CATARACT

What is cataract?

Normally, the crystalline lens of the eye and its capsule is clear and allows ordered refraction of rays of light to the retina so that we can see everything clearly. Cataract is a state of opacification of this crystalline lens of the eye or its capsule, as shown in the diagram above. Due to this opacification rays of light entering the eye get dispersed in an unorderly fassion causing glare, foggy vision, and reduced visual acuity. The amount of light entering the eye varies with the amount of opacification of the lens or the capsule of the lens.

Why does it occur?

By far the most common form of cataract seen is "age related", starting somewhere in the late 50's or 60's. Theoretically cataract occurs due to either water imbibement into the lens fibres or their coagulation, causing opacification. The former is reversible, the later is not. There are numerous hypotheses as to why such changes occur in the lens. Some of the common causes of lens opacification are listed below.

1. As a normal ageing process
   
2. Due to the presence of Diabetes Mellitus
   
3. Due to physical or chemical injury to the eye
   
4. Due to a local disease of the eye (for example iridocyclitis)
   
5. Due to medications instilled in the eye; for example for glaucoma, steroids for iritis, etc.
   
6. Due to exposure to Ultraviolet or Infrared radiations, X-rays, persons exposed to such radiations in their professions develop cataract earlier
   
7. Profound debilitation or illness
   
8. Following sever diarrhoea, dehydration, undernutrition, starving, unsupervised dieting

Cataract in the eyes of the young are usually due to genetic defects and such syndromes, in which case they may be seen at birth or immediately after birth. The other common cause in children is injury to the eye.
Any of the above insults to the cyrstalline lens of the eye cause disruption in the ordered arrangement of lens fibres within the lens causing opacification (cataract).




Types of cataracts

Cataract types include:

• Cataracts that affect the center of the lens (nuclear cataracts). A nuclear cataract may at first cause you to become more nearsighted or even experience a temporary improvement in your reading vision. But with time, the lens gradually turns more densely yellow and further clouds your vision. Nuclear cataracts sometimes cause you to see double or multiple images. As the cataract progresses, the lens may even turn brown. Advanced yellowing or browning of the lens can lead to difficulty distinguishing between shades of color.
• Cataracts that affect the edges of the lens (cortical cataracts). A cortical cataract begins as whitish, wedge-shaped opacities or streaks on the outer edge of the lens cortex. As it slowly progresses, the streaks extend to the center and interfere with light passing through the center of the lens. Problems with glare are common for people with this type of cataract.
• Cataracts that affect the back of the lens (posterior subcapsular cataracts). A posterior subcapsular cataract starts as a small, opaque area that usually forms near the back of the lens, right in the path of light on its way to the retina. A subcapsular cataract often interferes with your reading vision, reduces your vision in bright light and causes glare or halos around lights at night.
• Cataracts you're born with (congenital cataracts). Some people are born with cataracts or develop them during childhood. Such cataracts may be the result of the mother having contracted an infection during pregnancy. They may also be due to certain inherited syndromes, such as Alport's syndrome, Fabry's disease and galactosemia. Congenital cataracts, as they're called, don't always affect vision, but if they do they're usually removed soon after detection.

Symptoms

Symptoms vary with the amount of lens opacity and the location of the lens opacity. If the opacity is situated in the center of the lens, vision is reduced in bright light due to constriction of the pupils and better in the evening or night due to dilation of the pupils. Similarly with peripheral opacities, vision is better during the day, or in good light, and worse at night or in poor light.

Patients with cataract experience "glare" due to haphazard dispersion of light in the eye due to opaque lens fibres. Some patients also experience "colored haloes" around sources of light at night due to prismatic dispersion of rays by the lens opacitites.

Another early symptom of cataract is "foggy" vision, as if seeing through a fog or a misty glass pane. This is because of opacification of the lens which is not sufficient to grossly reduce the entry of light into the eye, just disperse it.

Advanced cataracts gradually produce reduced vision, inability to make out faces, read, watch television,
Occasionally neglected cataracts can "hypermature" causing an increased pressure within the eyeball (glaucoma), causing pain, loss of vision, redness, and watering from the affected eye. This is a medical emergency and should be attended at once, or eyesight may be permanently lost.



How is Cataract detected?

To detect a cataract, an eye care professional examines the lens. A comprehensive eye examination usually includes:

• Visual acuity test: This eye chart test measures how well you see at various distances.
• Pupil dilation: The pupil is widened with eyedrops to allow your eye care professional to see more of the lens and retina and look for other eye problems.
• Tonometry: This is a standard test to measure fluid pressure inside the eye. Increased pressure may be a sign of glaucoma.

Your eye care professional may also do other tests to learn more about the structure and health of your eye.

How is it treated?

For an early cataract, vision may improve by using different eyeglasses, magnifying lenses, or stronger lighting. If these measures don't help, surgery is the only effective treatment. This treatment involves removing the cloudy lens and replacing it with a substitute lens.

A cataract needs to be removed only when vision loss interferes with your everyday activities, such as driving, reading, or watching TV.

You and your eye care professional can make that decision together. In most cases, waiting until you are ready to have cataract surgery will not harm your eye. If you decide on surgery, your eye care professional may refer you to a specialist to remove the cataract. If you have cataracts in both eyes, the doctor will not remove them both at the same time. You will need to have each done separately.

Sometimes, a cataract should be removed even if it doesn't cause problems with your vision. For example, a cataract should be removed if it prevents examination or treatment of another eye problem, such as age-related macular degeneration or diabetic retinopathy.

Is cataract surgery effective?

Cataract removal is one of the most common operations performed today. It is also one of the safest and most effective. In about 90 percent of cases, people who have cataract surgery have better vision afterward.

How is a cataract removed?

There are two primary ways to remove a cataract. Your doctor can explain the differences and help determine which is best for you:

• Phacoemulsification, or phaco. Your doctor makes a small incision on the side of the cornea, the clear, dome-shaped surface that covers the front of the eye. The doctor then inserts a tiny probe into the eye. This device emits ultrasound waves that soften and break up the cloudy center of the lens so it can be removed by suction. Most cataract surgery today is done by phaco, which is also called small incision cataract surgery.

• Extracapsular surgery. Your doctor makes a slightly longer incision on the side of the cornea and removes the hard center of the lens. The remainder of the lens is then removed by suction.

In most cataract surgeries, the removed lens is replaced by an intraocular lens (IOL). An IOL is a clear, artificial lens that requires no care and becomes a permanent part of your eye. With an IOL, you'll have improved vision because light will be able to pass through it to the retina. Also, you won't feel or see the new lens. Some people cannot have an IOL. They may have problems during surgery, or maybe they have another eye disease. For these people, a soft contact lens may be suggested. For others, glasses that provide powerful magnification may be better.

What happens before surgery?

A week or two before surgery, your eye care professional will do some tests. These may include tests to measure the curve of the cornea and the size and shape of the eye. For patients who will receive an IOL, this information helps your doctor choose the right type of IOL. Also, doctors may ask you not to eat or drink anything after midnight the morning of your surgery.

What happens during surgery?

When you enter the hospital or clinic, you will be given eye drops to dilate the pupil. The area around your eye will be washed and cleansed.
The operation usually lasts less than 1 hour and is almost painless. Many people choose to stay awake during surgery, while others may need to be put to sleep for a short time. If you are awake, you will have an anesthetic to numb the nerves in and around your eye.
After the operation, a patch will be placed over your eye and you will rest for a while. You will be watched by your medical team to see if there are any problems, such as bleeding. Most people who have cataract surgery can go home the same day. Since you will not be able to drive, make sure you make arrangements for a ride.

What happens after surgery?

It's normal to feel itching and mild discomfort for a while after cataract surgery. Some fluid discharge is also common, and your eye may be sensitive to light and touch. If you have discomfort, your eye care professional may suggest a pain reliever every 4-6 hours. After 1-2 days, even moderate discomfort should disappear. In most cases, healing will take about 6 weeks.

After surgery, your doctor will schedule exams to check on your progress. For a few days after surgery, you may take eyedrops or pills to help healing and control the pressure inside your eye. Ask your doctor how to use your medications, when to take them, and what effects they can have. You will also need to wear an eye shield or eyeglasses to help protect the eye. Avoid rubbing or pressing on your eye.

Problems after surgery are rare, but they can occur. These can include infection, bleeding, inflammation (pain, redness, swelling), loss of vision, or light flashes. With prompt medical attention, these problems usually can be treated successfully.

When you are home, try not to bend or lift heavy objects. Bending increases pressure in the eye. You can walk, climb stairs, and do light household chores.

When will my vision be normal again?

You can quickly return to many everyday activities, but your vision may be blurry. The healing eye needs time to adjust so that it can focus properly with the other eye, especially if the other eye has a cataract. Ask your doctor when you can resume driving.
If you just received an IOL, you may notice that colors are very bright or have a blue tinge. Also, if you've been in bright sunlight, everything may be reddish for a few hours. If you see these color tinges, it is because your lens is clear and no longer cloudy. Within a few months after receiving an IOL, these colors should go away. And when you have healed, you will probably need new glasses.

What is an "after-cataract"?

Sometimes a part of the natural lens that is not removed during cataract surgery becomes cloudy and may blur your vision. This is called an after-cataract. An after-cataract can develop months or years later.
Unlike a cataract, an after-cataract is treated with a laser. In a technique called YAG laser capsulotomy, your doctor uses a laser beam to make a tiny hole in the lens to let light pass through. This is a painless outpatient procedure.

Risk factors

Increasing ageFactors that increase your risk of cataracts include:

• Diabetes
• Drinking excessive amounts of alcohol
• Excessive exposure to sunlight
• Exposure to ionizing radiation, such as that used in X-rays and cancer radiation therapy
• Family history of cataracts
• High blood pressure
• Obesity
• Previous eye injury or inflammation
• Previous eye surgery
• Prolonged use of corticosteroid medications
• Smoking

Expectations (prognosis)

Vision may not improve to 20/20 after cataract surgery if other eye diseases, such as macular degeneration, are present. Ophthalmologists can usually, but not always, determine this in advance.

Prevention

The best prevention involves controlling diseases that increase the risk of a cataract, and avoiding exposure to factors known to promote cataract formation.
Wearing sunglasses when you are outside during the day can reduce the amount of ultraviolet (UV) light your eyes are exposed to. Some sunglasses do not filter out the harmful UV. An optician should be able to tell you which sunglasses filter out the most UV. For patients who smoke cigarettes, quitting will decrease the risk of cataracts.

Please Note

Call for an appointment with your doctor/ophthalmologist if you have:

• Decreased night vision
• Problems with glare
• Vision loss

EPILEPSY AND SEIZURE

The brain consists of millions of nerve cells, or neurones, and their supporting structure. Each neurone maintains itself in an electrically charged state. It receives electrical signals from other neurones, and passes them on to others. What actually happens is that a tiny quantity of a special neurotransmitter substance is released from the terminals of one neurone. This chemical excites an electrical response in the nuerone next in the chain, and so the signal moves onward.

All the functions of the brain, including feeling, seeing, thinking and moving muscles depend on electrical signals being passed from one neurone to the next, the message being modified as required. The normal brain is constantly generating electrical rhythms in an orderly way.

One must remember that different parts of the brain control different parts of our body and functions.
Left side of the body is controlled by right half of the brain and the right side The left half of the brain controls the right side of the body. In such a scenario, if a seizure starts from the right side of the brain, a person may jerk off the left hand or thumb or the left side of the body may be affected.


In epilepsy this order is disrupted by some neurone discharging signals inappropriately. There may be a kind of brief electrical "storm" arising from nuerones that are inherently unstable because of a genetic defect (as in the various types of inherited epilepsy), or from neurones made unstable by metabolic abnormalities such as low blood glucose, or alcohol. Alternatively, the abnormal discharge may come from a localised area of the brain (this is the situation in patients with epilepsy caused by head injury, or brain tumour).A seizure is not a disease in itself but it is a symptom of neurological conditions such as epilepsy.

A seizure may vary from staring at something for a few seconds to serious convulsions. These are caused by a sudden surge of an electrical activity in a particular area of the brain or the whole brain.

It does not mean that if a person has had a single seizure, he is sure to get epilepsy. Sometimes, children who have high fever can also suffer with a seizure. Sometimes one may also get a seizure caused by an imbalance of body fluids or chemicals, or also by drug or alcohol withdrawal.

A person who has missed his/her medication, or has been unable to sleep well for long, or has been severely ill with high fever or even without it can get a seizure. People, who are under a severe psychological stress, drink excessive alcohol, or even take to drugs such as ecstasy are prone to get a seizure. Seizures can also be provoked by nutritional deficiencies in people or during a menstrual cycle.

A doctor may be able to predict whether you will have more seizures by a test called as an EEG, electroencephalogram, in which wires are attached to your scalp to record your brain waves. Some patterns that appear on the test are very typical to epileptic conditions. If such patterns appear on your test, you are more likely to develop epilepsy.

Safety?

People who are otherwise healthy but suffer with epilepsy live as long as any normal person does. However, if epilepsy is caused by strokes or a brain tumor, the life expectancy of such people is less than an average person.

However, certain type of long-lasting convulsive seizure called as tonic-clonic status epilepticus is a life-threatening condition and is a medical emergency, which may last for more than 30 minutes. However, if not controlled within that time frame, it may cause a permanent injury or even death.

If not stopped within about 30 minutes, it may cause permanent injury or death.

Accidents during a seizure can become dangerous. People who suffer with epilepsy must be careful of going to the water as drowning is common. Showers must be preferred as tubs may also be dangerous. Safety on roads, railway platforms and busy streets must be doubly-assured.

Types of seizures

There are many different types of epilepsy, partially in infancy, childhood and adolescence. Epilepsy can be regarded in terms of--

• Generalized and partial epilepsy - the site of seizure origin in the brain
• Primary epilepsy - the underlying cause of seizures idiopathic where epilepsy occurs in a normal person. It can be traced to a hereditary predisposition to seizures.
• Secondary or symptomatic epilepsy - seizures are due to the inherent abnormality of brain structure and sometimes related with the neurological problems.

Sometimes brain damage is caused by a complicated birth and a hard blow to the head; a stroke that hampers oxygen to the brain, or the infection of brain like meningitis

Symptoms

Because epilepsy is caused by abnormal activity in brain cells, seizures can affect any process your brain coordinates. A seizure can produce:

• Temporary confusion
• A staring spell
• Uncontrollable jerking movements of the arms and legs
• Loss of consciousness or awareness

Symptoms vary depending on the type of seizure. In most cases, a person with epilepsy will tend to have the same type of seizure each time, so the symptoms will be similar from episode to episode.
Doctors generally classify seizures as either focal or generalized, based on how the abnormal brain activity begins.

Focal seizures

When seizures appear to result from abnormal activity in just one part of the brain, they're called focal or partial seizures. These seizures fall into two categories.

• Simple focal seizures. These seizures don't result in loss of consciousness. They may alter emotions or change the way things look, smell, feel, taste or sound. They may also result in involuntary jerking of part of the body, such as an arm or leg, and spontaneous sensory symptoms such as tingling, vertigo and flashing lights.
• Complex focal seizures. These seizures alter consciousness or awareness, causing you to lose awareness for a period of time. Complex focal seizures often result in staring and nonpurposeful movements — such as hand rubbing, chewing, swallowing or walking in circles.

Generalized seizures

Seizures that seem to involve all of the brain are called generalized seizures. Six types of generalized seizures exist.

• Absence seizures (also called petit mal). These seizures are characterized by staring and subtle body movement, and can cause a brief loss of awareness.
• Tonic seizures. These seizures cause stiffening of the muscles, generally those in your back, arms and legs and may cause you to fall to the ground.
• Clonic seizures. These types of seizures are associated with rhythmic, jerking muscle contractions, usually affecting the arms, neck and face.
• Myoclonic seizures. These seizures usually appear as sudden brief jerks or twitches of your arms and legs.
• Atonic seizures. Also known as drop attacks, these seizures cause you to lose normal muscle tone and suddenly collapse or fall down.
• Tonic-clonic seizures (also called grand mal). The most intense of all types of seizures, these are characterized by a loss of consciousness, body stiffening and shaking, and sometimes loss of bladder control or biting your tongue.

The Causes of Epilepsy

An inherited instability in the functioning of neurones seems to be responsible for the common forms of generalised epilepsy, especially absence attacks, and tonic-clonic seizures where there is a family history of similar disorder. How this genetic defect operates has yet to be established - perhaps the abnormality lies in the structure of the neurone's outer membrane, leading to electrical instability.
Injury to the brain may certainly cause epilepsy. This includes deprivation of oxygen at birth, trauma to the head at any time of life, and stroke (injury to part of the brain caused by blockage or haemorrhage of one of its blood vessels).
Metabolic disturbance can produce generalised seizures through disturbing the normal functioning of neurones. This may occur when there is severe lowering of blood glucose levels, and when there is severe malfunctioning of the liver or kidneys.
Alcohol and drug abuse may cause seizures during intoxication, or when the offending substance is being withdrawn. Withdrawal of certain medications, such as barbiturates and other sedatives, can cause epileptic seizures in those who have taken them for long periods.
Brain tumour is, fortunately, a relatively uncommon cause of epilepsy, but it must be excluded in all patients who develop epilepsy for the first time during adult life. Tumour should also be excluded in children and adolescents in whom the appearances of the EEG test are not typical of genetic epilepsy, or where these does not seem to be an adequate alternative explanation (such as birth injury).


Diagnosis of Epilepsy

Epilepsy is essentially a clinical diagnosis i.e. from history and physical examination. Detailed account of the attack from patient and the eyewitness is more important than the results of all the investigations as regards confirmation of the diagnosis. It often gives clues to the basic cause as well. Thus every effort must be made to obtain this.

Investigations are done to confirm the diagnosis and determine the cause. Depending on the age of the onset of the first seizures and associated symptoms and signs, the doctor decides the number and priority of the investigations. They include:

• Plain X–rays of skull and chest.
• Blood count and haemoglobin concentration.
• Electroencephalogram (EEG).
• Cerebrospinal Fluid Examination obtained through lumbar puncture.
• CT Scans and MRI Scans of the brain.
• Angiography.
• IQ test and personality tests.

Diagnosing a case of epilepsy

A patient’s detailed medical history is of utmost importance in diagnosing epilepsy. Many times family members who witness the seizure activity might be asked to keep a record of the time of the seizures, how long each seizure lasts, any aggravating factors like emotional stress, certain foods, smells or sounds etc.. This information can be crucial in the diagnosis of the type of epilepsy.

Usually, a neurologist would look into a case of epilepsy, although general physicians can also treat a person with seizures. The laboratory that would be required for epilepsy are:

• Primary care investigations
  Chest X–ray to rule out malignancy. Blood tests (eg. full blood count, erythrocyte sedimentation rate, electrolytes, renal function, liver function, calcium, and glucose) could show an underlying disorder or metabolic disturbance.
• Secondary care investigations
  Such as electroencephalography, neuroimaging, and metabolic screening in children, may aid seizure classification and help to determine the aetiology but they have limitations.
• Magnetic resonance imaging (MRI)
  Can better define the structures of the brain in three dimensions and can look at discrete areas of brain activation.
• Computed axial tomography (CAT)
  Has a role in the urgent assessment of seizures or when MRI is contraindicated, but it is less effective in detecting lesions.
• Electroencephalography (EEG)
  The EEG is not foolproof. It can only measure abnormal electrical activity that occurs during the test period and should not be performed to ‘Exclude’ a diagnosis of epilepsy but should be used to support the classification of epileptic seizures and epilepsy syndromes when there is clinical doubt.
• Positron emission tomography (PET)
  Scanning is a highly specialized, expensive and largely unavailable technique that detects cerebral blood flow and metabolism.
• Single proton emission computerized tomography (SPECT)
  scanning is much cheaper and technically simpler than PET scanning it shows the areas where blood flows through your brain.

Risk factors

There are some people who are prone to get epilepsy especially if one has a family history of seizures.

Here are the following people who could be at an increased risk of getting a seizure disorder or may suffer with epilepsy.

• Babies who suffer with a seizure in the first month
• Some babies have a poorly developed brain or an abnormal brain structure.
• People who suffer with a head injury and suffer with internal bleeding.
• Strokes may also trigger epilepsy. Many vascular diseases can also cause epilepsy.
• People who do not get enough oxygen for the brain.
• Sometime people who get high fever can also get febrile seizures and may cause epilepsy if continues.
• Excessive alcohol intake and a poor nutritional diet can cause epilepsy.
• Use of illegal drugs such as cocaine and taking ecstasy pills can also trigger an epilepsy attack.

Related risks

Most people lead an active and a healthy life even while suffering with epilepsy. However, their life could be at great risk.

Status Epilepticus: This is a serious condition in which a person may either have an abnormally prolonged seizure or may be slightly unconscious even in between a seizure. This could be life threatening and for all safety measures, any seizure that lasts more than five minutes must be brought to the doctors notice.

Such people do not necessarily get long convulsive seizures or severe symptoms but may experience several small episodes.

Sudden Unexplained Death: People who suffer with epilepsy may die suddenly without any reason. Although researchers are still unsure as to what causes the death, experts suggest that an increased dose of drugs or taking more than one or two types of anti-convulsant drugs at a time may cause the death.

Other risks: Head injury is common in people suffering with a seizure. People may also drown if a seizure occurs in water. Even minimal water in a bath tub can cause a person to drown. Drugs or pills taken to control epilepsy may cause drowsiness and may also cause accidents while driving and so on. Pregnant ladies are at risk along with their babies during an epilepsy attack. And epilepsy medications do not ease the problem. In fact they may cause birth defects.

How can epilepsy be treated?

There are different ways of treating epilepsy. Doctors who treat epilepsy come from different backgrounds of medicine. Doctors who specialize on treating epilepsy are called epileptologists. 

Once epilepsy is diagnosed it is important to treat it as soon as possible. According to reports medications and other treatments to treat epilepsy may not be successful once the seizures and their consequences become conventional.

People with can use antiepileptic drugs to avoid and cure seizures. Children with medication-controlled epilepsy can lead a seizure free life by discontinuing medications.

It’s a difficult task to find the right dosage and medication for treating epilepsy. Initially you will be prescribed a low dose, which may be increased if the seizures still remain uncontrolled.

The side-effects caused by anti-seizure medications are:

• Mild fatigue
• Dizziness
• Gain in weight

Severe side-effects include:

• Skin rashes
• Depression
• Loss of coordination
• Extreme fatigue
• Speech problems

Consult your doctor before changing your medications and taking up prescription medicines or over-the-counter drugs.

You may be suggested other treatment options such as surgery, vagus nerve stimulation or a ketogenic diet. New medications such as Tegretol and Epilim are known to suppress epilepsy in most patients without any serious side-effects.

Emergency measures for a seizure case

If you see a person having an epileptic seizure, please do not turn away and do try and help him/her… The following measures are to be employed in case you see a person suffering from a seizure.

Do’s in Epilepsy

To aid someone having a seizure, take these steps:

• Keep calm.
• Prevent the patient from injuring himself.
• Block the fall of the person onto the ground.
• Loosen their belt, necktie, or other tight clothing, remove the spectacles.
• Cushion their head.
• Clear away any sharp or hard objects.
• When the seizure is over, turn them on their side to prevent choking.
• After the seizures stops turn the patient to a side and wipe the froth from his mouth.

Don’ts in Epilepsy

• Do not panic and do not be afraid!!!
• Do not insert spoon or any such articles into the mouth.
• Do not restrict convulsive movements as it may cause fracture.
• Do not try to insert a gag in the mouth it may cause difficulty in breathing and also hurt the helpers fingers.
• Do not crowd around the patient.
• Do not give water or any other liquid till he is fully consciousness.
• Do not try and physically hold the person, this may injure both the person and the helper.
• Medical aid is usually not required except in case of the person being in water and drowning is a danger then mouth to mouth resuscitation maybe required. The duration of the seizure is usually not more than 2 minutes after which the person enters a state of deep sleep.

  
  

  Lifestyle restrictions

  
  
  
  
  
  It is important for people with epilepsy to try to get over any fear of seizures and live their lives as normally as possible. However, there are a number of restrictions such as those outlined below.
  
  • To hold a civilian driving licence in the UK you need to have been seizure-free for 12 months, or only had seizures at night while asleep.
  • Activities such as climbing and diving are best avoided if you are still having seizures.
  • If you decide to go swimming it is best to go with a friend who can keep an eye on you, and help out if necessary. Inform the lifeguard when swimming in a public pool.
  • Flickering lights, such as strobe lights in nightclubs, can trigger seizures in some people. If this is the case, clubs with strobes are best avoided. It is also sensible to avoid playing computer games for long periods of time as the flickering screen has been associated with seizures in some susceptible people with epilepsy.
  • Some people's seizures can be brought on by lack of sleep, or by drinking alcohol the night before. This calls for a more moderate lifestyle, which can be particularly difficult for teenagers for whom this is more commonly a problem.
  Rigid guidelines are impossible as each person's epilepsy is different. For example, it makes a big difference whether the fits are unpredictable or whether they always occur at the same time.
  

  
  

  Complications

  
  

  

  
  

  • Difficulty learning
  • Inhaling fluid into the lungs, which can cause aspiration pneumonia
  • Injury from falls, bumps, or self-inflicted bites during a seizure
  • Injury from having a seizure while driving or operating machinery
  • Many epilepsy medications cause birth defects -- women wishing to become pregnant should alert their doctor in advance in order to adjust medications
  • Permanent brain damage (stroke or other damage)
  • Prolonged seizures or numerous seizures without complete recovery between them (status epilepticus)
  • Side effects of medications
    

    
    

    Prevention

    

    
    

    
    

    
    Generally, there is no known way to prevent epilepsy. However, proper diet and sleep, and staying away from illegal drugs and alcohol, may decrease the likelihood of triggering seizures in people with epilepsy.
    Reduce the risk of head injury by wearing helmets during risky activities; this can help lessen the chance of developing epilepsy.
    Persons with uncontrolled seizures should not drive. Each state has a different law that determines which people with a history of seizures are allowed to drive. If you have uncontrolled seizures, you should also avoid activities where loss of awareness would cause great danger, such as climbing to high places, biking, and swimming alone.
    
    
    

    

    
    

    Please Note

    Call your local emergency number or doctor if this is the first time a person has had a seizure .
    
    In the case of someone who has had seizures before, call emergency for any of these following situations:
    
    

    • This is a longer seizure than the person normally has, or an unusual number of seizures for the person
    • Repeated seizures over a few minutes
    • Repeated seizures where consciousness or normal behavior is not regained between them (status epilepticus)
      
      

    Call your doctor if any new symptoms occur, including possible side effects of medications (drowsiness, restlessness, confusion, sedation, or others), nausea/vomiting, rash, loss of hair, tremors or abnormal movements, or problems with coordination.
    
    
    

    

    
    
    Some people with certain types of seizures may be able to reduce or completely stop their seizure medicines after having no seizures for several years. Certain types of childhood epilepsy goes away or improves with age -- usually in the late teens or 20s.
    
    
    
    
    
    
    

    

    
    
    
    

SLEEPWALKING(SOMNAMBULISM)

Sleepwalking is a disorder that occurs when a person walks or does another activity while they are still asleep.

Causes

The normal sleep cycle has distinct stages, from light drowsiness to deep sleep. During rapid eye movement (REM) sleep, the eyes move quickly and vivid dreaming is most common.

Each night people go through several cycles of non-REM and REM sleep. There are five stages of sleep. Stages 1, 2, 3 and 4 are characterized as non-rapid eye movement (NREM) sleep. REM (rapid eye movement) sleep is the sleep cycle associated with dreaming as well as surges of important hormones essential for proper growth and metabolism. Each sleep cycle (stages 1,2,3,4 and REM) last about 90-100 minutes and repeats throughout the night. The average person experiences four to five complete sleep cycles per night. Sleepwalking most often occurs during deep, non-REM sleep (stage 3 or stage 4 sleep) early in the night. If it occurs during REM sleep, it is part of REM behavior disorder and tends to happen near morning.

The cause of sleepwalking in children is usually unknown. Fatigue, lack of sleep, and anxiety are all associated with sleepwalking. In adults, sleepwalking may be associated with:

• Mental disorders
• Reactions to drugs and alcohol
• Medical conditions such as partial complex seizures

In the elderly, sleepwalking may be a symptom of an organic brain syndrome or REM behavior disorders.
Sleepwalking can occur at any age, but it happens most often in children aged 4 - 8. It appears to run in families.

Symptoms

When people sleepwalk, they may sit up and look as though they are awake when they are actually asleep. They may get up and walk around, or do complex activities such as moving furniture, going to the bathroom, and dressing or undressing. Some people even drive a car while they are asleep.
The episode can be very brief (a few seconds or minutes) or it can last for 30 minutes or longer. If they are not disturbed, sleepwalkers will go back to sleep. However, they may fall asleep in a different or even unusual place.
Symptoms of sleepwalking include:

• Eyes open during sleep
• May have blank look on face
• May sit up and appear awake during sleep
• Walking during sleep
• Performing other detailed activity of any type during sleep
• Not remembering the sleep walking episode when they wake up
• Acting confused or disoriented when they wake up
• Rarely, aggressive behavior when they are awakened by someone else
• Sleep talking that does not make sense

Exams and Tests

Usually, people do not need further examinations and testing. If the sleepwalking occurs often, the doctor may do an exam or tests to rule out other disorders (such as partial complex seizures).
If you have a history of emotional problems, you also may need to have a psychological evaluation to look for causes such as excessive anxiety or stress.

Treatment

Some people mistakenly believe that a sleepwalker should not be awakened. It is not dangerous to awaken a sleepwalker, although it is common for the person to be confused or disoriented for a short time when they wake up.
Another misconception is that a person cannot be injured while sleepwalking. Sleepwalkers are commonly injured when they trip and lose their balance.

Self-Care at Home

A person who has a sleepwalking disorder can take the following measures:

• get adequate sleep;
  
  
• meditate or do relaxation exercises;
  
  
• avoid any kind of stimuli (auditory or visual) prior to bedtime;
  
  
• keep a safe sleeping environment, free of harmful or sharp objects;
  
  
• sleep in a bedroom on the ground floor if possible to prevent falls and avoid bunk beds;
  
  
• lock the doors and windows;
  
  
• remove obstacles in the room, tripping over toys or objects is a potential hazard;
  
  
• cover glass windows with heavy drapes; and
  
  
• place an alarm or bell on the bedroom door and if necessary on any windows.

Medical treatments

If sleepwalking is caused by underlying medical conditions, for example, gastroesophageal reflux, obstructive sleep apnea, periodic leg movements (restless leg syndrome), or seizures; the underlying medical condition should be treated.
Medications for the treatment of sleepwalking disorder may be necessary in the following situations:

• when the possibility of injury is real;
  
  
• when continued behaviors are causing significant family disruption or excessive daytime sleepiness; and
  
  
• when other measures have proven to be inadequate.

Medications

Benzodiazepines, such as estazolam (ProSom), or tricyclic antidepressants, such as trazodone (Desyrel), have been shown to be useful. Clonazepam (Klonopin) in low doses before bedtime and continued for three to six weeks is usually effective.
Medication can often be discontinued after three to five weeks without recurrence of symptoms. Occasionally, the frequency of episodes increases briefly after discontinuing the medication.

Other remedies

Relaxation techniques, mental imagery, and anticipatory awakenings are preferred for long-term treatment of persons with sleepwalking disorder.

• Relaxation and mental imagery should be undertaken only with the help of an experienced behavioral therapist or hypnotist.
  
  
• Anticipatory awakenings consist of waking the child or person approximately 15-20 minutes before the usual time of an event, and then keeping him or her awake through the time during which the episodes usually occur

Outlook (Prognosis)

Sleepwalking usually decreases as children get older. It usually does not indicate a serious disorder, although it can be a symptom of other disorders.
It is unusual for sleepwalkers to perform activities that are dangerous. However, you may need to take care to prevent injuries such as falling down stairs or climbing out of a window.

Possible Complications

The main complication is getting injured while sleepwalking.

Prevention

• Avoid the use of alcohol or central nervous system depressants if you sleepwalk.
• Avoid getting too tired and try to prevent insomnia, because this can trigger a sleepwalking episode.
• Avoid or minimize stress, anxiety, and conflict, which can worsen the condition.

  
  

  Please Note

  Please discuss the condition with your doctor if:
  
• You also have other symptoms
• Sleepwalking is frequent or persistent
• You perform potentially dangerous activities (such as driving) while sleepwalking.

  
  

  Sleepwalking At A Glance

  
  
  
  
  
  
  
• Sleepwalking is not a serious disorder, although children can be injured by objects during sleepwalking.
  
  
• Although disruptive and frightening for parents in the short-term, sleepwalking is not associated with long-term complications.
  
  
• Prolonged disturbed sleep may be associated with school and behavioral issues.
  
  
• The outlook for resolution of the disorder is excellent

DIARRHOEA AND DYSENTERY

Diarrhoea is a term that is used to describe stools that are more liquid and frequent than normal. There is no absolute definition of what constitutes diarrhoea, but various definitions are utilized for the purpose of research, such as three or more unformed stools within 24 hours. Dysentery is a term used for diarrhoea when there is evidence that the organisms are invading the intestinal wall, causing pus, mucus, and blood to appear in the stool. There is often fever and abdominal cramps as well.




Causes of Diarrhoea and Dysentery

Diarrhoea may be caused by a temporary problem like an infection, or a chronic problem like an intestinal disease. A few of the common causes of diarrhoea are :

Viral infection : Many viruses cause diarrhoea, including rotavirus, Norwalk virus, cytomegalo virus, herpes simplex virus, and viral Hepatitis virus.
Bacterial infections : Several types of bacteria, consumed through contaminated food or water, can cause diarrhoea. Common culprits include Campylobacter, Salmonella, Shigella, and Escherichia coli.
Food intolerances : Inability to digest some component of food, such as lactose, the sugar found in milk.
Parasites : Parasites can enter the body through food or water and settle in the digestive system. Parasites that cause diarrhoea include Giardia lamblia, Entamoeba histolytica, and Cryptosporidium.
Reaction to medicines : Antibiotics, blood pressure medications, and antacids containing magnesium are known to cause diarrhoea in some.
Intestinal diseases : Diseases like inflammatory bowel disease or celiac disease can also lead to diarrhoea.
Functional bowel disorders : Irritable bowel syndrome, in which the intestines do not work normally, can result in diarrhoea.

Bacteria and viruses that can cause diarrhoea have an incubation period of a few hours up to 2-3 days. Protozoa such as Giardia and E. histolytica have an incubation period of 7-14 days. Food poisoning generally occurs within2-8 hours after eating the toxin.

Bacterial diarrhoeas invariably have an abrupt onset. That means the patient can tell the exact time of the day that he/she began to feel ill. Often, the illness begins in the middle of the night, or early morning. The patient suffers sudden cramps and feels the urge to defecate, and the result is a very liquid stool. As soon as he gets back to bed, he has to run again. Bacterial diarrhoea can be accompanied by nausea, vomiting, and fever, but the diarrhoea can occur all by itself.

With Giardia, the day starts with a couple of loose bowel motions and the rest of the day the bowels are normal. In the evening there may be one or two more loose stools. The night is peaceful. The cycles repeat the next day. After a few days, there will be a grumbly feeling in the intestines, increased gas, and a growing sense of fatigue.

Amoebic diarrhoea presents as a chronic, low-grade diarrhoea that alternates every 1-3 days. The patient experiences diarrhoea for a day or so, then no diarrhoea the next day, and then diarrhoea again. Gradually he/she experiences weight loss and fatigue, and comes to the doctor after being sick for a month or more. Amoebic dysentery is a severe form of amoebic infection that causes severe crampy diarrhoea with multiple small bowel movements, often with blood.

Some people develop diarrhoea after stomach surgery or removal of the gall bladder. The reason may be a change in how quickly food moves through the digestive system after stomach surgery or an increase in bile in the colon that can occur after gall bladder surgery.

Diarrhoea can be either acute(short term) or chronic(long term). The acute form, which lasts less than four weeks, is usually related to a bacterial, viral, or parasitic infection. Chronic diarrhoea lasts more than four weeks and is usually related to functional disorders like IBS or inflammatory bowel diseases.

Symptoms and Signs of Diarrhoea and Dysentery

Diarrhoea may be accompanied by cramping abdominal pain, bloating, nausea, or an urgent need to defecate. Depending on the cause, a person may have fever or blood stools. Prolonged diarrhoea leads to dehydration. The signs of dehydration include.

1 Thirst
2 Less frequent urination
3 Dry skin
4 Fatigue
5 Light-headedness
6 Dark-coloured urine


Diagnosis of Diarrhoea and Dysentery

History is the single most useful tool in determining the probable cause of diarrhoea.

Stool examination

Presence of white blood cells or red blood cells, which can be indirect signs of bacterial infection ( such as Shigella). The organisms that can be identified by stool examination are the

protozoa : Giardia, Entamoeba histolytica, Cycolospora, and Cryptosporidium.

When should a doctor be consulted

Although usually not harmful, diarrhoea can become dangerous or signal a more serious problem. The doctor should be consulted if any of the following occurs :

1 Presence of signs of Dehydration.
2 Severe pain in the abdomen or rectum.
3 Fever of 102o F or higher
4 Blood in stool or black, tarry stools.
5 Diarrhoea for more than three days. 

Treatment of Diarrhoea and Dysentery

In most cases, replacing lost fluid to prevent dehydration is the only treatment necessary. This is the main treatment in viral diarrhoea. However, a variety of medications exist to help ease the discomfort and length of diarrhoea. These are :
Drugs that provide symptomatic relief without shortening the infection. These are bowel paralysers ( lomotil, Imodium, dicyomine) and bulk formers (kaolin land pectate). These are not recommended for people whose diarrhoea is caused by a bacterial infection or parasite, as stopping the diarrhoea traps the organism in the intestines, prolonging the problem. Instead, antibiotics are usually prescribed.
Drugs that are aimed at curing the infection, like antibiotics and antiprotozoals. Bacterial diarrhoea can be safely cured with an antibiotic. ,The antibiotics used are either norfloxacin or ciprofloxacin. The length of illness can usually be reduced to 1-2 days with treatment. 

Preventing Dehydration of Diarrhoea and Dysentery

Dehydration occurs when the body has lost too much fluid an electrolytes ( the salts potassium and sodium). The fluid and electrolytes lost during diarrhoea need to be replaced promptly- the body cannot function properly without them. Although water is extremely important in preventing dehydration, it does not contain electrolytes. To maintain electrolyte levels, one should drink the juice of half a lemon with a pinch of salt, a teaspoon of sugar and a glass of water. This is also known as Oral Rehydration Solution (ORS). It is also commercially available in a variety of flavours. A glass of ORS should be consumed for every loose motion.

Tips about Food for Diarrhoea and Dysentery

Until diarhoea subsides, milk products, greasy, high-fibre, or very sweet foods should be avoided, as these aggravate diarrhoea. As diarrhoea improves soft, bland foods like bananas, plain rice, boiled potatoes and bread can be added to the diet.

Prevention of Diarrhoea and Dysentery

The best way to avoid getting diarrhoea is to be conscious of how one can avoid eating or drinking substances that may be contaminated with stool. However, the cleanliness maintained to restaurants at which one has food is something that may not be obvious, and over which one has no control. A few ordering tips may help prevent some cases of diarrhoea:

Many vegetables and fruits become contaminated on their surfaces, either in the fields or in transit to markets. The insides stay clean, and can be eaten safely after the skin is removed.
Sufficient heat destroys all microorganisms and their toxins. Any food item which is thoroughly cooked or heated throughout, and is served while still hot is safe to eat.
Water served at hotels and restaurants may not have been boiled, and should be avoided. Ice is often made from untreated water, and freezing does not kill the organisms that can cause diarrhoea. 

Carbonated soft drinks are safe because carbonation lowers the pH of the drink (making it acidic) , and this acidic environment kills all the bacteria.
Beer would be a safe choice. Stronger alcoholic beverages would be safe in themselves, but any drink mixed with water will not make it safe to drink. 

Water Purification and Personal Hygiene

There are three main methods of decontaminating water: (i) heat (boiling) ; (ii) chemical disinfection (iodine or chlorine); and (iii) filtration. The first two methods are equally effective. Filtration alone almost never renders water safe to drink because of the presence of viruses that can't be filtered. Filtration must be used in conjunction with chemical treatment in this setting. Boiling has the advantage of not altering the flavour of the water. Chemical decontamination does not require wood or fuel, but can add a slight taste to the water.

There are tow different end points in water purification: disinfection ( to make it safe to drink), and sterilization ( which would make it safe to use in surgery, for example). Therefore, for the purpose of drinking water, disinfection should be the goal. All organisms that can cause diarrhoea begin to get killed at 140oF (65oC). The length of time that water takes to go from 140oF to boiling point ( 212oF; 100oC) is sufficient to decontaminate the water for drinking. A few bacteria exist as hardly 'spores', which can resist high temperatures for a certain length of time. The boiling time of 20 minutes has been suggested to sterilize water and completely eliminate these spores. However, the spores cannot cause diarrhoea when ingested. Therefore, just bringing water to a boil renders it safe to drink.

Many brands of filters are marketed to the public to purify drinking water. A filter has to have an absolute filter side of 0.2 microns or less in order to filter out pathogenic bacteria. Giardia and amoebic cysts are easy to filter, as they are 5-8 microns in size. Viruses are more than 8 times smaller than a 0.2 micron filter pore, so they can readily pass through. This is why chemical treatment is necessary in addition to filtration.