IOP Spike Control after Intravitreal Anti-VEGF

IOP Spike Control after Intravitreal Anti-VEGF In ophthalmology many ophthalmic procedures are there in which there is a spike of intraocular pressure after the procedures. Cataract surgery, argon laser trabulectomy (ALT), yag laser capsulotomy, yag laser iridotomy, trabulectomy, pars plana vitrectomy are few to be named. The new anti VEGF therapy is an addition to the prior list. Many IOP lowering drugs have been used in different procedures to stop these spikes. For ALT 1% apraclonidine, an alpha agonist has been found to be the most effective against the IOP spikes, but 0.5% has also been found to be equally effective. Brimonidine an alpha 2 adrenergic agonist has also been shown to be effective and safe choice. For cataract surgery different drugs have been used treat the postoperative increase in IOP. These include carbonic anhydrase inhibitors, prostaglandin analogs like latanoprost, alpha agonists like apraclonidine and brimonidine, beta-blockers and miotics (intracameral carbachol and acetylcholine). Similarly intravitreal injection of triamcinolone has been complicated with a rise of IOP and have been controlled effectively by beta blockers, but some may need aggressive treatment. Different researchers have worked on the control of acute spikes after the intravitreal injection of anti-VEGF, showing varied result. Some have advocated the use of IOP lowering medicine while other negating the need all together. Lim Young et al showed that the prophylactic use of fixed dorsolamide/timolol combination eye drops before the intravitreal anti-VEGF injection was a safe method of preventing IOP spikes occurring immediately after the intravitreal injection of anti-VEGF. He showed that the mean IOP at 5 minutes and 30 minutes postoperative was 14.12 Â ± 4.18 mm Hg and 10.87 Â ± 1.58 mm Hg in group 1 using IOP lowering medication while it was 28.21 Â ± 3.16 mm Hg and 17.48 Â ± 2.34 mm Hg in control group 2, respectively.9 He showed that there was a significant lowering of mean IOP at each reading at 5 minutes of interval. Frenkel et al showed the use of IOP-lowering medication prior to injection of pegaptanib, ranibizumab, or bevacizumab had little effect on the IOP spike. The failure of lowering the IOP spike was implicated to be due to the inability of these medications to counteract the volume-related mechanism of the IOP spikes after anti-VEGF injections. However, it was stated that there might be benefit to lower the IOP before intravitreal injection. In their study 2 cases of sudden loss of vision were reported due to the high IOP spike which prompted them to do anterior chamber paracentesis.8 It was also stated that the prophylactic use of medication in patients with advanced glaucoma receiving pegaptanib intravitreal injection or patients receiving 0.1 ml of bevacizumab could be considered because their study showed that it lowered IOP at the 3- to 10-minute interval in these patients. In another study done in 2013 the IOP lowering effect of Dorzolamide/Timolol and Brinzolamide/Timolol were compared with a control group. They measured the IOP after every 5 minutes for the first half hour and the next day and week after that. For all the 3 groups, the changes relative to the baseline at 5 and 30 minutes after intravitreal injection was found to be significant. Also when the groups were broken down as to whether receiving bevacizumab or ranibizumab, again the mean decrease of IOP compared to the control group was found significant. El Chehab et al have also found that the prophylactic use of fixed combination of timolol with brimonidine or dorzolamide and of 1% apraclonidine could not only reduce the IOP spikes but also their duration; and both the combination and 1% apraclonidine had equal effect. However the use of oral acetzolamide 20 minutes prior to the intravitreal injection was not proven to be effective. Evaluating the efficacy of timolol 0.5 % and brimonidine 0.2 % eye drops as a fixed combination in preventing IOP spikes Theoulakis et al found that twice a day instillation on the day before and before the time of injection in eyes which were scheduled for intravitreal ranibizumab was a safe and also effective in controlling the IOP spikes. IOP LOWERING MEDICATIONS Most of the IOP lowering medicines are administered topically. They are absorbed through the cornea and conjunctiva; mainly acting locally on the eye. Many anti glaucoma medicines have been used. The main groups of drugs are as following: BETA- ADRENERGICANTAGONISTS They are the most prescribed drugs of IOP control. There are a total of five topical beta-adrenergic antagonists which are currently FDA approved for managing high intra ocular pressure. They are timolol betaxolol, carteolol, metipranolol, levobunolol. Betaxolol is selective beta1 selective antagonist, and is safe to use this drug in patients with pulmonary and cardiac problems. The mechanism of action is to reduce IOP by decreasing the production of aqueous by inhibiting the production of cyclic adenosine monophosphate (cAMP) in ciliary epithelium. The IOP reduction is upto 20 to 35%. The effects of beta blockers occur within an hour after its instillation. Timolol is available in the market in concentrations of 0.1%, 0.25% and 0.5%. The recommended dosage is 1 drop two times a day. Burning, allergy and corneal epithelial erosions are the main ocular side effects. It can be absorbed systemically and can cause systemic side effects like bronchospasm, bradycardia, hypotension, respiratory failure. Timolol maleate has a molecular weight of 432.50. It is an odorless, white, crystalline powder that is soluble in methanol, water and alcohol. It is compounded as an isotonic, sterile, buffered solution available in two strengths: 0.25% Timolol maleate eye drops contains 2.5 mg of timolol (about 3.4 mg of timolol maleate). It has a pH of approximately 7.0, and an osmolarity of 274-328 milliosmole. And each ml of 0.5% Timolol Maleate eye drops contains 5 mg of timolol (about 6.8 mg of timolol maleate). The Inactive ingredients are usually monobasic and dibasic sodium phosphate and sodium hydroxide to adjust pH. Preservative used is Benzalkonium chloride 0.01%. PARA SYMPATHOMIMETIC AGENTS They act by stimulating sphincter pupillae and ciliary body by acting on the muscarinic receptors. They cause the contraction of the ciliary muscles which thus increases the aqueous outflow through the trabecular meshwork. Pilocarpine is the commercially available drug in this group and is compounded in concentration of 1%, 2%, 3%, and 4% and the recommended dosage is 1 drop 4 times per day. Ocular side effects are miosis, induced myopia with brow ache, retinal detachment, and cataract. Systemic side effects after its absorption can be of diarrhea, vomiting, abdominal cramps and bronchial spasm. CARBONIC ANHYDRASE INHIBITORS (CAIs) The enzyme required for aqueous formation is carbonic anhydrase. The CAIs cause inhibition of this enzyme and thus cause a decrease in the aqueous humor secretion by the ciliary epithelium. Carbonic anhydrase is required for catalyzing the reaction of CO2 to H2CO3 which further splits into HCO3 _ and H+. The bicarbonate ions are pumped along with sodium ions into the posterior chamber along with diffusion of water for the formation of aqueous humor. Carbonic anhydrase is present in ciliary body in excess. 99.9 % of the enzyme must be inhibited before a significant decrease in IOP can occur. Dorzolamide and brinzolamide are the commercially available eye drops in market. They have a good corneal penetration, and are also water soluble. These agents are able to reduce IOP upto 14-17%. Adverse effects of topical CAIs are burning and stinging of eyes on instillation, conjunctivitis, blephritis, corneal allergy, corneal punctuates keratitis and can also cause bitter taste. The systemic used CAIs are methazolamide and acetazolamide. They also cause inhibition of carbonic anhydrase in ciliary epithlium thus reducing the reduction of aqueous humor. As it is taken orally systemic side effects of CAIs include metabolic acidosis, leading to alkaline diuresis which result in hypokalemia. So potassium levels should be regularly checked in patients using CAIs on long term basis and oral potassium supplement should be recommended to all these patients. Other side effects include renal stones formation and central nervous system side effects like numbness and tingling of hands and feet, depression, anorexia, and nausea. Dorzolamide hydrochloride has a molecular weight of 360.91. It is a white to off-white in colour, in a crystalline powder form, which is also soluble in water, methanol and ethanol. ADRENERGIC AGONISTS Adrenergic agonists act by increasing the uveoscleral and trabecular meshwork outflow thus causing decrease in IOP. Epinephrine has a mixed action of being an alpha and a beta agonist. Its effect usually begins at 1 hour and reaches a maximum at 2-6 hours. Topical epinephrine drops usage has been stopped due to frequent systemic side effects of headache, palpitation and cardiac arrhythmias. The main ocular side effect is cystoid macular edema and black pigmentation of conjunctiva. Commercially available topical form is dipivefrin hydrochloride 0.1%eye drops, which is a prodrug of epinephrine. It is converted by the enzyme esterase into epinephrine in the cornea. Because of its high lipid solubility and corneal penetration a low dose is required as compared to epinephrine and thus has less side effects. The selective alpha 2 agonist apraclonidine and brimonidine are indirect acting adrenergic agonist which act by decreasing aqueous production and also the episcleral venous pressure and thus improving the trabecular outflow. Apraclonidine is associated with tachyphylaxis while brimonidine has less of this problem. Brimonidine tartrate is available commercially in 0.25 and 0.15% eye drops. Its reduces IOP by 26% at 2 hour of interval. PROSTAGLANDIN ANALOGUES Prostaglandin analogues are relatively a new class of IOP lowering drugs. Four prostaglandin analogues have been approved by the FDA for clinical use. Latanoprost was the pioneer drug to be developed and used in this group. Others are travoprost, bimatoprost, and unoprostone. Latanoprost is a pro drug which penetrates the cornea and then is turned into active form. It enhances the uveoscleral outflow and thus lowers the IOP upto 25-35%. The dosage is one drop per day which makes the compliance of the patient better. The main ocular side effect is darkening of the iris and the periocular skin, by increase in the number of melanosomes in the melanocytes. Other side effects include conjunctival hyperemia, hypertrichosis, uveitis and cystoid macular edema. Systemic side effects are flu like symptoms, skin rash and uterine bleeding. OSMOTIC AGENTS Osmotic agents act by decreasing the vitreous volume by removing the liquid out of the eye into the circulation. The osmotic agents can be given orally or intravenously. Oral agent is glycerin while urea and mannitol are given intravenously. The osmotic activity is dependent upon the number of particles in the solution which cannot cross over and maintains the osmotic gradient between the compartments. Mannitol is given intravenously because it cannot be absorbed from the gastro-intestinal tract. A rebound increase in IOP and local tissue necrosis limit the use of urea. Glycerin is most commonly used oral osmotic agent which is given along with cracked ice to dilute its nauseating feeling. In patients with diabetes a non-metabolized sugar isosorbide can be used instead. Several fixed combinations have been developed which are available in markets used for IOP-lowering. Most of these fixed combinations contain timolol (dosed once or twice daily) combined with either adrenergic agonists, prostaglandin analogs, and CAIs. COMBINATION Fixed combination timolol maleate 0.5% with dorzolamide hydrochloride 2% was first introduced in market in 1998. Each milliliter of drug consisting of 6.83 mg timolol maleate and 22.26 mg dorzolamide hydrochloride. Timolol inhibits aqueous humor production by down-regulating adenylate cyclase by inhibiting ÃŽ ²2-adrenergic receptor sites on the ciliary process . While dorzolamide acts as a selective inhibitor of Carbonic anhydrase II enzyme, present on the ciliary process. The local bicarbonate production is slowed down, which as a result decreases sodium and fluid transport and, finally, decreases the aqueous humor production thus lowering the IOP. Because the mechanisms of action of both the drugs differ, they provide an additive effect when used together. Fixed combinations of drugs have been found to improve the compliance of the patient by reducing the number of eye drops used daily. Moreover the IOP-lowering effect of fixed combination timolol and dorzolamide was found to be greater than that of either drug instilled as monotherapy. In addition the load of preservative is also reduced along with any wash out of drug when the drugs in monotherapy are instilled one after the other.

Black History: Facts and People

The way black people have been represented throughout history has affected the way black people are treated in the American society, their values, and their identities. Yes, black men were treated disgustingly and horrifically, but Black women have been the most overworked and unappreciated people and had to fight much, much harder than black men. â€Å"†¦sex and race are sued to ascribe to people a different rank, role and status, so long will they have a deferent historical experience from that of the dominant group† (pg xix Lerner) Many of these women were brutally raped and were seen as property rather than human beings. They were not allowed to receive any sort of education due to fear of them escaping. As women in the United States started to excel, black women had to fight harder to get the same level of appreciation. Race was always seen first before anything else even for women. The primary motivation for establishing black women studies as well as the key obstacles to its establishment as an academic discipline was done by fighting for respect in academia, their rights as women, and their struggles. Black women have significantly progressed in academia over the years. During slavery, black slaves were not allowed to learn or teach education and if caught could be severely punished or killed. Black women in academia were not taken seriously or be acknowledge for their work even if it was astounding. In the book by Lerner, â€Å"Black Women in White America,† black women's name and publications would be buried deep to ensure never to be found. â€Å"The papers of outstanding figures such as Mary McLeod Bethune, Charlotte Hawkins Brown, and Nannie Burroughs are scattered in various libraries, have never been edited nor even partially published.† Their published work was never read or even on the shelf due to the fact a black women had written them. The political position in America of black women has been historically tormented. Black Women's Studies emerged because of the failure of Black Studies and Women's studies. Black feminism in particular, needs to be perceived as intersectional and not just one-dimensional. Black women had to prove their work much more in a white-male dominated field where they're continuously questioned for every detail. â€Å"No white historian can ever again approach his work without recognizing that there were black people in the American past whose contributions and whose viewpoint must be considered†¦there is a female aspect to all history, that women were there and that their special contributions to the buildings and shaping of society were different from those of men† (pg xix, Lerner). It wasn't until black women like Lucy Terry Prince or Phyllis Wheatley, â€Å"the second woman to publish a book in America, in 1773.† (pg 4, Hine and Thompson)Black women who were teaching this course had to be extremely courageous and due it being a committed and passionate job. Even though black women studies was growing it was only until the 1970s where it was seen as an actual study. Facing the racism of white women and the sexism of black men, black women had to fight the fight on their own. At the end of slavery and the civil war, many white women still had the racist mindset of not wanting to be inclusive with the black community. Women's rights were a huge conflict in the early 1900's. The women who were fighting for equal rights to vote would be seen as Feminist. Feminism advocates women to be seen as equals to everyone else. The only problem with this was that even though they called themselves â€Å"feminists† they were not fighting for all women, just the white women. In 1920, Congress passed the 19th Amendment granting American women the right to vote. This excluded black women from voting meaning they were the minority in the country when it came to voting, they were the only group not allowed the same rights as everyone else when it came to voting. It was until 1960 when black American women were granted the right to vote through the African-American women's suffrage movement. Women in America were split up into groups due to their race that allowed white women to be more superior to black women regardless of their same biological makeup. Black women have consistently â€Å"had the lowest status in society- the economic and social-political status ranking order consisting of white men, white women, black men, black women.† (pg xxiii, Lerner). They were always the last ones to be considered because they were seen as caretakers, cooks, cleaners, or objects during slavery whereas a black man was considered to be better equipped based on their physical strength. Many black women were forced to become â€Å"mammies† to their white masters. Their jobs were to take care of the family, cook, clean over their own families. Many of the black women were put into the Fancy Girl Market, which was a sexual slave market. During slavery, black women were not allowed to be educated and would have to succumb to their everyday life of obeying their masters. They formed their own black communities in the salve quarters where they taught their children, especially their daughters, how to behave and follow rules when it came to their white masters. Their sense of closeness and kinship helped strengthen their bonds due to the lack of opportunities they were allowed. Black women were also selfless when it came to protecting their own families by obeying their masters in hopes of their children not being sold. Their protection over their own families is ironic because they were trying to give their love and affection to the families they worked in order for their own families close.

Education and its impacts in students learning Essay

The paper is about education and how its impacts enhance students learning. Universal access to education is one of the millennium goals of development. The main observations have been made together with the impacts. There is a brief introduction to what education really is. In addition, the essay further concludes by giving recommendations to what should be done to ensure every person has access to learning facilities both in the developing and undeveloped countries. Introduction Education can be termed as wealth of awareness. It can be picked up by a person and passed from one generation to the next after studying a certain subject or undergoing life lessons. It can be said to be a form of learning. Unfortunately, universal access to education has not been completely attained. A great education begins at home hence the kind of a background a child comes from will have an impact on their education. Observations made on education It has been observed that poverty particularly in developing countries is a major cause for education inequality. Secondly, the importance of education in modern world cannot be taken for granted. For instance, some sectors such as the military previously did not put emphasis on education requirements but currently they have raised minimum education requirements. It has also been observed that most countries are adopting modern technology in their learning institutions. There has been an increase in use of electronic devices such as laptops and I pads. More so, learning has been made easier since one can be educated from home through the e-learning. The observations made can be compared to the education indicators as listed by Aud et. al (2013). Impacts on students learning The Social economic status is based on the parent’s level of learning, their profession, earnings and their position in their social order. Parents with a high social economic status are likely to lay a good background for their children education than those of low status. They can afford to buy their children most of education materials they require such as pens, books and toys for young kids to enhance their early schooling. They are also capable of ensuring that their offspring have access to quality health care. In addition, these parents can access information about the well performing schools and they can also afford to pay the fees. On the other hand, parents with low social economic status usually do not have high levels of education hence their children will not be well prepared at home to start schooling unlike those with high social economic status. Gender in most African countries is still an issue to be looked upon. Boys are always preferred when it comes to access to education especially when resources to take children to school are limited. For instance, even if a girl had a better score than a boy, parents in most of African countries will prefer to take the boy for higher learning. Studies have shown that most of the poorest women in most countries have not even completed their primary school. Poverty is another impact on education. Children from poor households are less likely to perform well in class. These children usually have less participation in class, their level of terminology is low hence unlikely to perform well. Their parents cannot afford good nutrition for their kids and as a result, kids may have nutritional related illnesses and their education is disrupted. Parenting is the process of upbringing children. A child’s parent is commonly their first educator. Parents have roles of ensuring that their children are prepared for school, for example by ensuring that they have sufficient food and good health, this is necessary for a child concentration in class which results to good performance. It is at home that parents mostly emphasis on virtues such as hard work, integrity and commitment. The Society also has an impact on education. Community customs and practices have a great impact on education, which can either be helpful or damaging. For example, communities with traditions that encourage early marriages for girls prevent them from accessing their fundamental right to education. Technology, which is being embraced quite well in most countries, has a great impact on students’ performance. This is majorly for students in higher learning institutions. Students with access internet are able to complete their assignments in time. Most of higher learning institutions have embraced modern technology and they are offering some courses or units online, this is convenient for those students with access to internet because they can take classes at their free time and can also learn at their own pace. Conclusion Social economic status and poverty have the greatest impact on children access to education. Other factors with impact on education are access to technology, parenting, and race among others. These factors may have positive or negative impacts on children access to education. Undesirable effects such as inequality in education can be dealt with by making primary school education free and compulsory. If possible, education at each stage should be made free or affordable to everyone, promoting women education, discouraging child labor and school dropouts. Embracing modern technology improves education quality worldwide. References Aud, S. , Wilkinson-Flicker, S. , Kristapovich, P. , Rathbun, A. , Wang, X. , Zhang, J. , & National Center for Education Statistics, (2013). The Condition of Education 2013. NCES 2013- 037 . National Center For Education Statistics, accessed on 24th May 2013.

Hydrogen as an Alternative Fuel Essay - 1003 Words

It’s so hot! Today, millions of motor vehicles are producing greenhouse gases that are flooding into our atmosphere. At the rate society is going, a theme such as global warming is being considered more and more. Not only is this petroleum addiction hurting our environment, it may also have adverse affects on our independence. The United States imports most of its petroleum from foreign nations which could pose problems in the future. This is why Alternative fuels such as hydrogen should be extensively researched. The motor transportation industry should invest in extensive research and development in hydrogen fuel to help the fuel economy create stronger national energy security, make fuel more efficient and renewable, and more†¦show more content†¦Although hydrogen can be beneficial, it poses a major problem; initial costs of hydrogen could be a detrimental barrier. To start a Hydrogen economy, high initial infrastructure costs would be inevitable (â€Å"Hydrogenà ¢â‚¬ ). The cost of distribution and even use of hydrogen would initially be excessively high (â€Å"Hydrogen†). Although initial cost may be extremely high to produce and use hydrogen, it is a necessity to help this nation become less dependent on foreign nations and to make fuel more efficient and renewable. Fossil fuels are clearly a non-renewable resource and will be depleted eventually, which is the reason hydrogen should be researched more extensively to help develop a more efficient and renewable resource. Hydrogen can prove to be more energy efficient and reliable than gasoline or diesel fuel. Gasoline and diesel fuel powered engines or internal combustion engines are not ideally energy efficient. Internal combustion engines are approximately twenty to thirty percent energy efficient (Woodbury). Most of the energy produced in the internal combustion engine is lost in heat and friction before the Brannan 3 piston is even pushed(Woodbury). 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