Aimco Properties L P is located at the address 1627 Country Lakes Dr in Naperville, Illinois 60563. They can be contacted via phone at (630) 983-8411 for pricing, hours and directions.
For maps and directions to Aimco Properties L P view the map to the right. For reviews of Aimco Properties L P see below.


Florida Cash Advances. ... Dedicated to observing the CFSA's best practices for responsible lending; ... Payday Loans. Online Payday Loans. Title Loans. Installment Loans. Online Installment Loans. Line of Credit. Flex Loans. Other Services. Check Cashing. Bill Pay.
Compare the max amounts, turnaround times and serviced states of top online payday loans to find the best one for you. Plus learn what to watch out for.
Depending on the state you live in, you may be able to obtain an installment loan or a line of credit. Snappy Payday Loans specializes in arranging payday loans online. However we also understand your need for more flexible payment terms than a traditional online payday advance.
Best payday loan services | apply now! | Online loans st. petersburg, florida Originally started back in 1995, Wisdom Novels was a mere concept of characters thrashing through an unknown land and trying to stop a growing Darkness.
Florida statutes limit the fee that can be charged on a payday loan to 10% of the loan amount. Costs, in the form of a verification fee, are limited to five dollars for each loan. This is not an annual interest rate but the rate that is being charged for the specific loan term.


text:
"I thought a lot about my mom and my grandfather" (EXCLUSIVE) – SwingComplete
Ukraine warns Russia 'almost complete' border build-up
Macías could leave Getafe, admits the club's Sports Director
"The threat of not playing does not work with us"
Ozzie Guillén set fire to the networks with his statements about David Ortíz
Alicia Villarreal and her husband Cruz Martínez in mourning: the brother of the Kumbia Kings leader dies | Famous
Resentful with Chivas? Marco Fabián's message on his arrival in Mazatlan
Good and bad news for the Samsung Galaxy A53 5G
Andrés García no longer divorces Margarita Portillo
NFL 2021: The brutal criticism of Kliff Kingsbury: 'The Anna Kournikova' of coaches
Home/World/Gaddafi's son presents his presidential candidacy
Gaddafi's son presents his presidential candidacy
Admin November 15, 2021	World Leave a comment 8 Views
Saif al Islam, son of the deposed Libyan dictator Muammar Gaddafi, presented his official candidacy for the presidential elections scheduled for December on Sunday, an official from the electoral commission reported. while being wanted by the International Criminal Court for "crimes against humanity."
Saif al Islam, 49, who had been missing for years, appeared at the office of the electoral commission in Sabha (south), one of the three authorized centers along with Tripoli (west) and Benghazi (east), according to images disseminated by local media.
Dressed in a brown abaya (a robe that reaches to the feet) and with a turban of the same color tied to the head in the style of his father, he signed the documents, assisted by his lawyer.
"He presented the documents of his candidacy at the office of the High Electoral Commission in Sabha, thus completing all the legal conditions required by Law number 1 on the election of the head of state, adopted by Parliament," the commission added in a statement in Facebook. Saif al Islam also received his voter card.
You may be interested in: Daniel Ortega gives another position to the nephew of Muammar Gaddafi, former dictator of Libya
The presidential elections, the first in the country, They are scheduled for December 24 and the parliamentarians a month later.
At the end of July, Gaddafi's son had said in an interview with the New York Times that he did not rule out returning to political life in his country.
The elections will be the culmination of a laborious political process sponsored by the United Nations and are expected to end a decade of chaos since the fall of the regime of Muammar Gaddafi, assassinated in 2011 in a popular uprising.
They are also expected to put an end to the fratricidal fighting between the two rival sides, one in the west and the other in the east of the country.
In June 2011, the International Criminal Court (ICC) issued an arrest warrant against Saif al Islam "for crimes against humanity" committed during the crackdown on the revolt in Libya.
He was arrested the same year by an armed group in Zenten, in the west of the country. He was sentenced to death four years later by the judicial authorities in Tripoli. But the group refuses to hand it over until 2017.
Read also: They release Saif al Islam, the son of Gaddafi who had been sentenced to death
However, the group never confirmed their release and their trail was lost. The ICC said it had located him in Zenten in late 2019.
"Saif al Islam Gaddafi's status at the ICC has not changed. According to the notification published in 2011, they are still looking for him, "Fadi Abdallah, an ICC spokesman, told the Libya al-Ahrar channel.
For the international community, holding elections is essential to carry out a peace process in the country, which has the most abundant oil reserves in Africa. However, the elections remain uncertain, with increasing tensions between rival sides. Following the confirmation of Saif's candidacy for Islam, questions remain about Marshal Khalifa Haftar, the strongman from eastern Libya, and Prime Minister Abdelhamid Dbeibah, who led the transitional government.
"It is unfair"
For Wolfram Lacher, Libya expert at the German SWP institute, the candidacy of Seif Al-Islam "presented despite the arrest warrants from the ICC (…) will only further complicate the electoral process."
On the streets of Tripoli, Nizar al-Hadi, 33, also expressed concern. This is totally unfair! We know what happened in 2011, "he added.
Previous TOP 5 of uses you can give the most basic iPad
Next The gin and tonic metaphor: what is a quantum algorithm and why are they so powerful? | Chronicles of the intangible | Technology
FITUR 2022 – Abinader confident that the DR will have more investments in tourism
Banreservas will set up offices in Spain
Hong Kong to cull hamsters after detecting Covid-19 cases in pets
Was the island of Tonga completely wiped out by the eruption? 2:01 (CNN) — The ... Read more
They already test a cargo vehicle that can do its job without a driver
Karla Panini announced the return of "The Güera Laundress" and unleashed the anger of Karla Luna's fans
Jenni Rivera is convinced that she was BETRAYED, says spiritual teacher
Unvaccinated couple dies of covid-19 weeks before their marriage
New data comes to light about the espionage that the Mexican State carried out for decades on singer Juan Gabriel

redpajama_set_name: RedPajamaCommonCrawl


text:
Q: Error when opening Screen Time on Mac OS X I get this error when opening Screen Time on my Mac:

The URL "prefs:root=SCREEN_TIME" is missing a hostname.
I just upgraded to Mac Os X Ventura 13.0.1; Screen Time has never worked since the upgrade.
Any suggestions on how to get Screen Time working again?

A: This has two questions in one, but I can answer the one shown in the screenshot.
Your Shortcut is not working because that's not the URL scheme for System Settings on macOS. The correct URL for Screen Time in Ventura is:
x-apple.systempreferences:com.apple.Screen-Time-Settings.extension
Which will work if you put it in a Shortcut like you have.

redpajama_set_name: RedPajamaStackExchange


text:
Government announcements are a 'huge leap' forward for Ireland's biodiversity.
Recent announcements on enhanced protections for Ireland's biodiversity by my Green Party colleague within the Department of Heritage,...
World Soil Day 2022
On World Soil Day, I welcome the increasing recognition of soil health as central to the future of agriculture and food security. Today...
Call for Proposals for an EIP on the theme of water quality.
Press Release Minister of State at the Department of Agriculture, Food and the Marine, Pippa Hackett has announced a Call for Proposals...
Midlands small producers rank among the best in Ireland
The 'Taking care of business' show, hosted by RTÉ Late Late Show, was inspiring and my thanks to Ryan Tubridy and RTE for promoting small...
First National Dialogue on Women in Agriculture
Under the watchful gaze of Countess Markievicz, Department of Agriculture colleagues, Minister Mc Conalogue, Minister Hackett and...
2022 Organic Scheme Payments announced
Press Release Minister of State in the Department of Agriculture, Food and the Marine, Senator Pippa Hackett announced today more than...
Meeting with Burren farmers
Press Release Minister for Agriculture, Food and the Marine, Charlie McConalogue, and Minister of State at the Department of Agriculture,...
Reports to address challenges related to peat supply in the Horticulture sector published
Press Release Minister for Agriculture, Food and the Marine, Charlie McConalogue, and Minister of State with responsibility for...
'Thank you' to farmers who are embracing new schemes
In my speech yesterday in the Seanad, I spoke about the two new schemes my Department opened last week; these schemes are positive for...
Online survey opens as part of public consultation on National Strategy for Horticulture Sector
Press Release Minister for Agriculture, Food and the Marine Charlie McConalogue T.D and Minister of State for Land Use and Biodiversity...
Minister Hackett announces opening of Organic Farming Scheme to new entrants following huge interest
Applications can be made from today until 9th December Press Release Minister of State at the Department of Agriculture, Food and the...
Advance Payments of 2022 Basic Payment Scheme announced
Press Release The Minister for Agriculture, Food and the Marine, Charlie McConalogue TD, today announced the commencement of advance...
Food Vision 2030 Event
Press Release Taoiseach Micheál Martin today gave the keynote address at an event to discuss Food Vision 2030, the shared strategy for...
Webinar on Supports for Local, Small and Micro Food Businesses
Press Release The Department of Agriculture, Food and the Marine in conjunction with Bord Bia, will co-host a webinar on Supports for...
Government approves Ireland's CAP Strategic Plan 2023-2027 worth almost €10bn
Press Release Today, the Minister for Agriculture, Food and the Marine, Charlie McConalogue, brought Ireland's finalised CAP Strategic...


text:
U.S. Edition	New Jersey	New Mexico	Wyoming
Statesmen Academy
A Busy Weekend and an Urgent Santa Fe Update
It's the last week of the session, and things are happening quickly. Thanks for staying engaged and taking action!
On Sunday, there were two big developments on bills that we've been telling you about.
ASSISTED SUICIDE. First, the Senate Judiciary Committee met for several hours on Sunday and heard House Bill 47, which would legalize assisted suicide in New Mexico. Family Policy Alliance was one of four groups allowed to testify against the bill in the minimal time allowed.
It was clear that the hundreds of emails you sent through our Action Center – plus countless phone calls to key senators – made a difference. For a time, it appeared that the bill might be defeated in the committee. But one of the senators with strong concerns about the bill ultimately voted to allow the bill to go to the Senate floor, where he will attempt to address some of its major problems. With his vote, the bill passed committee, 5-3.
Despite the fact that it only passed committee last night, it could be voted on by the full Senate as early as today!
Your action is needed!
Please take five minutes to call these key senators and leave a simple message asking them to vote NO on assisted suicide (HB47):
Senator Campos: (505) 397-8818
Senator Ivey-Soto: (505) 397-8830
Senator Munoz: (505) 397-8836
Senator Pinto: (505) 397-8841
Senator Rodriguez: (505) 397-8844
Senator Shendo: (505) 397-8849
Please also take 30 seconds to send a message to your senator – even if you have done so previously.
RECREATIONAL POT. Thank you to the hundreds of you who also reached out to the Senate committee that was scheduled to hear the bill to fully legalize Big Marijuana in New Mexico. Yesterday, at the last minute, that bill (House Bill 12) was moved to the Senate Judiciary Committee, where it may be considered today or tomorrow.
That move to a new committee is likely an indication that your messages were making a difference! But now Senate Judiciary needs to hear from New Mexicans who are concerned about the Colorado-style damage that this bill will inflict on our state!
Please take a moment to urge the Senate Judiciary Committee to oppose recreational marijuana (HB12). When you send a message, it will also include your own senator, even if they aren't on the committee.
From the elderly and infirm (assisted suicide) to vulnerable young people (Big Marijuana), these attacks devalue life and must be fought. Thanks again for standing firm and taking action!
The Family Policy Alliance of New Mexico Team
Callousness and disrespect for life takes many forms, and this year at the Roundhouse, we're seeing it at both ends of life.
In regard to life in the womb, hundreds of you have used our Action Center to send messages urging the Governor to veto the radical abortion bill. Thank you.
Today, we're appealing to you to speak out about a bill that disrespects the lives of the sick and the elderly.
House Bill 47 legalizes assisted suicide in New Mexico. Virtually identical bills have been defeated in the past here, but after last fall's elections, the outcome of this bill could go either way.
After passing the House last week, HB47 is now headed for a hearing in the Senate Judiciary Committee – and it's URGENT that we prevent this bill from going any further.
Here is what you can do to make the biggest difference in stopping this deadly bill:
Take a few moments to call (anytime day or night) and leave a message for these three key senators on the Senate Judiciary Committee. Ask them to vote NO on HB47, the assisted suicide bill.
Sen. Bill O'Neill: (505) 397-8838
Sen. Daniel Ivey-Soto: (505) 397-8830
Sen. Joseph Cervantes: (505) 397-8820
After making these calls (which are most important), also take 30 seconds to send a message to the entire committee, urging them to reject assisted suicide.
There are many reasons why assisted suicide is a tragic mistake. Here are three:
Assisted suicide gives insurance companies and governments the ability to save money by pushing lethal drugs that are less expensive than treatment. This has happened in Oregon and California where patients were refused coverage for life-saving treatment and offered lethal drugs instead.
A six-month prognosis for death is extremely difficult to predict accurately, with many patients living far beyond the six months. A major study of physician prognoses in Chicago revealed that of 468 predictions, only 20 percent were accurate in predicting when death would occur.
No trained medical personnel are required to be present at the time the lethal drugs are taken or at the time of death, creating the opportunity for an heir or abusive caregiver to coerce the patient to take the deadly drugs or put them in the patient's food without the patient's knowledge or consent.Source: Patients Rights Action Fund
In addition, New Mexico is home to one of the largest Hispanic populations, as well as one of the largest indigenous populations in the nation. Physician-assisted suicide contributes to the continued unfair access to equal healthcare for disadvantaged and vulnerable populations.
That's why the League of United Latin American Citizens states:
"The practice of distributing a pharmaceutical poison to the medically dependent and emotionally vulnerable, particularly where individuals and families are financially burdened by severe illness and not provided access to appropriate palliative care and caregiver supports, is unconscionable."
The assisted suicide bill will soon be heard by the Senate Judiciary Committee. Please call and leave messages at the numbers above as soon as possible – and then spread the word to other New Mexicans who care about upholding life.
Thanks for speaking up and making a difference!
The pro-death folks are at it again, and your voice is needed to stop them!
Once again, Maryland legislators have brought forward a bill to legalize assisted suicide. This bill (SB 701) will be heard in the Senate Judicial Proceedings Committee on Friday afternoon.
This assisted-suicide bill will allow doctors to prescribe a lethal dose of drugs to anyone who has been "qualified" to end their own life. The so-called "protections" in these bills are weak, leaving our most vulnerable people – the disabled, the mentally ill and our teens – at higher risk for abuse.
Sadly, suicide tends to generate copycats among the emotionally vulnerable via a phenomenon called suicide contagion, where one suicide leads to many. Suicide is already the second leading cause of death for teens, and suicides among veterans far outnumber combat fatalities.
This bill sends a very bad message to our most vulnerable teens and veterans – that suicide is okay in some instances.
We need your help to encourage the senators on the committee to vote NO on assisted suicide. In just 30 seconds, you can send a message to all of the committee members – that in Maryland every life is worth fighting for.
Thank you for speaking up for life!
The Family Policy Alliance Team
P.S. Please spread the word and forward this information to family and friends using the share button below so they can make their voice heard, too!
Our Christian Civic League of Maine allies report that the battle over assisted suicide has now moved to the Governor's office as the House of Representatives approved it by one vote (73 to 72) on Monday.
We let you know late last week that this critical vote was going to happen and many of you took action over the weekend. Now, Physician-Assisted Suicide (LD1313) is headed to the Governor's desk and we need you to act once more asking her to veto the bill.
Here is that you need to know about this legislation
LD 1313 lacks necessary safeguards and endangers the weak and marginalized in society.
LD 1313 will change the culture in which medicine is practiced. It changes the medical profession by permitting the tools of healing to be used as techniques for killing. In essence, it distorts the Physician-Patient Relationship.
LD 1313 undermines social solidarity and true compassion. It changes how we view disabled and elderly family members and how we will look at them in the future…how they will look at themselves.
Physician-Assisted Suicide's most profound injustice is that it violates human dignity and denies equality before the law. Our culture must believe all people have immeasurable worth and dignity.
Because LD1313 has been sent to Governor Mills for her signature, we need your quick help!
Please call Governor Mills at 207-287-3531 today to encourage her to veto this legislation and send the message that in Maine every life is worth fighting for.
Thanks for making your voice heard!
I'll be honest. This is one of the most difficult articles I've ever had to write for Family Policy Alliance®. But it's also one of the most important.
Three years ago, we introduced you to Elizabeth, a wife and mother of two from Minnesota. I first learned about Elizabeth's story when she bravely testified against an assisted suicide bill in her state. As I got to know Elizabeth and meet her beautiful family, she agreed to share her story with us so that people around the country could learn what it's like to advocate for your own life.
Elizabeth shared with me that she was an adventurer at heart, and her marriage began with traveling, exploring, skiing, and more. But what she certainly never expected out of life was a brain cancer diagnosis—shortly after her first child, a daughter, was born.
The doctors gave her three to five years to live, and so Elizabeth prayed and asked for the doctors' help to see her daughter off to her first day of kindergarten.
When I met Elizabeth, her daughter was seven years old. Elizabeth had already outlived her prognosis and even given birth to another child, a son.
Her children, though young, were already full of their parents' adventurous and fiery spirits. And perhaps what was most remarkable about meeting Elizabeth was her deep understanding about life, suffering, and helping others.
She shared with me the most beautiful words describing every person created in God's image—worth fighting for and worth advocating for. She said we are all "unique and unrepeatable people."
And Elizabeth certainly was.
This past weekend, Elizabeth went home to her Savior, with this verse as a final reminder to all of her faithfulness, joy, and the One in whom she placed her hope and trust:
I have fought the good fight, I have finished the race, I have kept the faith. Henceforth there is laid up for me the crown of righteousness, which the Lord, the righteous judge, will award to me on that day, and not only to me but also to all who have loved his appearing. 2 Timothy 4:6-8
Watch Elizabeth tell us her story 3 years ago:
As the Family Policy Alliance team considered how to best honor Elizabeth—and her husband and two young children—we rededicated ourselves to the fight against assisted suicide that led us to Elizabeth and her family in the first place.
Proponents of legalized assisted suicide paint a picture of an easy, painless and dignified way to honor a suffering loved one's last wishes and say goodbye.
But Elizabeth taught us that every life is worth fighting for—and that our loved ones suffering from serious illnesses deserve far more than abandonment to hopelessness, depression and suicide.
She taught us that people who say they want to end their own lives should receive proper care and intervention—no matter who they are. We should absolutely intervene when the healthy want to end their lives. Those suffering from illness should be treated no differently—not abandoned to suicidal thoughts.
And our medical professionals should continue to be trusted as healers—not complicit in acts of suicide.
If all we can offer those who suffer is a bottle of pills and a stamp of approval on their suicide, we have lost all compassion and dedication to the sanctity of human life.
Elizabeth's life was worth fighting for till her Savior took her home. And Family Policy Alliance will continue to honor her—and every person who suffers from a serious illness—by fighting for policies that affirm the life and worth of each person. And we will unashamedly oppose efforts to legalize assisted suicide.
Seven states, including New Jersey this year, and D.C. have legalized assisted suicide, and 21 others considered doing so this year.
Thank you, Elizabeth, for helping every person who knew you—and many who didn't—understand that every life is worth fighting for.
And to your beautiful family, we pray you know your wife and mother was—and continues to be—an inspiration to all. We will never abandon the fight for life, from conception to natural death.
Thank you, Elizabeth.
Autumn Leva,
Vice President of Strategy
P.S. Will you help us honor Elizabeth and her family today? Will you share her video story on your social media using the hashtag #WorthFightingFor or by simply forwarding this email to your friends? We pray Elizabeth continues to inspire countless lives, even from Heaven, and that her impact will be a source of comfort to her husband and children.
As you know, efforts to legalize assisted suicide in New Mexico have been growing in recent years. Following the November election, advocates now believe 2019 will be the year that assisted suicide is passed by the Legislature and signed into law by Governor-Elect Michelle Lujan-Grisham.
People on both sides of this issue agree on one thing—assisted suicide is a serious matter and it should not be addressed lightly. Consequently, Family Policy Alliance of New Mexico has been working with other local allied organizations to help educate the public on the unintended and dangerous consequences of assisted suicide, and the slippery slope we have seen in other states and countries.
Take Canada for instance. Recently, it was reported that just two years after legalizing assisted suicide nationally, physicians from Toronto's Hospital for Sick Children are already pursuing policies that would extend assisted suicide options to minor children, without parental notification or consent.
You read that right—assisted suicide for children, without parental input!
The unintended consequences of assisted suicide—including death after misdiagnosis and/or inaccurate prognosis; intimidation from family members; and/or abuse from profit-driven insurance companies—should be enough for us to reject this legislation come January. However, if more reason is needed, look to Canada's slippery slope.
Friends—when a society determines that some lives are not worth living and that assisted suicide is a "dignified" and "compassionate" option, it is only a matter of time before that "option" is extended to more and more individuals.
There is a reason that our State Legislature has rejected this legislation every time it has been presented. There is a reason that the overwhelming majority of other states have consistently rejected this legislation. Because when it comes to caring for those facing serious illness and end of life, we can and should do much better than abandoning them to hopelessness and death.
Instead, let us work together to find solutions that offer genuine compassion and comfortable care to those when they need it most.
Every life is worth fighting for.
Vince Torres
President and Executive Director
By Autumn Leva, VP of Strategy for Family Policy Alliance
The American Medical Association (AMA) has had a longstanding position against legalizing assisted suicide because it is "fundamentally incompatibly with the physician's role as healer." Instead, the AMA rightly guides its physicians nationwide to "aggressively respond to the needs of patients at the end of life."
In other words, the AMA supports what we all believe—every life is worth fighting for. And, no one should be abandoned to the hopelessness and lack of true compassion found in assisted suicide. Suicide always comes with a type of "giving up," and American families don't want the professionals they trust with their very lives to be in the business of "giving up" on them.
Last year, political activists pushing to legalize assisted suicide pressured the AMA into considering changing their position opposing assisted suicide. The AMA referred the matter to their Ethics committee to compile data, research, and feedback from people like you across the country to help them make their decision.
Family Policy Alliance, our state-based allies, and Focus on the Family joined together to send the AMA two letters asking the AMA to maintain their position opposing assisted suicide and to refuse to allow a form of suicide to be considered "care" for a patient. The letter shared with the AMA many of the points made by Dr. Bolthouse in this video about what assisted suicide means for the medical community. Thousands of you also signed onto the letter to the AMA!
And good news—the AMA's Ethics Committee listened!
Last week, the AMA's Ethics Committee produced a report after all their fact-finding on assisted suicide. They ultimately recommend that the AMA continue to oppose assisted suicide—and that doctors continue to work with patients to understand their goals and what brings them meaning at the end of life, and to explore legally available options for care. When the AMA meets in June, the Ethics Committee will present their report and conclusion.
Thank you to all of you who joined in asking America's doctors to choose caring over killing! This is especially important as we see what is happening in other countries with legal assisted suicide. Switzerland has become the "final tour destination" where assisted suicide is legal for anyone who requests it in writing—not just those diagnosed with "terminal illnesses." This raises serious questions about pressures that the elderly or frail may face to prematurely end their lives.
Even in the U.S. states that have legalized assisted suicide, men and women have reported insurance companies already declining to cover treatment for serious illnesses like cancer but instead offering to cover the far cheaper assisted suicide drugs—leaving patients with no real choice or hope.
Thank you again for partnering with us to send the letters to the AMA. We thank God that the AMA agreed that every life is worth fighting for! We ask that you continue to join with us in praying that our doctors will continue to stand strong against political pressure. And, we hope you will also join us in working to advance policies in every state that value life and reject suicide.
By Autumn Leva, Vice President of Strategy
In 2016, we shared with you the story of JJ Hanson, the "man of steel," who served as President of one of Family Policy Alliance's national allied organizations, Patients Rights Action Fund, fighting against assisted suicide.
Produced by Patients Rights Action Fund
JJ was diagnosed with terminal brain cancer in 2014. Rather than choosing the path of assisted suicide that was highly sensationalized by 29-year-old Brittany Maynard who had the same kind of cancer, JJ chose to move past his depression and live every moment with his family.
Through his position with Patients Rights Action Fund, he also devoted his days, not ever knowing how many there would be, to helping lawmakers in states across the country understand the implications of legalizing assisted suicide for patients, for the medical field, for persons with disabilities, and especially for families. He gave his time to providing official testimony, sharing his personal story, and meeting with lawmakers one-on-one to encourage them to oppose any bill that would legalize assisted suicide.
JJ was only supposed to live about four months from his diagnosis in May 2014. He just passed away on December 30th.
Paul Weber, President and CEO for Family Policy Alliance believes JJ's life greatly influenced our nation and, most importantly, his family: "JJ devoted his last days to his family and to making sure that lawmakers around the country got the message that every life is worth fighting for—what an incredibly legacy for his wife and children. My team and I at Family Policy Alliance send our deepest sympathies and prayers to the Hanson family, and to our friends at Patients Rights Action Fund."
We pray JJ's family takes comfort in knowing that despite efforts in nearly 30 states by Compassion & Choices, the leading activist organization attempting to legalize assisted suicide, no state legalized the practice in 2017 (with the exception of D.C.). Family Policy Alliance is committed to making sure that as lawmakers head back to state Capitols in 2018, no bills to legalize assisted suicide advance. We hope you'll join us in honoring JJ by declaring that every life is worth fighting for.
For more stories about why assisted suicide is bad policy, check out these short videos:
A woman with quadriplegia shares why assisted suicide is bad policy for people with disabilities
This doctor explains why assisted suicide harms doctors' duty to care for their patients
Elizabeth has brain cancer—she explains why assisted suicide is bad for patients and their families
If you'd like to offer condolences to JJ's family, his wife Kris requested individuals send donations to the Can't Hurt Steel Community Foundation, PO Box 333, Eldred, NY 12732.
Elizabeth and her family know what it's like to live with cancer.
The bag full of prescription drugs, the good days and bad days, the priceless value of just being there when her son and daughter hit a new milestone. All of that gives her a unique perspective on the issue of assisted suicide.
It's a hot topic in state capitols around the country. But her pro-life perspective is often lost in the political posturing.
Before you decide what you think about this important issue, please listen to what she has to say.
Learn more about our Worth Fighting For project.
#WorthFightingFor
Learn exactly how God loves you. And discover the value of every life.
Jean Swenson was in a tragic car accident in 1980 that left her paralyzed.
She shares how she found hope in a most unexpected way. And she explains why it's important to focus on "eliminating the problem, not the patient."
Stay connected with email updates
Unleash your citizenship! Get news, commentary and alerts delivered right to your inbox.
I'd Like to Give a Gift
KX (For Allies)
866.655.4545 | 8675 Explorer Drive, Suite 112 | Colorado Springs, CO 80920
This is the website of Family Policy Alliance and Family Policy Foundation. Learn more.
© 2022 Family Policy Alliance
#AfterRoe - Are You Ready?
We are ready to compete with the abortion lobby for Every. Single. Precious. Life.--and WIN. Are you with us?


Archie Rodia, co-owner of Homewatch CareGivers in Temecula, with his wife, Sabrina, learned about caregiving firsthand when his father became ill. Initially he and his siblings tried to provide round-the-clock care, but as they all had full-time jobs and families at home, they discovered the blessing of professional in-home care to partner with. He also was involved in caring for an uncle with Alzheimer's disease and an aunt who has lost much of her vision. Archie has a degree in business management and worked for many years as a supervisor at Southern California Edison. Archie is the proud father of four and grandfather to nine!
Sabrina Rodia, co-owner of Homewatch CareGivers in Temecula, with her husband, Archie, has spent many years working as a nurse. She worked as a registered nurse (RN) in medical, surgery, and telemetry units and labor and delivery, and as a RN case manager in hospice. She has two degrees in Nursing. Through her work, Sabrina observed the importance of professional caregiving—both to support family caregivers and to be there when no one else can be. "It's through these experiences that I realize I can bring compassion and excellent standards to meet the care needs of clients and families in my community," she says. Sabrina and Archie have four grown children and nine grandchildren to date.
Brianna Becvar has been with Homewatch CareGivers of Temecula from the beginning as an office manager and scheduler. Before joining the team and journey with Homewatch CareGivers Brianna was a stay-at-home Mom providing care for her children for over 9 years, while also managing and running a photography business and children's boutique. She has worked with many kinds of customers over the years building her businesses while providing constant care to her family. When the opportunity to join the Homewatch CareGivers team was presented to Brianna,she was eager and excited to embark on this journey and grow along with this company. Among her responsibilities, Brianna helps to make client and caregiver matches and onboard new caregivers as we grow to meet community needs. Brianna is also a registered caregiver so you might meet her if she is caring for you or a loved one. In her off-time Brianna enjoys quality time with her family, including her husband, children, and pugs she adores.
Sarah Sharifi-Tabesh joined Homewatch CareGivers of Temecula as a caregiver and later transitioned into a secretary and scheduler position also. Before joining the team at Homewatch CareGivers, Sarah worked as a registered caregiver in an assisted living and memory care facility. She has worked with a variety of clients with various needs and has a strong background with the business aspect of an office. Sarah has been involved with companion care, surgery aftercare, as well as being one of the first caregivers at Homewatch CareGivers of Temecula to be involved in a series of 24-hour caregiving shifts. Since joining the office team she has been involved in orientating wonderful caregivers, creating customized matches between our amazing caregivers, and unique, wonderful clients, being a part of the intake process of onboarding clients, as well as many other tasks in and out of the office. Sarah continues to provide client care as needed and loves connecting with new and previous clients. Sarah has a heart for caring for each client in a unique and personalized manner and ensuring caregivers know they are a vital part of our team. In her off-time Sarah enjoys cooking a variety of cuisines, crafting, and spending time with her loved ones and Jack Russel Terrier named Jack.


The difference between success and failure in any endeavour in life lies not in Race, Creed, Colour, Gender or Socio-economic background but in Our attitude towards the people and circumstances that we encounter.
Positive or Negative Our Attitude is Our choice.
So how can we choose to have a more positive and empowering State whenever we want it?
In short, Programming, just like a computer. Only in this instance the "software" is the stimulus that we are exposed to on a daily basis – YouTube, Facebook, people, places, TV, radio, magazines, books and papers.
If you recall, during the introduction I made reference to what I called "Social Hypnosis" and the nature of humanity being, "survival by adaptation." In order to better understand this we need to take a look at a couple of very important factors that underpin our basic character.
Beliefs are formed from our values, those things in life that we feel to be important. That which we see as being inherently right or wrong, good or bad all forms the basis for our beliefs.
Who do we believe we are?
Our self-image is the foundation on which the rest of our lives are built. It will determine every aspect of our existence, from the way that we feel about our-selves, to the quality of our relationships with others and the careers that we pursue. How we see ourselves is our "blueprint" for success.
The way we think about ourselves determines everything that we say, do, believe and feel. If we want a happy fulfilled successful life we must first believe our-selves to be happy, successful and fulfilled individuals.
Don't panic if you are one of the many challenged with self-esteem issues. As you begin to understand the true power of thought you will be able to see yourself in a different light.
We all have them, good bad or indifferent we can't get away from them, but we can control them, to a point. I say to a point because whilst we cannot control what pops into our head we can certainly control whether or not we let it influence us negatively. Let me explain.
Our thoughts in our waking state our no more real than our dreams are in our sleep. The difference is in the function of our conscious mind. When we sleep "our little Voice" sleeps too. This means that the most weird and wonderful thoughts can race through our minds completely unchallenged by our sleeping conscious mind. Fast forward to our waking state and it is a whole different ball game.
If you remember from earlier the purpose of the conscious mind is to compare, contrast, analyse and try and understand or make sense of things. It is vital for our ability to adapt and survive long term, so in this context it is a valuable tool.
Unfortunately when a thought pops into our head in our waking state our conscious mind wants to know why it appeared. After all it must have appeared for a reason right? Wrong! Your conscious mind will try to compare, contrast and analyse this thought to try and make sense of it. Dependent on how much attention you give your thought this process can last for a fraction of a second or sadly in some cases a lifetime.
Imagine if you will, walking through the park, the sun is shining, the sky is blue and a light breeze keeps you cool as you reflect on what has been a great day. All seems good with life until in the distance you notice someone looking in your direction; they seem to be staring straight at you, a cold hard stare -unflinching. You glance around to see if they could be looking at any one else but no one else is around. As you get closer there is no doubt in your mind, they are staring straight at you. Initially, you think to yourself, what's their problem? Why are they staring at me? You check yourself over to make sure a bird hasn't left an unwelcome gift on your clothing. As you get closer you can see that this guy is looking a bit rough, dishevelled and you begin to think to yourself that he might be about to mug you, after all there is no one else around and he looks like your stereotypical down and out. Your heart begins to beat faster and you can feel your stomach starting to churn, your mind races on, your breathing starts to speed up as you think to yourself what if he tries to take my phone or my money, how will I get home, has he got a knife? Will he stab me…..what should I do? Should I run……that might provoke him and make things worse?
The reality of the situation is that this down and out mugger who is about to pounce on you for your money or phone (according to your logical thought process) is in fact a company director who has recently lost his business and has been struggling to sleep. He has lost interest in personal hygiene and his appearance. He is worried that he will not be able to provide for his wife and young family. The cold hard stare that triggered your avalanche of thoughts was no more than a guy caught up in his own little world of challenges totally unaware of your existence!
The point behind this tale is to identify what I refer to as a Choice Point. When the first thought of "why is he staring at me?" popped into your head you had a choice (even if you didn't know it at the time!) if you had thought "poor guy is obviously having a bad day" your experience of the walk would have been very different than the fearful one that took place. You could have continued your walk in the sunshine letting life drift by. Instead, your logical conscious left brain had to do it's thing and from this one thought developed a thought attack!
So how do we protect against such thought attacks and ensure that we are able to make the right decision at a choice point?
We begin by raising awareness of thought. Most of our 60,000 thoughts per day happen in an instant and pass pretty much un-noticed.
The early stages of meditation are an excellent tool for raising awareness of thought. When you first sit and try and think of nothing (as most beginners do) you get the polar opposite, an avalanche of thoughts popping into your head. It is a bit like a computer downloading!
With time and regular practice will come a greater awareness of thought, first in meditation and then in life in general. Once you are more aware of your thoughts you are better placed to decide what choices to make.
If choosing one particular thought process will lead to pain, anguish distress or a less than positive outcome and another to happiness, contentment, peace and your desired outcome, you dont have to be a rocket scientist to work out which choice to make, so long as we remember WE DO HAVE A CHOICE!
Our thoughts profoundly influence every aspect of our lives.
Our interpretation or perception of a particular set of circumstances is once again profoundly influenced by our own experience of life and the state that we happen to be in at the time of participating in or witnessing an event.
In the example of the mugger, had we been used to communicating with people down on their luck and outside societies norm our perception, thought processes, behaviour and subsequent experience would have been very different from that detailed in our example.
Our "states" of mind are dynamic, changing minute-by-minute, hour-by-hour, continuously evolving in response to the people, circumstances and environments that we encounter and the choices that we make. Our state at any given time is a culmination of our thoughts, feelings and actions towards life's experiences. A meeting with the boss, a chance encounter with an old friend, the opportunity to meet with new experiences all create changes in our moods or states.
The link between our thoughts and actions.
Have you ever noticed how difficult it is to think one way and behave another? After a disagreement with a partner, friend or colleague how difficult is it to act as if nothing has happened? Our heads are filled with the sights and sounds (thoughts) of this disagreement constantly replaying over and over again. We are in effect reliving that incident that made us feel uncomfortable in the first place. Is it any wonder that each time this happens we feel equally uncomfortable? Are we being unreasonable to expect any other outcome?
The secret to a more confident, successful, empowering, dynamic and energised outlook on life lies in understanding what influences and underpins our basic character and then consciously choosing to surround ourselves with positive stimulus.
Paraphrased from Paul Mc Kenna: Success For Life and Dr Richard Carlson: You can be happy no matter what….
© Copyright 2013, Think Eat Do.


text:
Ophthalmologic Procedures
Filed under Emergency Medicine
Kevin J. Knoop and William R. Dennis
The following discussion focuses on procedures performed by emergency clinicians during the evaluation and treatment of injuries and diseases of the eye. Emphasis is placed on practical application of the techniques; cautions to be heeded by the emergency clinician are included.
Assessment of Visual Acuity
Evaluation of visual acuity may initially be deferred with simple, obvious, or straightforward cases, such as a stye, periorbital laceration, or minor eye irritation; however, assessment of visual acuity should be the first procedure performed in the majority of patients seen in the emergency department (ED) with an eye complaint. Even though it may initially be deferred in the triage or trauma room setting or under other relevant scenarios, it is incumbent on the emergency clinician to ensure that visual acuity or function is ultimately assessed adequately.
Visual acuity should be assessed as soon as practicable and before the patient is examined with bright lights. In the event of blepharospasm from an injury (e.g., abrasion, chemical exposure), a topical anesthetic may facilitate the examination. Patients are often encountered in the context of an eye complaint and say that they "can't see." In these instances, emergency visual acuity assessment should be performed first, beginning with evaluation of light perception, then hand motion, and finally counting fingers at 3 ft (Fig. 62-1). If the patient succeeds in performing these assessments, a near vision card may then be used or distant visual acuity assessed. In emergency circumstances, detailed formal vision testing is not essential; however, some form of visual acuity assessment is needed. In this situation, the ability to count fingers or read newsprint gives some indication of gross visual function. Formal visual acuity testing should never delay important therapeutic interventions such as eye irrigation.1
Figure 62-1 The "routine" progression for assessing visual acuity is reversed in the emergency situation. Assessment of an intact visual pathway begins with quickly discerning whether the patient has light perception (LP), can see hand motion (HM), and can count fingers at 3 ft (CF). Subsequent progression to assess vision at 10 and then 20 ft from a standard eye chart ensues.
Distant Visual Acuity Procedure
For formal vision testing, ask the patient to face a well-lit standard Snellen or similar eye chart from a premeasured distance of 20 ft. Use a card or the palm of the hand to occlude one eye at a time. If possible, examine all patients while wearing their current lens correction to obtain the best corrected distant visual acuity. If not available, measure visual acuity first without correction and then with a pinhole device, and note any improvement in visual acuity. This device functions as a corrective lens by reducing corneal refractive error. In general, visual acuity is improved with the pinhole device. Decreased visual acuity that is not improved with this device suggests that corneal refractive error is not the cause. Construct a pinhole device by punching one to several holes in the center of a card (3- × 5-inch index card) with an 18-gauge needle. Devices with one or more pinholes drilled into an eye cover are available commercially (Fig. 62-2A and B) or can be constructed from readily available material in the ED, such as the index card with holes just mentioned. Figure 62-2C presents a chart for testing visual acuity while the patient is on a stretcher or in a chair. The chart can be used directly from this text if held 14 inches from the eye. Begin by testing the affected eye or the one presumed to have the worst visual acuity. First, instruct the patient to read the smallest letters on the chart that can easily be seen. Then ask the patient to read letters that can just barely be made out (i.e., they do not have to be clear). If the patient is unable to read the largest letter on the chart, move the patient to half the distance from the chart (10 ft), or if using the figure in this text, move it 7 inches closer to the eye and repeat the procedure. Record the results reflecting the change in distance (e.g., 10/200). The numerator in the vision ratio is the distance of the patient from the chart and the denominator is the distance at which a patient with normal vision can read the line of letters. For patients who still cannot read the letters on the chart, test vision progressively as follows: the ability to count fingers, detect hand motion, and perceive light (with or without projection—the ability to perceive the direction of light), and finally, the inability to perceive light.2
Figure 62-2 A commercial pinhole device reveals refractive error caused by corneal aberration (excessive tearing or nearsightedness). A, First measure visual acuity without the device. B, Then measure with the pinhole cover lowered. Document the acuity with and without the pinhole device. C, If the patient cannot stand or a formal eye chart is not available, ask the patient to read this "distance equivalent" chart by holding the card 14 inches away from the patient.
Near Visual Acuity Procedure
Perform near visual acuity assessment in the ED at the bedside or at triage. Hold a pocket near vision card (see Fig. 62-2C) or any printed material in good light at a distance of approximately 14 inches in front of the patient and occlude each eye alternately as described earlier. When using available printed material in lieu of a near vision card, measure the size of the letters that are discerned by the patient. At a later time compare these letters with the size of the letters on the near vision card to deduce the patient's actual visual acuity. When near vision is decreased, it is usually caused by either loss of visual function or poor accommodation as a result of advancing age (presbyopia). Less commonly, it is caused by traumatic mydriasis. Thus, examine patients with presbyopia with their reading correction in place to obtain the best corrected near visual acuity.
For patients who cannot communicate or in whom factitious blindness or malingering is suspected, check for optokinetic nystagmus (OKN) to determine whether the visual pathway is intact. To test for OKN, pass a regularly sequenced pattern in front of the eyes. If an optokinetic drum is available, rotate the drum in front of the patient (Fig. 62-3). This is not available in many EDs, however. In place of the drum, substitute a printed piece of paper such as newsprint (without photographs or large areas with no print) or a standard tape measure. Pass it in front of the patient's eye at reading distance while instructing the patient to look at it as it moves rapidly by. Evaluate for tracking as demonstrated by nystagmus-like eye movements seen when the test object is moved from side to side in front of the patient. Such movement indicates an intact visual pathway. Finally, another effective method is to hold a mirror in front of the patient and slowly rotate the mirror to either side of the patient. Patients with an intact visual pathway will maintain eye contact with themselves as demonstrated by eye movement as the mirror is moved. A large mirror that reflects the patient's entire face is most effective for this purpose.
Figure 62-3 Optokinetic nystagmus (OKN) testing will determine whether the visual pathway is intact. Induce OKN by passing a regularly sequenced pattern in front of the eye such as this commercially available drum. Hold the drum in front of the patient. Direct the patient to look at the drum as you rotate it slowly. Alternatively, draw a tape measure across the line of sight while asking the patient to look directly at it as it passes.
All patients with decreased visual acuity from baseline require routine referral for further ophthalmologic follow-up; however, patients with moderately or severely decreased visual acuity not explained by refractive error require ophthalmologic consultation in the ED.
Dilating the Eye
Dilating the eye is useful for both diagnostic and therapeutic purposes. Be advised, however, that an attack of narrow-angle (angle-closure) glaucoma may be precipitated by dilating the pupil. The most common form of glaucoma, however, is open-angle glaucoma, and this type is not precipitated by dilating the pupil. Some patients may have a "mixed mechanism" glaucoma with both open-angle and narrow-angle components. Systemic reactions, such as bradycardia or even heart block from β-blocker eyedrops, can be induced by mucosal absorption of dilating medications.
There are two types of dilators: sympathomimetic agents, which stimulate the dilator muscle of the iris, and cycloplegic agents, which block the parasympathetic stimulus that constricts the iris sphincter. Cycloplegic agents also block contraction of the ciliary muscles, which control focusing of the lens of the eye. This second effect of cycloplegic agents is beneficial in the therapeutic use of dilators for iritis.
Cycloplegic agents were used cosmetically as early as Galen's time. Beginning in the early 1800s, extracts from the plants Hyoscyamus and belladonna were used in ophthalmology. Atropine was first isolated in 1833. Epinephrine was used on eyes in 1900 as the first sympathomimetic agent.3
Indications and Contraindications
There are several diagnostic and therapeutic indications for dilating the pupil. Dilation is indicated for diagnosis when the fundus cannot be examined adequately through an undilated pupil. An elderly patient with miotic pupils and cataracts is an example of a patient in whom dilation may facilitate funduscopic examination. Dilation is therapeutically useful for many ophthalmic conditions, including inflammation of the eye. In the emergency setting, corneal injury with secondary traumatic iritis is a common example. Dilation helps the inflamed eye in two ways. First, it may hinder adhesions (synechiae) from forming between the iris and other ocular structures. Such adhesions eventually limit movement of the pupil and may precipitate glaucoma. Second, cycloplegic dilating agents relax the ciliary muscle spasm that often accompanies an inflamed eye and thus may reduce the pain associated with inflammation. Though traditionally used for these purposes, both benefits are largely theoretical with little formal evidence to support or refute their use in the ED.
Dilation is discouraged in patients with head injury who are at risk for herniation when it is necessary to monitor pupil findings. Dilation is contraindicated in the presence of narrow anterior chamber angles. Patients predisposed to having narrow angles may be unaware of this condition. Evaluate the depth of the anterior chamber before this procedure, and do not dilate the eye if there is any question of a narrow angle. To estimate the depth of the anterior chamber, shine a penlight tangentially from the lateral side of the eye. When the depth of the anterior chamber is normal, uniform illumination of the iris is seen. However, when the iris has a forward convexity as in the case of a narrow anterior chamber, only a sector of iris is illuminated and there will be a shadow on the medial (nasal) side of the iris (Fig. 62-4). With a slit lamp, the depth of the anterior chamber angle can be assessed directly. The definitive test for assessing the anterior chamber angle is gonioscopy, in which the anterior chamber angle structures are viewed directly by means of a special mirrored contact lens and a slit lamp. Gonioscopy is not a technique normally performed by emergency clinicians.
Figure 62-4 A, Left: The normal eye. Aqueous humor, produced in the posterior chamber, flows through the pupil into the anterior chamber. The major pathway for the egress of aqueous humor is through the trabecular meshwork into Schlemm's canal. Right: Primary angle-closure glaucoma. In anatomically predisposed eyes, transient apposition of the iris at the pupillary margin to the lens during pupil dilation blocks the passage of aqueous humor from the posterior chamber to the anterior chamber. Buildup of pressure in the posterior chamber bows the iris forward and occludes the trabecular meshwork. B, Left: Normal anterior chamber with a negative transillumination test. Note that the entire iris is illuminated. Right: Shallow anterior chamber with a positive transillumination test. Note the shadow on the outer half of the iris. C, Left: Clinical use of the penlight examination to assess the depth of the anterior chamber of the right eye. The examiner sits face to face with the patient to ensure that the light source is perfectly perpendicular to the line of vision. Right: The axial anterior chamber depth of the right eye is less than normal. This can be demonstrated by shining a light across the eye from the temporal side. Because of the convexity of the iris-lens diaphragm, the nasal iris manifests a crescentic shadow (eclipse sign). (A, From Kumar V, Abbas AK, Fausto N, et al, eds. Robbins and Cotran Pathologic Basis of Disease, Professional Edition. 8th ed. Philadelphia: Saunders; 2009; B, from Swartz MH. Textbook of Physical Diagnosis. 6th ed. Philadelphia: Saunders: 2009. C, from Kanski JJ. Clinical Diagnosis in Ophthalmology. St. Louis: Mosby; 2006.)
Systemic effects can develop after the application of eyedrops.4–10 Review the following sections on agents and complications before using these drugs in patients with compromised cardiovascular function.
Only two dilating agents are really needed in the ED. Phenylephrine (Neo-Synephrine) 2.5%, a potent sympathomimetic, is used for diagnostic dilation of the pupil and visualization of the fundus. The drug is short acting, and because accommodation is not affected, the patient's vision is not altered. Phenylephrine 10% should not be used routinely because it can be absorbed systemically and, in rare cases, has caused hypertensive crisis, myocardial infarction, and death.8,9
For therapeutic cycloplegia in patients with iritis, 5% homatropine works well. Even though Table 62-1 indicates a maximum duration of 3 days, 24 hours is more common. Therefore, 5% homatropine is a useful therapeutic agent for traumatic iritis. Atropine should not be used for traumatic iritis because the undesirable effects of pupillary dilation and blurred vision persist for a week or longer after the associated corneal abrasions have healed. Atropine drops may be prescribed as part of the therapy for nontraumatic iritis after appropriate ophthalmologic consultation. Individuals with lightly pigmented irides tend to have greater sensitivity to cycloplegic agents than do individuals with greater pigmentation; the cycloplegic effect might therefore be more prolonged in people with light eyes. It might be difficult to dilate some patients with deeply pigmented irides, however, and numerous applications of drops might be required.
TABLE 62-1
Mydriatic Agents
*The duration of effect shows considerable individual variation. These are general estimates.
†Preferred for funduscopic examination.
‡A 10% solution may produce cardiovascular reaction and hence should not be used.
§Preferred for iritis or corneal abrasion therapy.
Malingerers may use mydriatic agents to dilate a pupil unilaterally for the purpose of feigning neurologic disease. Normally, the pupillary dilation caused by intracranial compression of the third cranial nerve will constrict with 2% pilocarpine eyedrops. A mydriatic-treated eye can be identified by full motor function of the third cranial nerve and absence of miosis after the instillation of pilocarpine. A fixed and dilated pupil in an awake and alert patient cannot be secondary to brain herniation. Although other neurologic problems may be present, in a normal-appearing patient with a fixed and dilated pupil, a pharmacologic cause is highly likely. It should be noted that legitimate patients may not recall the name of an eye medicine that they used but will usually recall whether the bottle had a red cap, as is found on all cycloplegic solutions. An unexpected mydriasis in a trusted patient may be the result of such an agent. Medications that constrict the pupil, such as pilocarpine, have a green cap. Pressure-lowering drops for glaucoma may be yellow or blue topped (β-blockers), purple topped (adrenergic agents), or orange topped (topical carbonic anhydrase inhibitors).
A fixed and dilated pupil from a pharmacologic cause may be encountered after both nasotracheal and orotracheal intubation (Fig. 62-5). In such ill or injured patients, cerebral herniation must be considered. When phenylephrine is used to constrict the nasal mucosa before nasal intubation (endotracheal tube, nasogastric tube), inadvertent spread to the eye can result in a fixed and dilated pupil. The same scenario may occur during resuscitation when endotracheal epinephrine has been instilled into the lungs and cardiopulmonary resuscitation has expelled epinephrine into the eye. In such scenarios, the affected pupil will not constrict after intraocular pilocarpine administration. Finally, a fixed and dilated pupil might occur as a result of inadvertent contamination of the eye with scopolamine after the application of a scopolamine patch.
Figure 62-5 A, After phenylephrine (Neo-Synephrine) drops were instilled in the nose to facilitate passage of a tube, this comatose patient was nasotracheally intubated for his drug overdose. B, On a subsequent examination a unilateral fixed and dilated pupil was noted. The pupil dilation resulted from Neo-Synephrine nose drops that were snorted from the nose into the eye during intubation and simulated cerebral herniation. Other unusual causes of a fixed and dilated pupil are endotracheal epinephrine expelled from the lungs and splashed onto the eye during cardiopulmonary resuscitation and inadvertent contamination of the eye after the application of a scopolamine patch behind the ear.
Instillation of mydriatic agents is similar to the administration of other eye solutions. For medicolegal purposes, note the patient's visual acuity before instillation of the medicine. This documents that any decreased vision is not the result of the mydriatic agent. Whenever dilation is performed, note on the patient's chart the dose and time that agents have been given to avoid confusion during subsequent neurologic evaluation.
Place the patient in a supine or a comfortable semirecumbent position. Instruct the patient to gaze at an object in the upper visual field, such as a fixture on the ceiling. Gently depress the lower lid with a finger on the epidermis. Instill a single drop of the solution into the lower lid fornix, and ask the patient to blink to spread the medication. Do not use more than a single drop because it produces reflex tearing and reduces the concentration in contact with the conjunctiva. Forewarn the patient that the medication is uncomfortable when it goes into the eyes. After the medication has been instilled, the patient may blot the eye when it is closed but should not rub it with a tissue. If the desired effect is not noted in 15 to 20 minutes, repeat the dose, but this is seldom required.
Any dilator can precipitate an attack of angle-closure glaucoma in susceptible patients.10 In the case of angle-closure glaucoma, it may take several hours before symptoms become evident. The patient often complains of smoky vision with "halos" around lights, as well as an aching pain that is sometimes severe. Nausea and vomiting may occur. If the affected eye becomes injected in association with a hazy cornea, elevated pressure on tonometry, and an oval, fixed pupil, consult an ophthalmologist immediately. Place the patient supine and administer analgesics and antiemetics. Treatment usually includes the agents suggested in Box 62-1, and later, definitive laser or surgical procedures.
Box 62-1
Treatment Options for Acute Angle-Closure Glaucoma*
Place patient supine; administer analgesics (such as IV morphine titrated to effect) and antiemetics (such as ondansetron 8 mv IV):
1. Beta blocker†: Timolol 0.5% (Timoptic), 1 drop to the affected eye, wait 1 minute, and then
2. Alpha agonist: Apraclonidine 1% (Lopidine), 1 drop to the affected eye, wait 1 minute, and then
3. Miotic agent: Pilocarpine 2% (Isopto Carpine), 1 drop to the affected eye every 15 minutes for 2 total doses; wait 1 minute after first dose, and then
4. Prednisolone acetate 1 percent, 1 drop to the affected eye every 15 minutes for 4 total doses
5. Acetazolamide 500 mg IV (may give by mouth, two 250-mg tablets, if IV medication not available)
*Empiric therapy, no controlled trials, based on clinical experience.
†Relative contraindications: severe bronchospasm, second to third degree heart block, uncompensated congestive heart failure.
Modified from Shields SR. Managing eye disease in primary care. Part 3. When to refer for ophthalmologic care. Postgrad Med. 2000;108(5):99-106.
Be aware that if contaminated, an eye medication can introduce infection. Most solutions contain bactericidal ingredients, but contamination of the tips of droppers can still occur (Fig. 62-6A).11 Use only newly opened bottles of eye medication or single-use vials, particularly if the patient has a deep corneal injury or has recently undergone eye surgery. Promptly discard out-of-date drops and those in which crust or other material is found around the nozzle.
Figure 62-6 A, Administration of eye drops. Position the patient with the head tilted back. Direct the patient's gaze upward. Pull the lower lid downward and instill a single drop of medicine in the lower conjunctival fornix. Ensure that the tip of the dropper does not touch the lid or lashes. Instruct the patient to close the eyelids for 1 minute to increase contact of the medicine with the globe and to decrease outflow of medication down the tear duct and over the lid margin. B, If administering large amounts of eye drops that have systemic effects, such as β-blocker drops, place the operator's index finger under the inferior eyelid along the nasal borders of the eye and firmly compress the nasolacrimal duct against the globe for a few minutes, thereby preventing migration of the drops into the nose and reducing systemic absorption.
Forewarn the patient that any cycloplegic (in contrast to a sympathomimetic) will blur a patient's near vision. Vision will be less blurred in adults older than 45 years, who generally have a reduced ability to focus for near vision. Although most adults will be able to drive safely, even with both eyes affected, it is advisable to have someone else drive whenever feasible. Light sensitivity caused by pupillary dilation may also be bothersome; sunglasses are sufficient for this problem.
Systemic reactions may rarely be induced by sympathomimetic and cycloplegic eyedrops.4–10 In one report of 33 cases of adverse reactions associated with 10% phenylephrine, there were 15 myocardial infarctions (11 deaths), 7 cases of precipitation of angle-closure glaucoma, and a variety of systemic cardiovascular or neurologic reactions.9
After instillation of eyedrops into the conjunctival sac, systemic absorption can occur through the conjunctival capillaries, as well as by way of the nasal mucosa, the oral pharynx, and the gastrointestinal tract after passage through the lacrimal drainage system. Mucosal hyperemia enhances absorption. Symptoms can often be avoided by maintaining digital pressure on the nasal canthus to occlude the puncta for several minutes after administration (Fig. 62-6B).4
The Fluorescein Examination
Perform fluorescein staining of the eye as part of the evaluation of all patients with eye trauma and infection. It is a quick and easy technique that is crucial for the proper diagnosis and management of common eye emergencies. View the fluorescein-stained cornea and conjunctiva under a "blue" light and ideally in conjunction with slit lamp magnification (see "Slit Lamp Examination," later in this chapter).
Sodium fluorescein is a water-soluble chemical that fluoresces. It absorbs light in the blue wavelengths and emits the energy in the longer green wavelengths. It fluoresces in an alkaline environment (such as in Bowman's membrane, which is located below the corneal epithelium) but not in an acidic environment (such as in the tear film over intact corneal epithelium).12 Thus it is useful in revealing even minute abrasions on the cornea.
Fluorescein was initially used in ophthalmology in the 1880s.13 It was first used as a drop, but when the danger of contamination by bacteria (especially Pseudomonas) was recognized in the 1950s,14 paper strips impregnated with fluorescein were developed. These strips are now supplied in individual sterile wrappers and should be used instead of the premixed solution.
Fluorescein staining is indicated for the evaluation of suspected abrasions, foreign bodies (FBs), and infections of the eye,15 including "simple" cases of conjunctivitis, which may actually be herpetic keratitis. Exposure of the face to pepper spray has been associated with corneal abrasions, and such patients should undergo fluorescein staining and be evaluated with a slit lamp or Wood's lamp.16 Corneal defects may be seen after even a few seconds of unprotected viewing of a welder's arc flame.
Fluorescein permanently stains soft contact lenses. Therefore, when fluorescein is used, remove soft contact lenses before instilling the fluorescein and caution the patient to not put the lenses back into the eye for several hours. Topically administered fluorescein is considered nontoxic, although reactions to a fluorescein-containing solution (not impregnated strips) have been described.17 These reports, which consist of vagal reactions18 and generalized convulsions,19 are rare, not rigorously supported, and believed to be caused by agents other than fluorescein in the solution. If using one of these fluorescein-containing solutions rather than the fluorescein-impregnated strips, be aware of these potential, yet scientifically suspect idiosyncratic reactions.
Also be aware that fluorescein dye may enter the anterior chamber of the eye in patients with deep corneal defects. This form of intraocular fluorescein accumulation is nontoxic. When the anterior chamber is viewed under the blue filter of the slit lamp, a fluorescein "flare" is visible and should not be confused with the flare reaction noted with iritis.
Theoretically, one should not use topical anesthetics before fluorescein staining because a superficial punctate keratitis may develop in some patients from the anesthetic,12 which can confuse the diagnosis. However, in patients who are tearing profusely and squeezing their eyes shut from an abrasion or an FB, the examination is often impossible if a topical anesthetic is not first used. Theoretical downsides notwithstanding, it is common practice to apply a local anesthetic before instilling fluorescein.
Grasp the fluorescein strip by the nonorange end and wet the orange end with 1 drop of saline. Several convenient forms are available, including a small bottle of artificial tears or a 5-mL "bullet" or "fish" of normal saline commonly used for nebulizer treatments. Alternatively, wet the strip with tap water or the recently used local anesthetic drops. Once the strip is moistened, place it gently on the inside of the patient's lower lid (Fig. 62-7, step 1). Withdraw the strip and ask the patient to blink, which spreads the fluorescein over the surface of the eye. The key to a good examination is to have a thin layer of fluorescein over the corneal and conjunctival surfaces. If the strip is too heavily moistened before placing it in the lower fornix, the eye may become flooded with the solution, which makes evaluation difficult. If too much dye accumulates, the patient can remove the excess dye by blotting the closed eye with a tissue. Conversely, placing a dry strip in an unanesthetized eye may be irritating. Next, use a Wood lamp (4× magnification), the blue filter of a slit lamp, or simply a penlight with a blue filter to examine the eye in a darkened room (see Fig. 62-7, step 2). Check for areas of bright green fluorescence on the corneal and conjunctival surfaces. The naked eye may not be able to see small defects. Ideally, use a slit lamp with 10× or 25× magnification to examine the stained cornea before ruling out a pathologic process. A new handheld magnification device, the Eidolon Bluminator ophthalmic illuminator, produces an intense blue light from a light-emitting diode with 7× magnification (see Fig. 62-7, step 3). After completion of the fluorescein examination, irrigate excess dye from the eye to minimize damage to the patient's clothing from dye-stained tears.
Figure 62-7 The fluorescein examination. Excessive fluorescein may obscure subtle findings and thus should be avoided. Fluorescein will permanently stain contact lenses if they are not removed. LED, light-emitting diode.
The Seidel test uses fluorescein to detect perforation of the eye.20 To perform this test, instill a large amount of fluorescein onto the eye by profusely wetting the strip. Examine the eye for a small stream of fluid leaking from the globe (see Fig. 62-7, plate 4). This stream will fluoresce blue or green, in contrast to the orange appearance of the rest of the globe flooded with fluorescein.12
Fluorescein is used mainly for evaluation of corneal injuries. Although conjunctival abrasions pick up the stain, most of the staining on the conjunctiva represents patches of mucus rather than a real pathologic condition. Corneal staining is more specific for injury, and the pattern of injury often reflects the original insult.
Corneal staining patterns are illustrated in Figures 62-7 and 62-8. Abrasions usually occur in the central part of the cornea because of the limited protection of closure of the patient's eyelids. The margins of the abrasions are usually sharp and linear if seen in the first 24 hours (see Fig. 62-7, plate 6). Circular defects are seen about embedded FBs and may persist for up to 48 hours after removal of a superficial foreign object. Deeply embedded objects may be associated with defects persisting for longer than 48 hours. Objects under the upper lid (including some chalazia) often produce vertical linear lesions on the upper surface of the cornea (see Fig. 62-7, plate 7). When vertical lesions are noted, search diligently for a retained FB under the upper lid. Overuse of hard contact lenses diminishes the nutrient supply to the cornea. The central part of the cornea sustains the most injury and thus fluoresces brightly when stained. Excessive exposure to ultraviolet light as a result of sunlamp abuse, snow blindness, or welding flashes produces a superficial punctate keratitis, which in its mildest form may not be visible without a slit lamp (see Fig. 62-7, plate 8). The central part of the cornea is the least protected by the lids, and a central, horizontal band–like keratitis can result. Herpetic lesions may develop anywhere on the cornea. Classically, these lesions are dendritic, although ulcers may also be punctate or stellate (see Fig. 62-7, plate 9).21,22
Figure 62-8 Patterns of acute corneal injury. 1, Traumatic abrasion, usually with linear features and sharp borders when seen early (<24 hours), occurs more in the central part of the cornea. 2, Abrasion from a foreign body (FB). Vertical abrasions on the upper part of the cornea are seen when an FB is embedded in the upper lid. Also shown is a rust ring with a metallic FB. 3, Exposure pattern seen with prolonged exposure to ultraviolet light (e.g., welding flash, sunlamp exposure). A bandlike keratitis is produced over the lower half of the cornea. Squinting in the setting of the bright light protected the upper corneal surface. 4, Herpes simplex keratitis, classic dendritic pattern. 5, Adenovirus keratitis. Diffuse minute corneal staining is seen in patients with epidemic keratoconjunctivitis about 7 days after the onset of symptoms. 6, Contact lens overuse, central punctate staining. (From Knoop K, Trott A. Ophthalmologic procedures in the emergency department—part III: slit lamp use and foreign bodies. Acad Emerg Med. 1995;2:227. Reproduced by permission.)
Any area of corneal staining with an infiltrate or opacification beneath or around the lesion should alert the practitioner to the possibility of a viral,21,22 bacterial,23 or fungal24 keratitis. Obtain urgent ophthalmologic consultation so that cultures of the possible etiologic agents can be procured and appropriate treatment initiated.
Many Pseudomonas organisms fluoresce when exposed to ultraviolet light25; therefore, the presence of fluorescence before the instillation of fluorescein in a red eye should suggest the possibility of infection with this organism.
Fluorescein staining is a quick and easy diagnostic procedure that should be part of every eye evaluation. The extra minute that the examination takes provides a wealth of diagnostic information on patients with eye trauma or infection. No complications are associated with the procedure with the exception of the reactions noted with the fluorescein solution, possible discoloration of soft contact lenses, and the potential for infection when premixed solutions rather than fluorescein-impregnated paper strips are used.
Eye Irrigation
The crucial first step in the treatment of chemical injuries to the eye is irrigation. Irrigate as clinically appropriate for the severity, length of exposure, and causative agent. Serious chemical injury to the eye requires irrigation at the site of the injury, even before the patient is brought to the ED.15 Corneal injury can occur within seconds of contact with an alkaline substance. Continue eye irrigation in the ED.
This section discusses methods of irrigation. Although it is best to irrigate liberally, copious irrigation is not needed when the patient has just a small amount of a noncaustic, nonalkaline compound in the eye.
Irrigation is indicated for all acute chemical injuries involving the eyes. Irrigation may also be therapeutic in patients with an FB sensation but no visible FB. Small, unseen foreign material in the conjunctival tissues may be flushed out with irrigation. There is no contraindication to eye irrigation, but in patients with a possible perforating injury, perform the irrigation especially gently and carefully.
The following equipment is necessary for eye irrigation:
Topical anesthetic, such as 0.5% proparacaine
Sterile irrigating solution (warmed intravenous saline or lactated Ringer's [LR] solution in a bag with tubing)*
A basin to catch the fluid
Cotton-tipped applicators
Gauze pads to help hold the patient's lids open
Lid retractors
Irrigating device (e.g., Morgan Therapeutic Lens, modified central venous catheter, or Eye Irrigator) for prolonged irrigation
Optimal: 10 mL of 1% lidocaine added to a liter of irrigating fluid
First, instill a topical anesthetic into the eye (Fig. 62-9, step 1). Evert the eyelid and sweep out any particulate matter in the conjunctival fornices with a moistened, cotton-tipped applicator15 (see "Ocular FB Removal," later in this chapter, and Fig. 62-9, step 2). Hold the eyelids open during irrigation (see Fig. 62-9, step 3). The easiest method is to use gauze pads to grasp the wet, slippery lids and hold them open. If the patient has severe blepharospasm, consider using lid retractors (Desmarres or paper clip retractors; Fig. 62-10). When lid retractors are used, be certain that the eye is well anesthetized, that the retractors do not injure the globe or the lids, and that chemicals are not harbored under the retractors. Be aware that simple retractors fashioned from metal paper clips (especially those that are nickel plated and shiny) may have surface chipping, which can create an ocular FB.26 Exercise caution to avoid ocular injury when using such a makeshift retractor.
Figure 62-9 Irrigation of the eye. Intravenous tubing is connected to a liter bag of saline or Ringer's solution, and irrigation occurs at a wide-open rate.
Figure 62-10 Devices for separating eyelids. A, A Desmarres retractor, lid specula, or retractor improvised from a paper clip allows active manipulation of the lids. Free-standing specula may require a seventh nerve block to reduce the blepharospasm. B, Lid retractor in place. (A, From Fogle JA, Spyker DA. Management of chemical and drug injury to the eye. In: Haddad LM, Winchester JF, eds. Clinical Management of Poisoning and Drug Overdose. 2nd ed. Philadelphia: Saunders; 1990. Reproduced by permission.)
Deutsch and Feller15 recommended an ipsilateral facial nerve block for severe blepharospasm (Fig. 62-11). To avoid swelling of periorbital tissue, block the facial nerve just anterior to the condyloid process of the ipsilateral mandible. Place a subcutaneous line of anesthetic (2% lidocaine) to temporarily paralyze the orbicularis muscle.
Figure 62-11 Injection points for facial and orbital anesthesia and akinesia. A, Van Lint technique for infiltration of the orbicularis. B, Retrobulbar injection site. C, O'Brien facial nerve block. C′, Alternative facial nerve block by injection into the tympanomastoid fissure. D, Infraorbital sensory block. E, Supraorbital sensory block. Injection of the orbicularis (A) or facial nerve (C or C′) permits examination and treatment of the eye in the setting of severe blepharospasm. Anesthetic is placed within several millimeters of the nerves. (From Deutsch TA, Feller DB, eds. Paton and Goldberg's Management of Ocular Injuries. 2nd ed. Philadelphia: Saunders, 1985:17.)
Irrigate with normal saline or LR solution directed over the globe and into the upper and lower fornices (see Fig. 62-9, step 4). The choice of fluid initially is less important than initiating irrigation as rapidly as possible. If tap water is available at the scene of the injury, begin irrigation immediately with copious amounts of fluid before transporting the patient to the hospital. Teach out-of-hospital care providers to irrigate all acid injuries of the eye for at least 5 minutes at the scene and to irrigate all alkali injuries for at least 15 minutes.27,28 LR or normal saline solution is preferred over tap water or 5% dextrose in water for eye irrigation because these solutions are isotonic and do not contain dextrose. Dextrose can be quite sticky if spilled and might serve as a nutrient for an opportunistic bacterial infection. Although one clinical trial found a balanced salt solution less painful in patients with a chemical eye injury,29 another volunteer study on uninjured eyes found that LR solution is better tolerated than normal saline and balanced saline solution when used with a Morgan lens.30 Warmed fluids are also better tolerated than fluids at room temperature.31 Warmed LR solution should be considered when both it and normal saline are available for eye irrigation.
Be careful to direct the irrigating stream onto the conjunctiva and then across the cornea without letting the stream splash directly onto the cornea because striking the eye with the solution can in itself be harmful and cause mechanical injury (see Fig. 62-9, step 5). Direct irrigation of the cornea can result in the development of a superficial punctate epithelial keratopathy.
Before irrigation, instill anesthetic eyedrops, such as 0.5% tetracaine. Adding 10 mL of 1% lidocaine to a liter of irrigating fluid can decrease patients' discomfort during prolonged irrigation.
Duration of Irrigation
Although Deutsch and Feller15 recommended that a full liter of irrigating solution be used in every case of caustic injury, the duration of irrigation is best determined by the extent of the exposure and the causative agent. Acids are quickly neutralized by proteins in the surface tissues of the eye and, once irrigated out, cause no further damage. The only exceptions are hydrofluoric and heavy metal acids, which can penetrate through the cornea. Alkalis can penetrate rapidly and, if not removed, will continue to produce damage for days because of slow dissociation of the cation from combination with proteins.15 Therefore, prolonged irrigation is indicated and at least 2 L of solution should be used. Although rapid flushing with the first 500 mL is prudent, slow continuous irrigation, as discussed later, at a rate sufficient to generate a continuous trickle is often more effective and better tolerated than continued high-volume flushing. If the nature of the offending agent is unknown or in question, use prolonged irrigation.
Consult ophthalmology for all alkaline, hydrofluoric acid, and heavy metal acid injuries. Irrigation on an inpatient basis may be required for a period of 24 hours or longer, especially when the cornea is hazy or obviously thickened. Note that the magnesium contained in sparklers combines with water from tears to produce magnesium hydroxide.32 Treat such fireworks injuries as alkaline injuries rather than as thermal injuries. Treat eye damage from hair straighteners,33 phosphate-free detergents,34 and automobile air bags35 as alkaline injuries also.
Measure the pH of the conjunctival fornices with a pH paper strip to check the effectiveness of irrigation (see Fig. 62-9, step 6). In addition to litmus paper, the pH indicator on urine multi-indicator sticks can be used. The pH indicator on urine dipsticks is conveniently closest to the handle; all the distal indicator squares can be cut off with scissors. Normal tear film pH is 7.4. Use the noninjured eye as a control if the results are equivocal. If the pH measured in the conjunctival fornices is still abnormal after the initial irrigation, continue to irrigate. If the pH is normal after irrigation, wait 20 minutes and check it again to make sure that it remains normal, especially if alkaline contamination has occurred. Delayed changes in pH are usually the result of incomplete irrigation and inadequate swabbing of the fornices. In anticipation of this deficiency, measure the pH deep in the fornices. Consider double-lid eversion with a lid elevator to expose the upper fornix for swabbing, irrigation, and pH testing.
Prolonged Irrigation
Alkaline burns may require prolonged irrigation, and it is essential to consult ophthalmology in such cases. The Morgan Therapeutic Lens is a contact lens–type irrigation device that can provide slow, continuous irrigation once the more vigorous initial irrigation has been completed (Fig. 62-12). First, anesthetize the eye with topical anesthetic drops. Then place the device carefully on the surface of the eye with the lids closed around the intravenous tubing adaptor. Attach the intravenous tubing to the adaptor and provide continuous flow through the device onto the cornea and into the fornices. As the local anesthetic agents wash out during the irrigation process, the device can become uncomfortable, so reapply the anesthetic drops frequently during irrigation for patient comfort. Such short-term use of local anesthetics will not inhibit healing of the cornea.
Figure 62-12 Morgan lens irrigation. A liter bag of saline or Ringer's solution is connected to the Morgan lens with intravenous tubing and irrigated at a wide-open rate.
The only significant complication from irrigation is abrasion of the cornea or the conjunctiva. This can be a mechanical injury from trying to keep the lids open in an uncooperative patient, a small corneal epithelial defect from a Morgan irrigating lens, or fine punctate keratitis from the irrigation itself.36 For this reason, do not direct the stream directly onto the cornea. If a superficial corneal defect occurs, treat it in the usual manner. Deep or penetrating corneal injuries are likely to be a result of the caustic chemical and require emergency ophthalmologic consultation. Continue to provide slow continuous irrigation pending arrival of the ophthalmologist. Some experimental evidence suggests that massive parenteral or oral ascorbic acid supplementation may prevent the development of deep corneal injury,37 but such treatment has not gained universal acceptance.
Eye irrigation is easy, and complications associated with the technique are usually minimal. At times the clinician may be unsure whether a chemical injury is toxic enough to warrant irrigation. If any doubt exists, err on the side of irrigating the eye rather than omitting this vital procedure and risking progression of the eye injury.
Ocular FB Removal
Patients with an external FB in the eye are frequently seen in EDs. They are often in pain and desperate for help. Maintain a high degree of suspicion for FB injuries and perforation of the eye because such injuries may be occult and not readily detected. Not all FB injuries are associated with pain. Glass embedded in the cornea may be particularly difficult to detect. This section reviews procedures for locating and removing extraocular FBs and appropriate postprocedural care. Finally, a brief discussion covering evaluation of the eye for potential perforation of the globe and detection of the presence of an intraocular FB is provided.
Extraocular FBs must always be removed. The timing of removal and the technique required vary according to the patient's clinical status and the type of injury. For the most part the emergency clinician can proceed directly to removal of the object via the techniques described in this section. When the patient is extremely uncooperative (e.g., an intoxicated patient, a mentally deficient patient, or a young child) or when the injury is complicated (e.g., deeply embedded object, multiple foreign objects from a blast injury, or possible globe penetration), consult ophthalmology immediately. A patient with a suspected FB or abrasion after exposure to a projectile (e.g., grinding wheel, hammering, metal objects colliding) should be rigorously evaluated for the presence of a deep intraocular FB. See further discussion later in this chapter. A penetrating injury of the cornea is of particular concern because the iris tissue may prolapse and have an appearance similar to a corneal FB (Fig. 62-13). Hence, in addition to the history of projectile exposure, an irregular pupil, especially a pear-shaped pupil, should alert the clinician that a penetrating injury might have occurred.
Figure 62-13 Serious eye injuries. A, Corneal laceration with prolapse of the iris. The extruded iris is dark and mimics a corneal foreign body (arrow). Frequently, the only clue is an abnormal pupil, and the extruded iris may not be appreciated as intraocular tissue. The pupil is irregular (often pear or teardrop shaped) and points toward the laceration. B, A pear-shaped pupil without protrusion of the lens is a more subtle, yet characteristic indication of a perforated globe (arrow). C, Another indication of a penetrating globe injury is periorbital fat protruding from an upper eyelid laceration (arrow). This patient was stabbed with a knife. D, This patient has an obviously cloudy lens soon after trauma. A projectile entered the temporal portion of the globe and produced a seemingly minor scleral hemorrhage. Patients with penetrating injuries to the globe should be treated with systemic antibiotics (such as a combination of cefazolin and gentamicin), tetanus toxoid if indicated, and antiemetics to control vomiting (which raises intraocular pressure). (A, Courtesy of Lawrence B. Stack, MD.)
Globe Protection
In the evaluation of a patient in whom a penetrating injury to the globe is suspected, perform a careful expeditious examination of the eye, preferably with a slit lamp. Avoid any pressure on the eye or rapid eye movements. If perforation is obvious (e.g., teardrop pupil, flaccid globe, flat anterior chamber, prolapsed iris) or confirmed by slit lamp (positive Seidel test; see Fig. 62-7, plate 4), do not perform any procedures (except perhaps irrigation) and consult ophthalmology early for definitive diagnosis and care. Until the ophthalmologist arrives, protect the eye from further harm by keeping the patient quiet, elevating the head of the bed, and placing a protective shield over the eye. Commercial shields are available for this purpose. When a metal shield is not available, construct a makeshift protective shield with the material available (e.g., paper, plastic, or Styrofoam cups; Fig. 62-14). The protective shield helps avoid pressure on the globe and overlying tissue and assists in preventing extrusion of vitreous and other ocular contents. Extend the edges of the shield up to or beyond the bony orbital rim for this purpose. Apply adhesive tape over the shield from the forehead to the cheek to secure the shield in position.
Figure 62-14 When a penetrating globe injury is suspected and a metal shield is not available in the emergency department or prehospital setting, a makeshift shield can be fashioned with available material. A paper cup was used to fashion this shield.
If a patient has a globe perforation, treat with systemic antibiotics (a combination of cefazolin and gentamicin is a good initial choice), tetanus toxoid, and antiemetics in doses aggressive enough to halt vomiting.
The following equipment is necessary for removal of an extraocular FB:
Sterile cotton-tipped applicators
Fluorescein strips
Magnification: loupes plus a Wood lamp, Eidolon Bluminator ophthalmic illuminator, or slit lamp
Eye spud or 25-gauge needle attached to a 1- or 3-mL syringe or to the tip of a cotton-tipped applicator
Dilator drops, such as 5% homatropine
Antibiotic ointment, such as erythromycin
Consideration of an Intraocular FB
When examining a patient with an ocular "FB" sensation, always remain cognizant of the potential for an intraorbital or intraocular FB. Penetrating injuries represent a greater threat to visual loss than an extraocular FB does and can be disastrous if overlooked. Note that an intraocular FB can be deceptively subtle on initial evaluation. Bedside ED ultrasound is a useful adjunct for identification of intraocular FBs (Fig. 62-15).
Figure 62-15 Metallic intraocular foreign body. Ultrasound shows a foreign body on the surface of the retina (short arrow). Note the marked shadowing just posterior to the foreign body (long arrow). (From Ryan SJ, Hinton DR, Schachat AP, et al, eds. Retina. 4th ed. St. Louis: Mosby; 2005.)
The clinical findings are most helpful in determining which patients are at risk for a penetrating injury to the globe. An individual who complains of an FB sensation in the absence of trauma or one whose history is simply that something "fell" or "blew" into the eye is at low risk for perforation of the globe. Conversely, there is a greater probability of globe penetration in an individual who has sustained a high-velocity wound to the eye (e.g., drilling, hammering, grinding metal, blasting rock). The presence of any of the following findings on physical examination should alert the clinician to a probable intraocular FB: irregular pupil, shallow anterior chamber on slit lamp examination, prolapsed iris, positive Seidel test (see "The Fluorescein Examination," earlier in this chapter), focal conjunctival swelling, hemorrhage, hyphema, lens opacification, and reduced intraocular pressure (IOP). Do not perform tonometry if penetrating injury to the globe is suspected. Be aware that a penetrating injury may not be associated with eye pain. If there is strong historical evidence and physical findings to support a diagnosis of globe penetration, obtain emergency ophthalmologic consultation.
An intraocular FB is often not visible on direct ophthalmoscopy. Although orbital radiography for radiopaque objects and ultrasonography of the globe have been used for indirect FB localization,15,38
Buy Membership for Emergency Medicine Category to continue reading. Learn more here
Management of Common Dislocations
Incision and Drainage
Resuscitative Thoracotomy
Emergency Cardiac Pacing
Peritoneal Procedures
Educational Aspects of Emergency Department Procedures
Assessment of Implantable Devices
Roberts and Hedges Clinical Procedures in Emergency Medicine


text:
Blunt, Wilfrid Scawen ___ 1840-1922 ___ British ___ diplomat, writer
Blunt was born into an old Sussex family at Petworth House, but his father died when he was only two. Thereafter, he was educated at Stonyhurst and Oscott, before entering the diplomatic service when only 18. He served in several European capitals and in Buenos Aires, taking full advantage of his single status in privileged society, and publishing love sonnets. In 1869, he left his government office, married Lady Anne Noel, Byron's granddaughter, and soon inherited Crabbet Park after the death of his brother. Thereafter, Blunt and his wife travelled and lived much in the Middle East, often travelling on horseback together. In 1873, after many miscarriages and the deaths of infant babies, Anne gave birth to Judith, her only surviving child. Blunt became increasingly outspoken on international issues, opposing British rule in Egypt, and British policy in the Sudan and sympathising with Muslim aspirations. His ideas were propagated in books such as 'The Future of Islam' and 'Ideas about India'. In 1888, he served a term in prison because of his championing of Irish home rule. Apart from poetry and controversial ideas on foreign policy, Blunt is also remembered for having an affair with Jane Morris, William Morris's wife, for breeding Arab horses, and for his spicy diaries.
The Diary Review - Seventy wax matches
1888-1914 ___ political social travel people love/sex nature horses Egypt India
good extracts
Cambridge University: Fitzwilliam Museum
My Diaries: Being a Personal Narrative of Events 1888-1914
India under Ripon: A Private Diary
May 2005, September 2008, March 2013


The crash occurred when a 2004 Chevrolet Blazer driven by Erica Stager, 31, of Saylorsburg and her passenger Ronald Lutz were traveling southbound on Mcllhaney Road and pulled out from a stop sign when it wasn't clear to do so, causing the Blazer to crash into a 1994 Jeep Wrangler driven by Maria Foti.
Foti was traveling southbound on Route 209.
Foti then crashed into a 2003 Saturn Ion driven by Lindsey Achenbach, which was stopped in the northbound lane of Route 209.
The Blazer and Ion sustained minor front end damage and the Wrangler was towed from the scene.