Choroidal Neovascular Membrane Associated with Sildenafil

Choroidal Neovascular Membrane Associated with Sildenafil CHOROIDAL NEOVASCULAR MEMBRANE ASSOCIATED WITH SILDENAFIL Â  Erectile dysfunction is an important problem among men aged 40 years and older. More than half of all men in this broad age group experience some degree of erectile dysfunction. Thus, the provision of an orally administrated efficacious treatment in the form of sildenafil represents a major therapeutic advantage.(1) Choroidal neovascular membrane (CNV) is ultimately the result of a break in a structural layer beneath the retina known as Bruch’s membrane, which separates the nourishing vascular layer called the choroid from the retina. A break in Bruch’s membrane may allow the ingrowth of vessels from the choroid to a position just beneath the retina.(2) Ocular side effects are not uncommon when sildenafil is used. Minor side effects include pupillary dilation, conjunctival injection (redness), sensitivity to light (photophobia), and dryness. Visual function studies in healthy subjects and in patients with eye disease suggest that sildenafil does not affect visual acuity, visual fields, and contrast sensitivity. Transient, mild impairment of color discrimination can occur around the time of peak plasma levels.(3-7) The purpose of the present case report is to describe a patient who developed CNV after ingestion of Sildenafil for erectile dysfunction. CASE REPORT The patient was a 53-year old male who presented with a blurred and loss of vision in the right eye. His physical examination did not reveal any significant signs. The patient was fit and healthy otherwise and had no history of glaucoma, diabetes, hypertension, or other systemic vascular disease. Visual acuity was 4/10 in the right eye and 10/10 in the left eye. Anterior segment examination was normal. Fundus examination of the right eye revealed that the macula upper temporal quadrant was characterized by hemorrhagia and an elevated area (Figure 1A), the left eye revealed an atrophic area outside the macula. The FA of the patient revealed an area of bright hyperfluorescence in the early phase and leaks in the late phase (Figure 1B). A diagnosis of CNV was made. Argon laser photocoagulation was applied on the right eye. The patient did not suffer until 6 months after the laser application and the visual acuity in the right eye had increased up to 9/10. However, 6 months after the las er application, the patient noted loss of vision in the right eye. Argon laser photocoagulation was applied again. The control FA of the patient did not reveal a leakage of the scar on the right eye (Figure 2). The visual acuity of the patient was 10/10 bilaterally and he didn’t reveal any complaints. After 3 years, the patient was referred to our clinic with blurred and loss of vision in the left eye and when the patient underwent rigorous historical questioning, he noted that all his complaints were revealed with the use of 50 mg sildenafil. He said that he had taken 50 mg sildenafil before his complaints were revealed. His visual acuity was 10/10 in the right eye and 4/10 in the left eye. The FA revealed CNV and photodynamic therapy and intravitreal anti-VEGF injection were applied to his left eye (Figure 3). DISCUSSION In this study we present a patient with CNV associated with sildenafil use. CNV is ultimately the result of a break in a structural layer beneath the retina known as Bruch’s membrane, which separates the nourishing vascular layer called the choroid from the retina. A break in Bruch’s membrane may allow the ingrowth of vessels from the choroid to a position just beneath the retina .2 These vessels may then leak fluid or blood, initially distorting or blurring vision, and may eventually lead to scarring in the macula and severe loss of central vision. CNV is associated with many diseases. The most common causes are age-related macular degeneration (AMD), presumed inflammatory and infectious conditions, myopic macular degeneration, trauma, angioid streaks and laser therapy, however many cases are idiopathic.(2) Sildenafil is a potent and selective inhibitor of cyclic guanosine monophosphate (cGMP)-specific phosphodiesterase type 5 (PDE5), an enzyme expressed throughout the smooth muscle of the vasculature.3 Through this mechanism, sildenafil potentiates the nitric oxide (NO)-cGMP pathway that mediates corpus cavernosum smooth muscle relaxation and thereby significantly improves penile blood flow. Basic science and clinical research have effectively documented the effects of sildenafil on the retinal and choroidal vasculature. Sildenafil also has a weaker inhibitory action on PDE6, located in the rod and cone photoreceptors. Modest, transient visual symptoms, typically blue tinge to vision, increased brightness of lights, and blurry vision, have been reported with sildenafil use and occur more frequently at higher doses. Visual function studies in healthy subjects and in patients with eye disease suggest that sildenafil does not affect visual acuity, visual fields, and contrast sensitivity.(5,6) Transient, mild impairment of color discrimination can occur around the time of peak plasma levels. However, we were not able to find any case of CNV associated with sildenafil use in the literature. Sildenafil induces angiogenic response in human coronary arteriolar endothelial growth factor (VEGF).(7) The same mechanism may be available on the retina and sildenafil may increase the levels of VEGF. This issue requires further studies and patients with CNV should be questioned about the use of sildenafil. Patients should consult with an ophthalmologist if there is any question about the health of their eyes prior to using sildenafil. REFERENCES Irwin Goldstei, Tom F. Lue, Harin Padma-Nathan et al. Oral sildenafil in the treatment of erectile dysfunction N Engl J Med 1998; 338:1397-1404 Bressler NM, Bressler SB, Fine SL. Age related macular degeneration. Surv Ophthalmol 1988;32:375-413. Michael F. Marmor, Robert Kesler. Sildenafil and Ophthalmology. Survey of Ophthalmology 1999;44:153-162. Alan M. Laties, Eberhart Zrenner. Viagra and Ophthalmology. Progress in Retinal and Eye Research. 2002;21:485-506 DÃ ¼ndar SO. Visual loss associated with erectile dysfunction drugs. Canadian Journal of Ophthalmology 2007;42(1):10-12 Zrenner E, Koppiker NP, Smith MD, Constable I, Littlewood R, Stuckey B. The effects of long-term sildenafil treatment on ocular safety in patients with erectile dysfunction. Invest Ophthalmol Vis Sci 2000;41:S592. Vidavalur R, Penumathsa SV, Zhal L. Sildenafil induces angiogenic response in human coronary arteriolar endothelial cells through the expression of thioredoxin, hemeoxygenase and vascular endothelial growth factor. Vascul Pharmacol. 2006;45:91-95. FIGURE FOR LEGENDS FIGURE 1A: Fundus examination of the right eye revealed that the macula upper temporal quadrant was characterized by hemorrhagia and an elevated area FIGURE 1B: The FA on the right eye of the patient revealed an area of bright hyperfluorescence in the early phase and leaks in the late phase FIGURE 2: The control FA of the patient did not reveal a leakage of the scar on the right eye after laser photocoagulation was applied. FIGURE 3: The FA on the left eye of the patient revealed an area of bright hyperfluorescence in the early phase and leaks in the late phase

A multicultural counselor Essay

It is crucial that a multicultural counselor have ample strategies in order to be effective in multicultural counseling. This is because the counselor handles clients who have diverse cultures and, therefore, need to be adaptive to the various cultural values and beliefs of the client. In order, for a multicultural counselor to be effective, it is vital that the counselor should first understand his or her own culture. This understanding of own culture comprises being aware of one own life philosophies, being able to recognize the different structures involved in reasoning and also being aware of how the understanding effect ones communication and also the style one uses to assist the client. Lack of this understanding may make the counseling process ineffective. Self-awareness helps the counselor identify specific cultural values and the influence they may have in the counseling process. This helps the multicultural counselor be able to counter the effects that the values may pose to the counseling intervention. It is also necessary that multicultural counselor prevent adhering to a specific counseling theory during the counseling process. This is because many cultural groups do not share the type of values, which are implied by the counseling methods (Gielen, Draguns & Fish, 2008). The various values usually do not share the same expectations for the conduct or the outcome of the counseling session of the counselor. This calls for a need for the counselor carry out an investigation about their clients cultural background, be open and flexible to the definitions of the appropriate of the correct behaviors according to the cultural values of the client. It is also beneficial for the multicultural counselor to have an understanding of many languages. This is because language barriers act as a hindrance to effective multicultural counseling. As a result, of the language barrier, the client and the counselor may not understand each other well making the client unable to express the complexity in their thoughts and their feelings. This may also make the counselor feel frustrated due to lack of bilingual ability. Language barriers also lead the counselor to offer the wrong diagnosis (Association for Multicultural Counseling and Development, 2009). Multicultural counselor should acknowledge cultural diversity he or she should appreciate the value of different cultures and use it in assisting the client. The counselor should not have any cultural bias or carry cultural stereotypes into the counseling process. He or she is supposed to understand that all cultural values are the same, and they should be respected. Respect of cultural diversity plays a great part in enhancing the effectiveness of multicultural counseling. This also calls for the multicultural counselor to have humility and modesty. (Gielen, Draguns & Fish, 2008). It is also essential that a multicultural counselor should have social conflict resolution strategies in order to carry out an effective counseling. This helps the counselor to be able to help the client to solve the problems he or she may be experiencing within himself and the conflict that may be existing between him or her and the community. It is also important that multicultural counselor take a pluralistic view in the counseling process. This is where the counselor puts into consideration all aspects of the client’s personal history, social and cultural orientation. (Association for Multicultural Counseling and Development, 2009). Therefore, it is important that multicultural counselors avoid culture stereotypes and false expectation. This is done by understanding their clients’ background and finding the most appropriate strategies to employ in the counseling process. The strategies should suit the needs of the client. The counselor should be sensitive the cultural values of the client. Reference Association for Multicultural Counseling and Development (AMCD), (2009) Journal of Multicultural Counseling, Birmingham, England, retrieved www. multiculturalcenter. org/jmcd/ on 8 April 2010. Gielen, U. Draguns, J. & Fish, J. (2008) Principles of multicultural counseling and therapy, New York, Brunner-Routledge, retrieved from http://www. netLibrary. com/urlapi. asp? action=summary&v=1&bookid=233302 on 8 April 2010.

Microsoft Office Word, Excel, and Powerpoint in the Business Enviornment.

In most work environments, Microsoft Office Word, Excel, and PowerPoint are being used on a daily basis. From being a Loan officer to a front desk cashier these three apps are very helpful in our work place. Microsoft Word is good with writing business letters and business cards, Excel is good with making spreadsheets or charts for your business, and lastly, PowerPoint is good with making presentation audio and visually. In the following paragraphs below I will explain why these three are most helpful and useful in the work place. For one, Microsoft Office Word is mostly used to writing business letters to their clients. From one paragraph or 4 pages it’s where they will have their letter written up and printed. There are also different tools like spell check and grammar, formatting tab, paragraph selection and etc. that also become useful. Business cards can also be used on Microsoft Word and then printed out which also is being used in the work place environment. (office Microsoft) Secondly, Microsoft Excel is mostly used because of its layout and widespread availability, it is often used as a tool to create and maintain a list. More users use it to store database records, create charts or graphs. A lot of organization uses excel to manage their budgets, business planning, customers records, business intelligence, analysis of sales data, customer data, performance dashboard, etc. (advanced excel) Lastly, Microsoft PowerPoint presentations utilize both audio and visual techniques, making for easier understanding. Normal teaching and training is interactive and more effective by using PowerPoint presentations instead of simple lectures. Many executives and managers use PowerPoint for this reason. Executives use this as a strategy to increase sales. Using PowerPoint in front of a potential client shows that you are up with the time. Plus, projecting charts that all can see also makes the presentation more interactive for the client. (powerpoints and apps) So all in all I hope you find Microsoft Word, Excel, and PowerPoint useful in the work place. Not only will it help you and your business be successful but also have that professionalism. ? Reference Microsoft office np November 1, 2011< http://www. baycongroup. com/powerpoint> Baptiste, Jason np November 1, 2011 < http://jasonlbaptiste. com/startups/microsoft-excel>

Grapes of Wrath the Theme of Decay in Chapter 25 - 864 Words

One of the most pervasive themes in this passage is that of a spreading decay that is taking over the society. This is first expressed in quite a literal sense, as an actual decay of fruit and produce, which spreads like a virus across the American countryside and farming lands. Due to the economic mismanagement of the farming industry, fruit and other produce are left to rot and decay on the trees because they are not picked by the farmers. The text gives many examples of different fruits being left to decay on the farms. We see, for example, the cherries, that are described at first as â€Å"full and sweet†, being left to turn into seeds which â€Å"drop and dry with black shreds hanging from them†. The purple prunes, which now â€Å"carpet the†¦show more content†¦Secondly, the repetition depicts figuratively the accumulation and spreading of the problem. It is not a problem that is isolated to one kind of fruit, or one particular farming community, but a p roblem that is rapidly becoming widespread. The image of â€Å"the smell of rot filling the country† also reinforces this idea of an unstoppable spread of decay, infiltrating the whole country bit by bit. This spreading decay is not only literal in the text, but it also symbolizes the proliferation of social injustice and inequality that is infecting the country. Interestingly, the text uses the spreading decay of the fruit as a cause, a symptom and a symbol of the spreading social inequality and discontent. The decaying fruit is a cause of the social discontent, as the rotting fruit is an affront to those who cannot afford to buy enough food for themselves and their families. As the text says: â€Å"a million people hungry, needing the fruit – and kerosene sprayed over the golden mountains†. People are literally forced to watch â€Å"potatoes float by†, â€Å"screaming pigs being killed in a ditch and covered with quicklime†, and â€Å"mountains of oranges slop down to a putrefying ooze†. The waste of good food is thus a cause of separation between producers and consumers, as the potential consumers of produce cannot understand the willful destruction of fruit and food that could have been such a benefit to them. We see in the text a very vivid depiction of this causal relationship: â€Å"childrenShow MoreRelatedGrapes of Wrath - Chapter 25 Analysis1462 Words   |  6 PagesAP Language, Per. 5 12 January 2013 Grapes of Wrath Analysis The cold, soaked earth, which was a source of life not too long ago, abducts a young child while the mother can only watch hopelessly as the husband shovels mounds of dirt. This event is not too different than most that citizens living during the Dust Bowl had to deal with. The self-destructive nature caused the American people to keep expanding and shaping the land as they saw fit. Because of this they overworked the land which, combinedRead More Chapter 25 of The Grapes of Wrath by John Steinbeck Essay examples2622 Words   |  11 PagesChapter 25 of The Grapes of Wrath by John Steinbeck In the twenty-fifth chapter of his novel The Grapes of Wrath, John Steinbeck presents the reader with a series of vivid images, accompanied by a series of powerful indictments. Steinbeck effectively uses both the potent imagery and clear statements of what he perceives as fact to convey his message. This short chapter offers a succinct portrayal of one of the major themes of the larger work. Namely, the potential bounty of nature corruptedRead MoreRastafarian79520 Words   |  319 Pagespolicy statements, pamphlets, and organization manuals have also provided useful information. Chapter 1 reviews and reï ¬ nes Webers theory of charisma and routinization, using insights from a number of social movement scholars. Though this book focuses on routinization, it is necessary to locate routinization and its twin concept, charisma, in the wider context of Webers view of social change.11 In chapter 2, I identify the economic, political, and cultural deprivation of the poor in Jamaica as the