation. However, this is not the best form of birth control and it can easily fail.

“But when is ovulation? When does ovulation occur?”

One of the common methods to track your cycles by using a basal thermometer. This thermometer is different from the regular thermometer used to determine a fever. A basal thermometer is an ultra-sensitive thermometer that tracks your body’s most minute temperature shift and helps you calculate ovulation. Following ovulation, your temperature can increase by 0.4 to 1.0 degrees. This temperature spike indicates that you’ve ovulated, because releasing an egg stimulates the production of the hormone progesterone, which raises body temperature.

You’re most fertile in the two or three days before your temperature hits its high point. A few experts think you may have an additional 12- to 24-hour window of fertility after you first notice the temperature creep up, but most say that at that point, it’s too late to make a baby.

“It can take one to two days after ovulation for progesterone to build up enough to raise your body temperature. But since the egg can only survive for about 24 hours, at that point, it’s too late for fertilization,” says Tracy Telles, an ob-gyn at the Permanente Medical Group in Walnut Creek, California. That’s why experts recommend that you chart your temperature by taking it each morning for a few months to detect a pattern and pinpoint your likely ovulatory date. Then you can plan to have sex during the two to three days preceding the day your temperature normally rises.

Another means for determining ovulation date is an ovulation prediction kit (OPK) . There are two kinds – the urine strips and also the saliva microscopes. The strips are like a pregnancy test stick, only they measure LH (or luteinizing hormone) instead of HCG (the pregnancy hormone). These are both GREAT ways to help you calculate date of ovulation. Available at drugstores and grocery stores without a prescription, ovulation predictor kits detect the surge in luteinizing hormone (LH) in your urine just before ovulation. They’re easier to use and often more accurate than the BBT method, and they can predict ovulation 12 to 36 hours in advance and help you maximize your chance of conception the very first month you use them.

But they’re not foolproof. Rarely, they can measure LH (you get either a positive or a negative result, not a number), but can’t indicate whether you ovulate after a positive response; LH can surge with or without the release of an egg. False LH surges can also take place before the real one.

Before a diabetic coma, you’ll usually experience signs and symptoms of high blood sugar or low blood sugar.

Early symptoms that may lead to diabetic coma if not treated include:

• Increased thirst
• Increased urination
• Weakness
• Drowsiness
• Altered mental state
• Headache
• Restlessness
• Inability to speak
• Paralysis

Symptoms of Ketoacidotic Coma

Ketoacidotic coma occurs mostly in patients with Type 1 diabetes, Diabetes.co.uk reports. It is caused by the build-up of ketones — by-products of fat breakdown — that cause the blood to become excessively acidic. When insulin is lacking, the body switches to using fat instead of glucose for energy, causing the ketone build-up. What causes ketoacidosis?

Here are three basic reasons for moderate or large amounts of ketones:

• Not enough insulin
  Maybe you did not inject enough insulin. Or your body could need more insulin than usual because of illness.
• Not enough food
  When you’re sick, you often don’t feel like eating, sometimes resulting in high ketone levels. High levels may also occur when you miss a meal.
• Insulin reaction (low blood glucose)
  If testing shows high ketone levels in the morning, you may have had an insulin reaction while asleep.

Usually, this is brought about or worsened by an infection or missed insulin dosage.

Ketoacidosis usually develops slowly. But when vomiting occurs, this life-threatening condition can develop in a few hours. Early symptoms include the following:

• Thirst or a very dry mouth
• Frequent urination
• High blood glucose (sugar) levels
• High levels of ketones in the urine

Late symptoms include fatigue, lethargy, extreme thirst, nausea, confusion, difficulty in breathing, vomiting, stomach pain, frequent urination and fruity smell on the breath.

Symptoms of Hyperosmolar Coma

High blood sugar (hyperglycemia)
If your blood sugar level is too high, you may experience:

• Increased thirst
• Frequent urination – The level of sugar causes the blood to change consistency and become thicker and syrupy. Excessive sugar in the blood causes the kidneys to try to remove it as a waste product. It does this through excessive urination. This can lead to dehydration which if prolonged can lead to unconsciousness and coma.
• Fatigue
• Nausea and vomiting
• Shortness of breath
• Stomach pain
• Fruity breath odor
• Fast heartbeat

This case can be due to the following three reasons. The first reason is due to forgotten insulin or diabetic medicines. The second reason is due to some infections like flu or pneumonia. These infections can lead to increase in the sugar levels of the body. The last possibility is that the diabetic person may have consumed a lot of sugar and glucose rich foods.

Symptoms of Hypoglycemia Coma

Low blood sugar (hypoglycemia)
If your blood sugar level is too low, you may feel:

• Shaky or nervous
• Tired
• Sweaty
• Hungry
• Nauseated
• Irritable
• An irregular or racing heartbeat
• Hostile or aggressive
• Confused

Some people develop a condition known as hypoglycemia unawareness and won’t have the warning signs that signal a drop in blood sugar.

The patient suffers from these symptoms because of overdose of insulin or diabetic medicines. Rigorous exercising may also lead to this state. Excessive alcoholism is another cause of diabetic coma.

If you experience any symptoms of high or low blood sugar, test your blood sugar and follow your diabetes treatment plan based on the test results. If you don’t start to feel better quickly, or you start to feel worse, call for emergency help. The difficulty with ALL of the diabetic coma symptoms above is that they can often simply be signs of the flu or other common sickness.

When to see a doctor

A diabetic coma is a medical emergency. If you feel extreme high or low blood sugar symptoms and think you might pass out, call 911 or your local emergency number. If you’re with someone with diabetes who has passed out, call for emergency help, and be sure to let the emergency personnel know that the unconscious person has diabetes.

Developing a diabetic coma is an extreme condition. Nonetheless, it can and does occur. How do you reduce the odds of prevent it?

1. Develop and Maintain a Self Management Plan: Stick with your meal and exercise plan. Take your medications.
2. Avoid Bad Habits. Ease off the alcohol and illegal drugs.
3. Inform Your Friends, Family and Co-workers of Symptoms.
4. Monitor your Blood Glucose and Ketone Levels Frequently.
5. Wear a Medical ID Bracelet.

As always, please speak with your health care provider about diabetic coma symptoms and your self-management plan.

These terms are confusing, and not because my blood sugar is too high. They don’t have any connection to reality. Indeed, if I was nicknaming medical conditions today, I would switch these.

Insulin Shock

Insulin shock makes it sound like the body is in shock, which isn’t true. Shock is, first and foremost, a lack of blood flow to important areas of the body, like the brain. It usually comes with a very low blood pressure. The most common symptom of low blood sugar is confusion (yeah, I know, that’s supposed to go with diabetic coma — just stay with me here), not a low blood pressure. In fact, insulin shock doesn’t affect the blood pressure much at all.

Insulin shock also implies that insulin is to blame, but insulin — at least from injections — is not required for someone to develop low blood sugar. Plenty of diabetics take pills, which are not insulin, to control their blood sugar levels. Some diabetics control their blood sugar levels simply by watching their diets. To make it even worse, some folks get low blood sugar even though they’re not diabetic at all, which means they would have no reason to take insulin.

The pancreas secrete a hormone called insulin, that maintains the levels of glucose or sugar in the blood. Insulin then stimulates the cells to supply glucose in the blood to various organs in the body. In hypoglycemia or insulin shock too much insulin is secreted by the pancreas, and this leads to lowered blood sugar level (a blood sugar level below 70mg/dL is considered low). Hypoglycemia can also occur if you are taking excess diabetes medications or are eating food that is low on carbohydrates.

So why is it called insulin shock? Because it sort of looks like shock. Shock, the real, low blood pressure kind, causes the body to react with what’s known as the Fight or Flight Syndrome. Low blood sugar does the same thing. The Fight or Flight Syndrome is the body’s normal reaction to any stress. It makes us ready to run away or fight for our lives. It causes our hearts to beat faster and it makes us sweat.

Having too little blood, too little oxygen, or too little sugar all make your body scared enough to get ready to do battle or run away. That’s where the name comes from, but it sure doesn’t explain much about the problem.

Severe hypoglycemia or an insulin shock is a medical emergency, and should be treated immediately as it can cause permanent damage to the nervous system. Treating the person with glucose injections is one of the ways to treat insulin shock.

SIGNS & SYMPTOMS: Fast breathing, fast pulse, dizziness, weakness, change in the level of consciousness, vision difficulties, sweating, headache, numb hands or feet, and hunger.

Diabetic Coma

At least with insulin shock, the victim usually knows about the diabetes. Diabetic coma, on the other hand, creeps up on you. It takes a lot of sugar in the bloodstream to reach confusion and unconsciousness. That doesn’t happen overnight. Diabetic coma is most likely to happen to those who don’t know they’re diabetic yet.

Worse, high blood sugar stimulates the production of urine — lots of urine. One of the symptoms of high blood sugar is frequent urination. Victims can urinate so often they become dehydrated, which can lead to shock.

Okay, so follow along with me here: Insulin shock causes confusion and unconsciousness very quickly and is not shock at all, but diabetic coma only causes unconsciousness after several days — maybe weeks — and leads to dehydration severe enough in some people to be considered shock.

Diabetic coma is a medical emergency, and can prove fatal in case it is left untreated. An extreme fluctuation in the blood sugar level (either too high or too low) is the chief reason for a diabetic coma. Other causes for a diabetic coma are Diabetic ketoacidosis (that is muscle cells do not get enough energy), and Diabetic hyperosmolar syndrome (that is the blood sugar levels cross as high as 600 mg/dL). People with diabetes (type 1 or type 2) are at a risk of diabetes coma. High consumption of alcohol, skipping insulin injections, certain injuries and trauma, and drug abuse are also the risk factors that can lead to a diabetic coma.

SIGNS AND SYMPTOMS: Diabetic coma develops more slowly than Insulin shock, sometimes over a period of days. Signs and symptoms include drowsiness, confusion, deep and fast breathing, thirst, dehydration, fever, a change in the level of consciousness and a peculiar sweet or fruity-smelling breath.

Overview of Double Eyelid Surgery

The main goal of double eyelid surgery is to make the eyes appear larger and wider. Aside from the use of the blepharoplasty procedure, double eyelid surgery also involves adding a crease or a fold of skin in the upper eyelid, which will then make the eyes appear larger and rounder. Creating an additional upper eyelid fold is a relatively simple and quick cosmetic plastic surgery method.

Asian double eyelid surgery is a specialized surgical procedure that has the ability to change not only the appearance of the upper eyelid itself, but that of the entire eye as well. Since almost fifty percent of Asians are born with the condition called “single fold” eyelid, a lot of them undergo this specialized procedure in order to get rid of this problem.

Because of the efficacy of double eyelid surgery in making the eyes of Asian people appear rounder and larger; this type of surgery is now very popular in almost all Asian nations. However, this type of surgery has a long and rich history, being performed for many decades now. Double eyelid surgery has been used by people with Asian descent long before Hollywood movie stars and Western media have influenced their country. In fact, the first reported double eyelid operation was in 1896 in Japan.

Factors that a Surgeon should consider before Performing a Double Eyelid Surgery

Asian cosmetic double eyelid surgery requires that the plastic surgeon have intimate knowledge as to where he or she should create the incisions. A double eyelid surgeon should also know how much fat and tissue to remove as well as where to put the additional crease.

Before a double eyelid surgery starts, the surgeon should already have taken into consideration the epicanthal fold of the patient. The epicanthal fold is one of the structures of the eyes that consist of a web of skin. This piece of skin overlaps the corner of the eye where the nose meets the eyelid. Depending on how pronounced the epicanthal fold is, the surgeon should be able to use a special technique in order to create a double eyelid.

How the Double Eyelid Surgery Procedure is performed

Double eyelid surgery involves a simple and a quick cosmetic plastic surgery procedure. It involves the removal of a miniscule amount of excess skin, a very small amount of fat pads, as well as under-skin tissue. The procedure that this type of surgery follows is similar to the more traditional upper eyelid surgery, but is not identical.

Before the double eyelid surgery is performed, the surgeon will give the patient either a local anesthesia or a general anesthesia. If a patient is under a local anesthesia, this means that the patient is awake while the procedure is being performed but will not feel any kind of pain. On the other hand, with a general anesthesia, the patient is asleep and will only wake up once the procedure has been completed and the anesthesia loses its effects.

Once the patient has been administered with a local or a general anesthesia, the surgeon will create an incision on the upper eyelid. This incision will be the opening that the surgeon will use in order to remove excess skin and fat as well as a tiny amount of muscle tissue. The incision will then be carefully closed using fine sutures to prevent conspicuous scars from developing. In fact, there are some cases wherein the sutures are responsible for creating the additional “fold” or crease in the upper eyelid.

The Results of Double Eyelid Surgery

After undergoing a double eyelid surgery, the new fold or crease in the upper eyelid is most likely to appear higher than where the patient would have imagined it to be. However, this is only going to be for the first few days after the successful double eyelid operation. After a month or two, the patient will notice that the additional fold or crease is already settling into the area where the plastic surgeon has intended it to.

The Required Recovery Period after a Double Eyelid Surgery

While the double eyelid surgery is a quick and simple cosmetic plastic surgery method, it is still a surgery nonetheless. This type of cosmetic surgery has a lot of benefits and advantages, but patients should also be aware of what to expect after the surgery. After undergoing a double eyelid surgery, the patient may experience some discoloration, bruising, and swelling around the eye area for a week. However, this can easily be resolved as long as the patient follows the eyelid surgery recovery directions in order to minimize and alleviate the side effects of the procedure.

Your health care provider will get a medical history and perform a physical examination.

Medical history questions may include:

• Are both eyelids affected or just one?
• How long has this been present?
• Is it getting worse or staying the same?
• Is it present all of the time or only sometimes?
• What other symptoms do you have?

The physical examination may include a detailed assessment of nerve functioning.

Diagnostic tests that may be performed include:

• Slit-lamp examination
• Tensilon test

Slit-lamp exam

The slit-lamp examination looks at structures that are at the front of the eye.

The slit-lamp is a low-power microscope combined with a high-intensity light source that can be focused to shine in a thin beam.

You will sit in a chair with the instrument placed in front of you. You will be asked to rest your chin and forehead on a support to keep your head steady.

The health care provider will examine your eyes, especially the eyelids, cornea, conjunctiva, sclera, and iris. Often a yellow dye (fluorescein) is used to help examine the cornea and tear layer. The dye is either added as a drop, or the health care provider may touch a fine strip of paper stained with the dye to the white of your eye. The dye rinses out of the eye with tears as you blink.

Next, drops may be placed in your eyes to widen (dilate) your pupils. The drops take about 15 to 20 minutes to work. The slit-lamp examination is then repeated using another small lens held close to the eye, so the back of the eye can be examined.

Pathology

Myasthenia gravis is a common neurogenic ptosis which could be also classified as neuromuscular ptosis because the site of pathology is at the neuromuscular junction. Studies have shown that up to 70% of myasthenia gravis patients present with ptosis, and 90% of these patients will eventually develop ptosis. In this case, ptosis can be unilateral or bilateral and its severity tends to be oscillating during the day, because of factors such as fatigue or drug effect. This particular type of ptosis is distinguished from the others with the help of a Tensilon challenge test and blood tests. Also, specific to myasthenia gravis is the fact that coldness inhibits the activity of cholinesterase, which makes possible differentiating this type of ptosis by applying ice onto the eyelids. Patients with myasthenic ptosis are very likely to still experience a variation of the drooping of the eyelid at different hours of the day.

The ptosis caused by the oculomotor palsy can be unilateral or bilateral, as the subnucleus to the levator muscle is a shared, midline structure in the brainstem. In cases in which the palsy is caused by the compression of the nerve by a tumor or aneurysm, it is highly likely to result into an abnormal ipsilateral papillary response and a larger pupil. Surgical third nerve palsy is characterized by a sudden onset of unilateral ptosis and an enlarged or sluggish pupil to the light. In this case, imaging tests such as CTs or MRIs should be considered. Medical third nerve palsy, contrary to surgical third nerve palsy, usually does not affect the pupil and it tends to slowly improve in several weeks. Surgery to correct ptosis due to medical third nerve palsy is normally considered only if the improvement of ptosis and ocular motility are unsatisfactory after half a year. Patients with third nerve palsy tend to have diminished or absent function of the levator.

When caused by Horner’s syndrome, ptosis is usually accompanied by miosis and anhidrosis. In this case, the ptosis is due to the result of interruption innervations to the sympathetic, autonomic Muller’s muscle rather than the somatic levator palpebrae superioris muscle. The lid position and pupil size are typically affected by this condition and the ptosis is generally mild, no more than 2 mm. The pupil might be smaller on the affected side. While 4% cocaine instilled to the eyes can confirm the diagnosis of Horner’s syndrome, Hydroxyamphetamine eye drops can differentiate the location of the lesion.

Chronic progressive external ophthalmoplegia is a systemic condition that occurs suddenly and which usually affects only the lid position and the external eye movement, without involving the movement of the pupil. This condition accounts for nearly 45% of myogenic ptosis cases. Most patients develop ptosis due to this disease in their adulthood. Characteristic to ptosis caused by this condition is the fact that the protective up rolling of the eyeball when the eyelids are closed is very poor.

Treatment

Aponeurotic and congenital ptosis may require surgical correction if severe enough to interfere with vision or if cosmesis is a concern. Treatment depends on the type of ptosis and is usually performed by an ophthalmic plastic and reconstructive surgeon, specializing in diseases and problems of the eyelid.

Surgical procedures include:

• Levator resection
• Müller muscle resection
• Frontalis sling operation

Non-surgical modalities like the use of “crutch” glasses or special Scleral contact lenses to support the eyelid may also be used.

Ptosis that is caused by a disease will improve if the disease is treated successfully.

Unilateral drooping eyelid

A drooping eyelid can stay constant, worsen over time (progressive), or come and go (intermittent). It can be one-sided or on both sides. When drooping is one-sided (unilateral), it is easier to be detected by comparing the two eyelids. Drooping is more difficult to detect when it occurs on both sides, or if there is only a slight problem.

A furrowed forehead or a chin-up head position may indicate that someone is trying to see under their drooping lids. Eyelid drooping can make someone appear sleepy or tired.

Drooping lids are either present at birth (congenital) or develop later in life. A drooping eyelid is not a reason to panic, but you should report it to your doctor.

Etymology

Ptosis is derived from the Greek wording (πτῶσις) “fall,” and is defined as the “abnormal lowering or prolapse of an organ or body part.”

Causes

Both eyelids drooping:

• Medical problem, such as myasthenia gravis
• Migraine headaches
• Normal aging process
• Normal variation of the eyelids

One eyelid drooping:

• Growth in the eyelid, such as a stye
• Medical problem
• Nerve injury
• Normal aging process
• Normal variation

Ptosis occurs when the muscles that raise the eyelid (levator and Müller’s muscles) are not strong enough to do so properly. It can affect one eye or both eyes and is more common in the elderly, as muscles in the eyelids may begin to deteriorate. One can, however, be born with ptosis. Congenital ptosis is hereditary in three main forms. Causes of congenital ptosis remain unknown. Ptosis may be caused by damage/trauma to the muscle which raises the eyelid, damage to the superior cervical sympathetic ganglion or damage to the nerve (3rd cranial nerve (oculomotor nerve)) which controls this muscle. Such damage could be a sign or symptom of an underlying disease such as diabetes mellitus, a brain tumor, a pancoast tumor (apex of lung) and diseases which may cause weakness in muscles or nerve damage, such as myasthenia gravis. Exposure to the toxins in some snake venoms, such as that of the black mamba, may also cause this effect.

Ptosis can be caused by the aponeurosis of the levator muscle, nerve abnormalities, trauma, inflammation or lesions of the lid or orbit. Dysfunctions of the levators may occur as a result of a lack of nerve communication being sent to the receptors due to antibodies needlessly attacking and eliminating the neurotransmitter.

Ptosis may be due to a myogenic, neurogenic, aponeurotic, mechanical or traumatic cause and it usually occurs isolated, but may be associated with various other conditions, like immunological, degenerative, or hereditary disorders, tumors, or infections.

Acquired ptosis is most commonly caused by aponeurotic ptosis. This can occur as a result of senescence, dehiscence or disinsertion of the levator aponeurosis. Moreover, chronic inflammation or intraocular surgery can lead to the same effect. Also, wearing contact lenses for long periods of time is thought to have a certain impact on the development of this condition.

Congenital neurogenic ptosis is believed to be caused by the Horner syndrome. In this case, a mild ptosis may be associated with ipsilateral ptosis, iris and areola hypopigmentation and anhidrosis due to the paresis of the Mueller muscle. Acquired Horner syndrome may result after trauma, neoplastic insult, or even vascular disease.

Ptosis due to trauma can ensue after an eyelid laceration with transection of the upper eyelid elevators or disruption of the neural input.

Other causes of ptosis include eyelid neoplasms, neurofibromas or the cicatrization after inflammation or surgery. Mild ptosis may occur with aging.

Drugs

Use of high doses of opioid drugs such as morphine, oxycodone or hydrocodone can cause ptosis, and it is a side effect commonly seen in the abuse of drugs such as diacetylmorphine (heroin). Pregabalin (Lyrica) has also been known to cause mild ptosis.

Classification

Depending upon the cause it can be classified into:

• Neurogenic ptosis which includes oculomotor nerve palsy, Horner’s Syndrome, Marcus Gunn jaw winking syndrome, Third cranial nerve misdirection.
• Myogenic ptosis which includes myasthenia gravis, myotonic dystrophy, ocular myopathy, simple congenital ptosis, blepharophimosis syndrome
• Aponeurotic ptosis which may be involutional or post-operative.
• Mechanical ptosis which occurs due to edema or tumors of the upper lid
• Neurotoxic ptosis which is a classic symptom of envenomation by elapids such as cobras, or kraits. Bilateral ptosis is usually accompanied by diplopia, dysphagia and/or progressive muscular paralysis. Regardless, neurotoxic ptosis is a precursor to respiratory failure and eventual suffocation caused by complete paralysis of the thoracic diaphragm. It is therefore a medical emergency and immediate treatment is required.
• pseudo ptosis due to:1-Lack of lid support: Empty socket or atrophic globe. 2-Higher lid position on the other side: As in      lid retraction

• To reattach the retina.
• To prevent or reverse vision loss.

Laser Surgery and Cryopexy

For small holes and tears, laser surgery or a freezing treatment called cryopexy may be recommended, which can usually prevent retinal detachment and preserve almost all vision. These procedures are usually performed in the doctor’s office.

Treating a retinal tear may be useful if the tear is likely to lead to detachment. Symptoms such as floaters or flashing lights are key factors in deciding whether to treat a tear. A tear that occurs right after a posterior vitreous detachment (PVD) with symptoms is usually much more dangerous and more likely to progress to a retinal detachment than one that occurs without symptoms.

In deciding when to treat a retinal tear, your doctor will evaluate whether the torn retina is likely to detach. If the tear is very likely to lead to detachment, treatment can usually repair it and prevent detachment and potential vision loss. If the tear is not likely to lead to detachment, you may not need treatment.

• Laser surgery (photocoagulation). During photocoagulation your surgeon directs a laser beam through a contact lens or ophthalmoscope designed for this procedure. The laser makes burns around the retinal tear, and the scarring that results usually “welds” the retina to the underlying tissue.
• Freezing (cryopexy). During cryopexy, your surgeon uses intense cold to freeze the retina around the retinal tear. After a local anesthetic numbs your eye, your surgeon applies a freezing probe to the outer surface of the eye directly over the retinal defect. This freezes the area around the hole, leaving a delicate scar that helps secure the retina to the eye wall.

After your procedure you’ll need to remain relatively still for the next two weeks or so, as the bonds created by your procedure strengthen.

Scleral Buckle, Vitrectomy, and Pneumopexy

For some cases, other types of surgery for detached retina may be recommended. These procedures may be done in conjunction with photocoagulation or cryopexy. The type, size and location of the retinal detachment will determine which surgical approach your eye surgeon recommends. In general, these surgeries can successfully treat most cases of retinal detachment, although a second treatment is sometimes necessary. These surgeries include scleral buckling, vitrectomy, or pneumopexy.

Scleral Buckling

A procedure called scleral buckling involves suturing a piece of silicone rubber or sponge to the white of your eye (sclera) over the affected area. The silicone material indents the wall of the eye, relieving the tugging of the vitreous on the retina. When you have several tears or holes or an extensive detachment, your surgeon may create an encircling scleral buckle that goes around the entire circumference of your eye like a belt. The buckle usually remains in place for the rest of your life. A scleral buckle is a tiny synthetic band that is attached to the outside of the eyeball to gently push the wall of the eye against the detached retina.

Vitrectomy and Pneumopexy

During a vitrectomy, the doctor makes a tiny incision in the sclera (the white of the eye). Next, a small instrument is placed into the eye to remove the vitreous, a gel-like substance that fills the center of the eye and helps the eye maintain a round shape. Then, gas is often injected into the eye to replace the vitreous and reattach the retina (known as a pneumopexy); the gas pushes the retina back against the wall of the eye. During the healing process, the eye makes fluid that gradually replaces the gas and fills the eye.

With no new fluid passing through the retinal tear, fluid that had previously collected under the retina is absorbed, and the retina is able to reattach itself to the back wall of your eye. Depending on where the retinal detachment is located in your eye, you may need to hold your head in a certain position for several hours in order to keep the bubble in place. With these two surgical procedures, after a couple of weeks, laser surgery or cryopexy is used to “weld” the retina back into place.

Expected Results of Surgery for Detached Retina

With modern detached retina surgery, more than 90 percent of cases can be successfully treated. In some cases, however, a second surgery is needed.

The visual outcome is not always predictable following surgery. The final visual result may not be known for up to several months following surgery for detached retina. Even under the best of circumstances, and even after multiple attempts at repair, treatment sometimes fails, and vision may eventually be lost. Visual results are best if the retinal detachment is repaired before the macula (the center region of the retina responsible for fine, detailed vision) detaches.

Controversy

The value of stenting in rescuing someone having a heart attack (by immediately alleviating an obstruction) is clearly defined in multiple studies, but studies have failed to find reduction in hard endpoints for stents vs. medical therapy in stable angina patients (see below). The artery-opening stent can temporarily alleviate chest pain, but do not contribute to longevity. The “vast majority of heart attacks do not originate with obstructions that narrow arteries.”

A more permanent and successful way to prevent heart attacks in patients at high risk is to give up smoking, exercise, and take “drugs to get blood pressure under control, drive cholesterol levels down and prevent blood clotting”.

Some cardiologists believe that stents are over-used; however, in certain patient groups, such as the elderly, GRACE and other studies have found evidence of underuse. Guidelines recommend a stress test before implanting stents, but most patients do not receive a stress test.

Clinical Trials

While revascularisation (by stenting or bypass surgery) is of clear benefit in reducing mortality and morbidity in patients with acute symptoms (acute coronary syndromes) including myocardial infarction, their benefit is less marked in stable patients. Clinical trials have failed to demonstrate that coronary stents improve survival over best medical treatment.

• The COURAGE trial compared PCI with optimum medical therapy. Of note, the trial excluded a large number of patients at the outset and undertook angiography in all patients at baseline, thus the results only apply to a subset of patients and should not be over-generalised. COURAGE concluded that in patients with stable coronary artery disease PCI did not reduce the death, myocardial infarction or other major cardiac events when added to optimum medical therapy.

• The MASS-II trial compared PCI, CABG and optimum medical therapy for the treatment of  multi-vessel coronary artery disease. The MASS-II trial showed no difference in cardiac death or acute MI among patients in the CABG, PCI, or MT group. However, it did show a significantly greater need for additional revascularization procedures in patients who underwent PCI.

• The SYNTAX Trialis a manufacturer-funded trial with a primary endpoint of death, cardiovascular events, and myocardial infarction, and also the need for repeat vascularization, in patients with blocked or narrowed arteries. Patients were randomized to either CABG surgery or a drug-eluding stent (the Boston Scientific TAXUS paclitaxel-eluding stent). SYNTAX found the two stratgies to be similar for hard endpoints (death and MI). Those receiving PCI required more repeat revascularisation (hence the primary endpoint analysis did not find PCI to be non-inferior), but those undergoing CABG had significantly more strokes pre or perioperatively. Use of the SYNTAX risk score is being investigated as a method of identifying those multivessel disease patients in whom PCI is a reasonable option vs those in whom CABG remains the preferred strategy.

Several other clinical trials have been performed to examine the efficacy of coronary stenting and compare with other treatment options. A consensus of the medical community does not exist.

Restenosis

One of the drawbacks of vascular stents is the potential for restenosis via the development of a thick smooth muscle tissue inside the lumen, the so-called neointima. Development of a neointima is variable but can at times be so severe as to re-occlude the vessel lumen (restenosis), especially in the case of smaller diameter vessels, which often results in reintervention. Consequently, current research focuses on the reduction of neointima after stent placement. Considerable improvements have been made, including the use of more bio-compatible materials, anti-inflammatory drug-eluting stents, resorbable stents, and others. Restenosis can be treated with a reintervention using the same method.

• On September 4, 2007, an international study showed that some heart attack patients would be better off without using drug-coated stents in emergency to open their clogged arteries (patients were 5 times more likely to die after 2 years than those who received bare-metal stents). Dr. Valentin Fuster, director of the Cardiovascular Institute at Mount Sinai School of Medicine in New York said stents are less commonly used in Europe, implanted in only about 15 % of patients there while drug-lined stents are used in up to 30% of Americans having heart attacks. The new research was presented by Dr. Gabriel Steg, of the Hospital Bichat-Claude Bernard in Paris, at a meeting of the European Society of Cardiology in Vienna. Dr. Eckhart Fleck, director of cardiology at the German Heart Institute in Berlin and a spokesman for the European Society of Cardiology said that “Drug-eluting stents are not for everyone.”

Similar stents and procedures are used in non-coronary vessels e.g. in the legs in peripheral artery disease.

History

The first type, developed by John Robert Dugan of Shelbyville, IN, were bare-metal stents. More recent are drug-eluting stents.

In development are stents with biocompatible surface coatings which do not elute drugs, and also absorbable stents (metal or polymer).

Placement

Treating a blocked (“stenosed”) coronary artery with a stent follows the same steps as other angioplasty procedures with a few important differences. The interventional cardiologist uses angiography to assess the location and estimate the size of the blockage (“lesion”) by injecting a contrast medium through the guide catheter and viewing the flow of blood through the downstream coronary arteries. Intravascular ultrasound (IVUS) may be used to assess the lesion’s thickness and hardness (“calcification”). The cardiologist uses this information to decide whether to treat the lesion with a stent, and if so, what kind and size. Drug eluting stents are most often sold as a unit, with the stent in its collapsed form attached onto the outside of a balloon catheter. Outside the US, physicians may perform “direct stenting” where the stent is threaded through the lesion and expanded. Common practice in the US is to predilate the blockage before delivering the stent. Predilation is accomplished by threading the lesion with an ordinary balloon catheter and expanding it to the vessel’s original diameter. The physician withdraws this catheter and threads the stent on its balloon catheter through the lesion. The physician expands the balloon which deforms the metal stent to its expanded size. The cardiologist may “customize” the fit of the stent to match the blood vessel’s shape, using IVUS to guide the work. It is critically important that the framework of the stent be in direct contact with the walls of the vessel to minimize potential complications such as blood clot formation. Very long lesions may require more than one stent—this result of this treatment is sometimes referred to as a “full metal jacket”.

The procedure itself is performed in a catheterization clinic (“cath lab”). Barring complications, patients undergoing catheterizations are kept at least overnight for observation.

Dealing with lesions near branches in the coronary arteries presents additional challenges and requires additional techniques.

How long does the procedure take? It can take anywhere from 30 minutes to an hour to perform the entire case. The duration is dependent upon the technical difficulty of the case and the number of balloon catheters that have to be employed.

How safe is the procedure? In the hands of experienced cardiologists, and with availability of modern day technology, it is estimated that the risk of death is during a stent procedure is usually less than 1%, while the chance of requiring emergency bypass surgery is around 2% or less. It is a relatively safe procedure and is carried out all over the world. An “out patient” or an inpatient uncomplicated stent case usually require 23 hours or less of hospitalization after the procedure.

The risk of a other serious complication is estimated to be less than 4 and probably around 1 to 2 per thousand, and similar to that described for cardiac cath. The risk of a heart attack and bleeding that requires a blood transfusion is increased when compared to cardiac cath. However, the risks are relatively low and acceptable in most cases when one balances the potential benefit against the expected risk (risk-benefit ratio).

The aggravation of kidney function (particularly in diabetics and those with prior kidney disease) is higher than that expected with cardiac cath because of the larger amount of contrast material that is usually required. In such cases, the cardiologist takes extra precautions to prevent this possible complication.

The stent is completely covered by natural tissue in a matter of 4 – 6 weeks.and the risk of clot formation is nearly absent by that time. In very few cases (1 chance out of 200) a clot may form during the first two weeks after a stent procedure). Such patients develop symptoms of a heart attack. With prompt treatment, the majority of these stents can be reopened.

Re-occlusion

Coronary artery stents, typically a metal framework, can be placed inside the artery to help keep it open. However, as the stent is a foreign object (not native to the body), it incites an immune response. This may cause scar tissue (cell proliferation) to rapidly grow over the stent. In addition, there is a strong tendency for clots to form at the site where the stent damages the arterial wall. Since platelets are involved in the clotting process, patients must take dual antiplatelet therapy afterwards, usually clopidogrel and aspirin for one year and aspirin indefinitely. In order to reduce the treatment, new generation of stent has been developed with biodegradable polymer.

However, the dual antiplatelet therapy may be insufficient to fully prevent clots that may result in stent thrombosis; these and the cell proliferation may cause the standard (“bare-metal”) stents to become blocked (restenosis). Drug-eluting stents were designed to lessen this problem; by releasing an antiproliferative drug (drugs typically used against cancer or as immunosuppressants), they can help avoid this in-stent restenosis (re-narrowing).