surgery

1. Risk factor for carcinoma Gall bladder are all except:

A. Female sex
B. Choledochal cysts
C. Xanthogranulomatous cholecystitis
D. Calcification of gall bladder
E. Gall stone

Ans. C (Xanthogranulomatous cholecystitis)

GALL BLADDER CA
1. Seventy-five percent to 98% of all patients with carcinoma of the
gallbladder have cholelithiasis.
2. Calcification of the gallbladder (porcelain gallbladder) is associated with
gallbladder cancer in 10% to 25% of cases. Calcification is the end stage
of a long-standing inflammatory process, and is therefore associated
with an increased risk of gallbladder cancer.
3. Case control studies have identified a history of biliary problems, older
age, and female sex as risk factors for the development of gallbladder
cancer.
4. "It is two to three times more common in females than males, and the
peak incidence is in the seventh decade of life"

Table: Risk Factors for Gallbladder Carcinoma:

1. Gallstones
2. Porcelain gallbladder
3. Anomalous pancreatobiliary junction
4. Choledochal cysts
5. Adenomatous gallbladder polyps
6. Primary sclerosing cholangitis
7. Obesity
8. Salmonella typhi infection
9. Gallbladder stones
10.Chronic diarrhea
11.Multiparas≥3
12.Obesity
13.Chronic cholecystitis, chronic mucosal
damage
 14.Polypoidal lesions of the gallbladder
15.Genetic predisposition
16.Exposure to carcinogens

2. Medical treatment of Acute pancreatitis includes:

A. Calcium
B. Glucagon
C. Aprotinin
D. Cholestryamine
E. Antibiotics

Ans. A (Calcium) & E (Antibiotics)

Medical Treatment of Acute Pancreatitis-
• Most (85-90%) cases subside over a period of 3-7 days. Conventional
measures:(l) analgesics, such as meperidine; (2) IV fluids and colloids; (3) no
oral alimentation; (4) treatment a/hypocalcemia, if symptomatic; (5)
antibiotics,
• If there is established infection or prophylactically in acute necrotizing
pancreatitis. Current recommendation is use of an antibiotic such as
imipenem-cilastatin, 500 mg tid for 2 weeks.
• . Not effective: cimetidine (or related agents),H2 blockers, protease
inhibitors, glucocorticoids, nasogastric suction, glucagon, peritoneal lavage,
and anticholinergic medications. Precipitating factors( alcohol, medications)
must be eliminated. In mild or moderate pancreatitis,a clear liquid diet can
usually be started after ~ days. "Several other drugs have been evaluated by
prospective controlled trials and found ineffective in the treatment of acute
pancreatitis. The list, by no means complete, includes glucagon, H2 blockers,
protease inhibitors such as aprotinin, glucocorticoids, calcitonin, nonsteroidal
anti-inflammatory drugs (NSAIDs), and lexipafani, a platelet-activating factor
inhibitor. A recent meta- analysis of somatostatin, octreotide, and the
antiprotease gabexate mesylate in therapy of acute pancreatitis suggested (1)
a reduced mortality rate but no change in complications with octreotide, and
(2) no effect on the mortality rate but reduced pancreatic damage with
gabexate" -
"There is currently no role for prophylactic antibiotics in either interstitial or
necrotizing pancreatitis. It is reasonable to start antibiotics in a patient who
appear septic while waiting the result of culture" -
3. Chronic pancreatitis seen in all except:
A. Chronic renal failure
B. Intraductal mucinus carcinoma
C. Alcohol
D. Gall stones
E. Pancreatic divisum

Ans. None(Seen in all)

"This refers to chronic inflammatory changes which are caused by the
compression or occlusion of the proximal ductal system by tumor, gallstone,
posttraumatic scar, or inadequate duct calibre (as in pancreas diuisumi' Q )
"Obstruction of the main pancreatic duct by inflammatory (posttraumatic) or
neoplastic processes, including pseudocysts, intraductal mucin-secreting
tumors, and ampullary and pancreatic tumors, can result in a form of chronic
pancreatitis associated with diffuse fibrosis, dilated main and secondary
pancreatic ducts, and acinar atrophy"
"Pancreas divisum represents a special case of obstructive pancreatitis. It is the
most common congenital anomaly involving the pancreas and occurs in up to
10% of children"

Table : Chronic Pancreatitis and Pancreatic Exocrine Insufficiency: TIGAR-O

Classification System

Toxic –metabolic Autoimmune

Alcoholic Isolated autoimmune CP
Tabacco smoking Autoimmune CP associated with
Hypercalcemia Sjogren’s syndrome
Hyperlipidemia Inflammatory bowel disease
Q
Chronic renal failure Primary biliary cirrhosis
Medications – phenacetin abuse Recurrent and sever acute pancreatitis
Toxis – organotin compounds (e.g., Postnecrotic (severe acute
DBTC) pancreatitis)
Idiopathic Recurrent acute pancreatitis
Early onset Vascular disease/ischemia
Late onset Postirradiation
Tropical Obstructive
Genetic Pancreas divisumQ
Hereditary pancreatitis Sphincter of Oddi disorders (
controversial)
 Cationic trypsinogen Duct obstruction (e.g., tumor)
CFTR mutations Preampullary duodenal wall cysts
SPINK1 mutations Posttraumatic pancreatic duct scars
4. Which of the following criteria is/are not included in Ranson scoring:
A. WBC> 16000/IlL
B. Serum amylase> 350 LV
C. Age>55yr
D. Serum LDH > 700 lUll
E. Serum AST >250 V/dL

Ans. B (Serum amylase> 350 LV) & D (Serum LDH > 700 lUll)
RANSON CRITERIA
• It is a clinical prediction rule for predicting the severity of acute
pancreatitis.

Table :Ranson's Prognostic Signs of Pancreatitis

Criteria for acute pancreatitis not due to gallstones
At admission During the initial 48 h
Q
Age >55 yr Hematocrit fall >10 points
3
WBC>16,000/MM BUN elevation >5 mg/dL
Blood glucose >200 mg/dL Serum calcium <8 mg/dL
Q
Serum LDH >350 IU/L Arterial PO2<60 mm Hg
Serum AST >250 U/dL Base deficit >4 mEq/L
Estimated fluid sequestration >6 LQ
Criteria for acute gallstone pancreatitis
At admission During the initial 48 h
Age >70 y Hematocrit fall >10 points
WBC >18,000/ mm3 BUN elevation >2 mg/Dl
Blood glucose >220 mg/dL Serum calcium <8 mg/dL
Serum LDH >400 IU/L Base deficit >5 mEq/L
Serum AST >250 U/dL Estimated fluid sequestration >4 L

Table : Risk Factors that Adversely Affect Survival in Acute Pancreatitis

Severe Acute Pancreatitis
 Associated with organ failure and/or local complications such as necrosis
 Clinical manifestation
 Obesity BMI > 30
 Hemoconcentration (hematocrit > 44%)
 Age >70
  Organ failurea
 Shock
 Pulmonary insufficiency (PO2 < 60)
 Renal failure (CR > 2.0 mg%)
 GI bleeding
 ≥3 Ransom criteria (not full utilizable until 48 h)
 Apache II score > 8 (cumbersome)

5. True about Dextran :

A. Cause Rouleaux formation
B. Impair factor VIII function
C. Sugar level
D. Improve microcirculation
E. Can cause anaphylaxis

Ans. A (Cause Rouleaux formation), B (Improve microcirculation), D (Improve

microcirculation) & E (Can cause anaphylaxis)
"Dextran interfere with blood grouping & cross matching (rouleaux formation)"
-
"Dextran improves microcirculation't"-

Dextran
Dextran is a complex, branched glucan composed of chains of varying lengths
(from 10 to 150 kilodaltons). In this family, dextran-40 (MW: 40,000 Da), has
been the most popular member for anticoagulation therapy.

Halflife: 2 to 8 hr
It is used medicinally as an antithrombotic (anti-platelet), to reduce blood
viscosity, and as a volume expander in anemia

These agents are used commonly by microsurgeons to decrease vascular

thrombosis. The antithrombotic effect of dextran is mediated through its
binding of erythrocytes, platelets, and vascular endothelium, increasing their
electronegativity and thus reducing erythrocyte aggregation and platelet
adhesiveness.

Dextrans also reduce factor VIII-Ag Von Willebrand factor, thereby decreasing
platelet function. Clots formed afte administration of dextrans are more easily
lysed due to an altered thrombus structure (more evenly distributed platelets
with coarser fibrin). By inhibiting a-2 antiplasmin, dextran serves as a
plasminogen activator and therefore possesses thrombolytic features.
It also increases blood sugar levels
Although there are relatively few side-effects associated with dextran use,
these side-effects can be very serious. These include anaphylaxis, volume
overload, pulmonary edema, cerebral edema, or platelet dysfunction. An
uncommon but significant complication of dextran osmotic effect is acute renal
failure.

1. True regarding urinary catheterization with 16 French size:

a. It is the suitable size to use in adult female
b. It can cause UTI in long term use
c. Used in management of urethral obstruction
d. Diameter is 4 mm
e. Sterile technique must be used for insertion

Ans. a. It is the suitable size to use in adult female , b. It can cause UTI in long
term use & c. Used in management of urethral obstruction
"Usually No. 14 or 16 F (French size) catheter is used for catheterization of a
female urethra"
Urinary Catheter (Foley's catheter)
- med.uottawa.ca/procedures/ucath
• A Foley catheter is a thin, sterile tube inserted into the bladder to drain
urine. It is held in place with a balloon at the end, which is filled with sterile
water to prevent the catheter from being removed from the bladder. The urine
drains through the catheter tube into a bag, which is emptied when full. The
procedure to insert a catheter is called catheterization.
• Sterile technique must be used for insertion to prevent spread of
infection.
• Following a thorough hand wash, sterile gloves are donned. The genitalia
are cleaned using soapy antiseptic
• By inserting a Foley catheter, you are gaining access to the bladder and
its contents. Thus enabling you to drain bladder contents, decompress the
bladder, obtain a specimen, and introduce a passage into the GU tract. This will
allow you to treat urinary retention, and bladder outlet obstruction.
• In the emergency department, catheters can be used to aid in the
diagnosis of GU bleeding.
• In some cases, as in urethral stricture or prostatic hyper- trophy,
insertion will be difficult and early consultation with urology is essential.
• Foley catheters are contraindicated in the presence of urethral trauma.
Urethral injuries may occur in patients with multisystem injuries and pelvic
factures, as well as straddle impacts. If this is suspected, one must perform a
genital and rectal exam first. If one finds blood at the meatus
of the urethra, a scrotal hematoma, a pelvic fracture, or a high riding prostate
then a high suspicion of urethral tear is present. One must then perform
retrograde urethrography (injecting 20 cc of contrast into the urethra) .
• Internal catheters usually have their outside diameters measured in
French sizes. The French catheter scale or "French units" (Fr) is commonly used
to measure the outside diameter of needles as well as catheters. 1 "French" or
"Fr" is equivalent to 0.33 mm = .013" = 1177" of diameter. The size in French
units is roughly equal to the circumference of the catheter in millimeters. A 14
to 16 French is used on most adults.
• Larger catheters of 22 French are recommended for patients with
hematuria or clots. Pediatric French sizes range from 3 to 14. A catheter that is
too big can lead to urethral irritation and difficult placement. A catheter that is
too small can lead to kinking and urinary leakage.

French Gauge Diameter (mm)

12 4
13 4.3
14 4.7
15 5
16 5.3
17 5.7
18 6

A Foley catheter is used with many disorders, procedures, or problems such as

these
• Retention of urine leading to urinary hesitancy, straining to urinate,
decrease in size and force of the urinary stream, interruption of urinary
stream, and sensation of incomplete emptying
• Obstruction of the urethra by an anatomical condition that makes it
difficult for one to urinate: prostate hypertrophy, prostate cancer, or
narrowing of the urethra.
• Urine output monitoring in a critically ill or injured person
• Collection of a sterile urine specimen for diagnostic purposes
• Nerve-related bladder dysfunction, such as after spinal trauma (A
catheter can be inserted regularly to assist with urination. )
• Imaging study of the lower urinary tract
• After surgery

Foley Catheter Risks

• The Foley catheter may introduce an infection into the bladder. The risk
of infection in the urine increases with the number of days the catheter is in
place.
• If the balloon is opened before the Foley catheter is completely inserted
into the bladder, bleeding, damage and even rupture of the urethra can occur.
In some individuals, long-term permanent scarring and strictures of the
urethra could occur.

2. True about brachial fistula:

a. External opening near the anterior border of sternocleidomastoid
b. External opening at junction of upper & middle third of sternocleidomastoid
muscle
c. Develop due to persistence of 2ndbranchial cleft
d. Open in oropharynx
e. Move with swallowing

Ans. a. External opening near the anterior border of sternocleidomastoid, c.

Develop due to persistence of 2ndbranchial cleft & d. Open in oropharynx
"B.fistuIa: Pierces the pharyngeal wall & ends in the tonsillar- fossa (which is
part of oropharynx) "Swelling which moves with deglutination (swallowing) -
thyroid swelling, thyroglossalcyst, prelaryngeal & pretracheal lymph node,
subhyoid bursitis
Branchial Fistula
• This is always congenital &occurs due to persistent 2nd branchial cleft
• External opening is situated at the junction of middle 1/3 & lower 1/3 of
sternomastoid
• The tract from the skin passes through the fork of common carotid
artery deep to the accessory & hypoglossal nerve & opens in the anterior
aspect of posterior pillars of tonsil
• The patient may complain of a dimple, discharging mucus & the dimple
becomes more obvious when the patient is asked to swallow
3. True about lip carcinoma:
a. Common in smoker
b. More common in lower lip
c. More common in upper lip
d. Always painful to touch
e. Distant metastasis is late

Ans. a. Common in smoker , b. More common in lower lip & e. Distant

metastasis is late
• The most common neoplasms are squamous cell carcinomas. Basal cell
carcinomas start on the skin of the lip and may secondarily invade the
vermilion.
• Persons with light-colored skin or with prolonged exposure to sunlight
are most prone to develop lip carcinoma
• The vermilion'is the most common site of origin.
• Squamous cell carcinoma may present as an enlarging discrete lesion
that is not tender until it ulcerates.
• Some lesions develop very slowly on a background of leukoplakia or
carcinoma in situ and present as superficially ulcerated lesions with little or no
bulk.
• Erythema of the adjacent skin suggests dermal lymphatic invasion.
Palpation of the lip will reveal the extent of induration. Paresthesia of the skin
of the lip indicate nerve invasion.
• Squamous cell carcinoma starts on the vermilion of the lip and invades
adjacent skin and the orbicular muscle. Advanced lesions invade the adjacent
commissures of the lip, the buccal mucosa, the skin and wet mucosa of the lip,
the adjacent mandible, and eventually the mental nerve.
• Lymphatic spread moves to the submental and submandibular lymph
nodes and then to the jugular chain.
The risk for lymph node metastases is approximately 5% at diagnosis and is
increased by high-grade ~istology, large lesions, invasion of the wet mucosa of
the lip and buccal mucosa, and for patients with recurrent disease
Carcinoma Lip
• Lower lip is more often involved
• Incidence of oral cancer is six times more in smoker than non-smoker
• Site of predilection is b/w the midline & commissure of the lip
• Mostly, it is squamous cell carcinoma, often seen in males in the age
group of 40-70 years
• L.N metastases develop late.Submental& submandibular nodes are the
first to be involved; other deep cervical nodes may also get involved later
Lip Cancer
• Lip cancer presents early as it is readily visible to the patient. It usually
arises as an ulcer on the vermilion border.
• In total, 95 per cent of carcinomas of the lip arise on the lower lip and 15
per cent arise in the central one-third and commissures.
• Tumours tend to spread laterally over the mucosal surface. Lymph node
metastases, usually to the submental or submandibular nodes, occur late.
• Blood spread is uncommon

4. True about inguinal hernia in children:

a. Occur due to persistence of processus vaginalis
b. Defect in abdominal may present
c. Most common variety is direct type
d. Difficult to reduce non-operatively
e. More common in girls

Ans. a. Occur due to persistence of processus vaginalis , b.Defect in

abdominal may present & d. Difficult to reduce non-operatively
Inguinal Hernia
• Repair of an inguinal hernia (IH) represents one of the most common
surgical procedures performed in the pediatric age group. Virtually all IHs in
children are indirect and congenital in origin.
• The variable persistence of the embryonicprocessusvaginalis offers a
spectrum of abnormalities, including a scrotal hernia, communicating
hydrocele, hydrocele of the cord, or
simple hydrocele
• In preterm infants, the incidence may be as high as 30%. About one third
of children with IH are younger than 6 months, and males are affected about
six times more often than females.
• The right side is involved in 60% and the left in 30% of patients; bilateral
hernias are seen in 10%. The higher incidence on the right side compared with
the left is probably related to the later descent and obliteration of the
processusvaginalis of the right testis.
• Most IHs present as a bulge in the region of the external ring extending
downward for varying distances to the scrotum or labia. Inguinal pain may also
be a presenting complaint.
• Incarceration and possible strangulation are the most feared
consequences ofIH and occur more frequently in premature infants. Because
of the risk for these complications, all IHs
in children need to be repaired.
• A communicating hydrocele is basically a small IH in which fluid, but not
peritoneal structures, traverses the processusvaginalis
Inguinal Hernia
• The presence of an inguinal hernia in a child is an indication for surgical
repair. The operation is termed a herniorrhaphy because it involves closing off
the patent processusvaginalis.

• This is to be contrasted with the hernioplasty that is performed in adults,

which requires a reconstruction of the inguinal floor.
• Inguinal hernia results from a failure of closure of the processusvaginalis
• High incidence of inguinal hernias occurs in premature infants.
• When the processusvaginalis remains completely patent, a
communication persists between the peritoneal cavity and the groin, resulting
in a hernia.
• Partial closure can result in entrapped fluid, which is known as a
hydrocele.
• Using the classification system that is typically applied to adult hernias,
all congenital hernias in children are by definition indirect inguinal hernias.
Children also present with direct inguinal and femoral hernias, although these
are much less common.
• Inguinal hernias occur more commonly in males than females (10: 1) and
are more common on the right side than the left.
• Infants are at high risk for incarceration of an inguinal hernia because of
the narrow inguinal ring.
• Spontaneous resolution does not occur, and therefore, a nonoperative
approach cannot ever be justified.
• An inguinal hernia in a female infant or child frequently contains an
ovary rather than intestine.

5. True regarding testicular tumour:

a. For stage I seminoma- orchidectomy alone used for treatment
b. For stage I seminoma- orchidectomy + radiotherapy used for treatment
c. Stage I non-seminomatous germ cell tumour-orchidectmy +radiotherapy
used for treatment
d. Staging is important for planning management
e. HCG & AFP may be used as marker the response of treatment
Ans. b. For stage I seminoma- orchidectomy + radiotherapy used for
treatment , d. Staging is important for planning management & e.HCG & AFP
may be used as marker the response of treatment
"Radical inguinal orchidectomy is the treatment of choice in all testicular
tumour irrespective of the histological type &- stage"
"Testicular tumour: In confirmed cases, staging is an essential step in planning
treatment. Blood is taken prior to orchidectomy to measure the levels of
tumour markers which are raised in around 50 per cent of cases. A rise in AFP
is seen in around 50-70 per cent of NSGCTs and a rise in HCG is seen in 40-60
per cent of NSGCTs and around 30 per cent of seminomas. When raised, these
markers are used to monitor the response to treatment. The mean serum half-
lives of AFP and HCG are
5-7 days and 2-3 days, respectively, and reassessment of the markers following
orchidectomy can indicate whether all the tumour tissue has been removed"

Testicular Tumour: Treatment

• Scrotal exploration and orchidectomy for suspected testicular tumour
• Management by staging and histological diagnosis (after orchidectomy) :
The treatment of patients with testicular tumours is usually successful, even in
cases that are advanced at presentation. This largely reflects the excellent
response of these tumours to platinum-based chemotherapy and (for
seminomatous tumours) to radiotherapy.
• Stage I tumours: Seminomas are radio sensitive and for many years
adjuvant radiotherapy to the para-aortic nodes was the mainstay of treatment
for stage I disease.
Some years ago, the excellent response to platinum-based chemotherapy led
to chemotherapy being introduced for most men with stage 1 seminoma.
However, current practice uses CT and tumour marker-based surveillance
protocols with chemotherapy being reserved for men who
demonstrate relapse. NSGCTs are not radiosensitive, but they are highly
sensitive to combination chemotherapy with bleomycin, etoposide andcis-
platinum (so called BEP chemotherapy). Some good prognosis NSGCTs can be
managed by surveillance protocols (using regular CT scanning and tumour
marker measurement) with the more high risk cases receiving chemotherapy.
• Stage II-IV tumours: Combination BEP chemotherapy is the mainstay of
treatment for stages II-IV seminoma and NSGCT. Retroperitoneal lymph node
dissection is sometimes needed in some cases of NSGCT when retroperitoneal
masses remain after chemotherapy.
Testicular Tumour: Staging
• Stage I: The tumour is confined to the testis;
• Stage II: Nodal disease is present but is confined to nodes below the
diaphragm;
• Stage III: Nodal disease is present above the diaphragm;
• Stage IV: Nonlymphatic metastatic disease (most typically within the
lungs)

6. True about extracorporeal shock wave lithotripsy (ECWL):

a. C/I in pregnancy
b. Less satisfactory for hard stones
c. Stone is breaked into small pieces which comes out with urine
d. Safer in coagulopathy
e. Endoscopic retrieval is sometimes used for impacted stone fragment
produced by lithotripsy

Ans. a. C/I in pregnancy , b. Less satisfactory for hard stones, c.Stone is

breaked into small pieces which comes out with urine & e. Endoscopic
retrieval is sometimes used for impacted stone fragment produced by
lithotripsy
• «Pregnant women and patients with large abdominal aortic aneurysms
or uncorrectable bleeding disorders should not be treated with ESWL"
• Patients with large renal pelvic calculi (>1.5 em) have a stone-free rate at
3 months approximating 75%, in comparison with those with a similar stone in
a lower calyx, which approximates only 50%. Patients with small renal pelvic
stones «1.5 ern) have approximately a 90% stone free rate in comparison to
those with similar stones in a middle calyx (approximately 75%) or lower calyx
(approximately 70%) . Lower calyceal stone-free rates are increased with a
small stone burden, a short and wide infundibulum, and a nonacute
infundibulo-pelvic angle. Overall, approximately 75% of patients with renal
calculi treated with ESWL become stone-free in 3 months. As stones increase in
size, stone-free rates decrease, more so in the lower and middle
calyces than in superior calyceal and renal pelvic locations.
• Large-volume stones (>3 cm, stone surface >500 mm2) (e.g., staghorn
stones). These stones can be treated by several sessions of ESWL, but only
about 30% of patients become stone free. However, problems associated with
passing large quantities of gravel (e.g., ureteral obstruction, pain, fever, sepsis)
can be prevented by first percutaneously debulking the stone and then
performing ESWL for endoscopically inaccessible stones.
• For extraction of distal ureteral stones that are unrespon- siveto ESWL,
short rigid ureterorenoscopes and alligator- forceps or Dormia baskets are
most helpful. Ureteroscop-
icclearance rates for distal ureteral stones reach 93-100%.
• Impacted proximal ureteral stones that did not respond toin situ ESWL
and could not be dislodged with a ureteral catheter usually can be repositioned
into the renal pelvis under direct vision for subsequent ESWL using a small
semirigid or rigid ureterorenoscope. If the stones are
too large or impacted, intraureteral lithotripsy for stone disintegration may be
necessary in a few cases.
• Ureteroscopic stone extraction is highly efficacious for lower ureteral
calculi.

Extracorporeal shock Wave Lithotripsy

• Crystalline stones disintegrate under the impact of shock waves
produced by the ESWL machine. The shocks may be aimed by ultrasound or x-
ray imaging. The devices also differ in the disruptive force that they can
develop. Less powerful machines break stones less effectively and several
treatments may be necessary. Weaker shocks hurt less and treatment can be
given without general anaesthesia.
• Ureteric colic is common after ESWL, and the patient needs analgesia,
usually in the form of a non-steroidal anti- inflammatory drug. Bulky stone
fragments may impact in the ureter, causing obstruction. To avoid this, a stent
should be placedin the ureter to drain the kidney while stone
fragments pass.
• Occasionally, impacted fragments have to be removed ureteroscopically
The principal complication of ESWL is infection. Many calculi contain bacteria,
which are released
from the broken stone.
• It is wise to give prophylactic antibiotics before ESWL, and an obstructed
system should be decompressed by a ureteric stent or percutaneous
nephrostomy before treatment.
• The clearance of stone from the kidney will depend up on the
consistency of the stone and its site. Most oxalate and phosphate stones
fragment well and, if lying in the renal pelvis, will clear within days. The results
with harder stones, especially cystine stones, are less satisfactory. When
treating calyceal stones, the patients should be warned that the clearance may
take months.
Ureteroscopic Stone Removal A ureteroscope is introduced transurethrally
across the bladder into the ureter to remove stones impacted in the ureter.
Stones that cannot be caught in baskets or endoscopic forceps under direct
vision are fragmented using an electro hydraulic, percussive or laser
lithotripter

7. True about paramedian incision:

a. It is made below umbilicus
b. Better in obese person
c. Cause abdominal hernia
d. Cut anterior surface of rectus sheath
e. Cut posterior surface of rectus sheath

Ans. c. Cause abdominal hernia , d. Cut anterior surface of rectus sheath

& e. Cut posterior surface of rectus sheath
"Nerve supply of abdominal wall: Lower six thoracic & first lumbar nerve. They
enter the rectus sheath laterally. In case of paramedian incisions, after opening
the anterior rectus sheath, rectus should be retracted laterally to define
&incise the posterior rectus sheath»
"Lumbar incision, lower midline incision & large transverse incision often give
rise to incisional hernia
"Whether the type of initial abdominal incision influences the incisional hernia
rate remains controversial. As noted, the incidence of incisional herniation
after midline laparotomy ranges from 3% to 20% & doubles if the operation is
associated with a surgical site infection. A meta-analysis of 11 studies
examining the incidence of incisional hernia formation after various types of
abdominal incisions has concluded that the risk is 10.5% for midline, 7.5% for
transverse & 2.5% for paramedian incisions"

Paramedian Incision
Use: provides laterality to the midline incision, allowing lateral structures such
as the kidney, adrenals and spleen to be accessed. Location: about 2-5 em to
the left or right of the midline incision. Incision is over the medial aspect of the
transverse convexity of the rectus.

Layers of the abdominal waIl: skin, fascia (camper's and scarpa's) and the
anterior rectus sheath are incised. The anterior rectus muscle is freed from the
anterior sheath and retracted laterally. The posterior rectus sheath or
transversalis fascia (if below the arcuate line), extraperitoneal fat and
peritoneum are then excised allowing entry to the abdominal cavity.

Advantages
• Provides access to lateral structures
• Rectus muscle is not divided
• Incisions in anterior and posterior sheath is seperated by muscle which
acts as a buttress, therefore closure is more secure
• Can be extended by a curvilinear incision towards the xiphoid process if
required

Disadvantages
• Takes longer to make and close
• Incision needs to be closed in layers
• Difficult extension superiorly as limited by the costal margin
• Tends to strip the muscles of their lateral blood and nerve supply
resulting in atrophy of the muscle medial to the incision

Midline Incision
Use: Virtually all abdominal procedures may be performed through this
incision.
Location: in the midline of the abdomen, and can extend from the xiphoid
process to just above the umbilicus. It can be continued to below the umbilicus
by curving the incision around the umbilicus.
Layers of the abdominal waIl: skin, fascia (camper's and scarpa's), linea alba,
transversalis fascia, extraperitoneal fat and peritoneum.

Advantages
• Adequate exposure of most if not all of the abdominal viscera
• Minimal blood loss as the incision is through the linea alba
• Minimal nerve injury
• Minimal muscle injury
• Can be quickly made, such as in an emergency and quickly closed with a
mass closure technique

Disadvantages
• Care needs to be taken just above the umbilicus where the falciform
ligament is
• Midline scar
Transverse Incision
Use: right or left colon, duodenum, pancreas, subhepatic space. Location: This
incision is made just above the umbilicus, dividing one or both of the rectus
muscles. Layers of the abdomen: skin, fascia, anterior rectus sheath, rectus
muscle (+/- internal oblique, depending on the length
of the incision), transversus abdominus, transversalis fascia, extraperitoneal fat
and peritoneum. The medial aspect of this incision will be through the layers
just like as in the midline incision.

Advantages
• Less pain than a midline incision
• Good access to midline upper GI structures
• Transverse incisions cause the least amount of damage
• As the recti have a segmental nerve supply, it can be cut transversely
without weakening a denervated segment
• Muscular segments can be rejoined
• Commonly used in children and the obese as greater abdominal
exposure is gained in comparison with the vertical midline. This is due to the
longer transverse length of the abdomen in children and the obese.

Disadvantages
• Limited lateral access in comparison with midline incisions that can then
be extended
• More wound infections compared to midline thought to be due to
greater difficulty in controlling bleeding and haematoma formation.

Abdominal Incisions
• In the past, traditionally vertical midline or paramedian incisions were
used for the majority of abdominal procedures, but there is a current trend to
utilise transverse incisions wherever possible as this minirnises postoperative
complications.
"The rectus sheath is composed of the aponeuroses of transversus abdominis,
external oblique and internal oblique muscles, which form an anterior and
posterior sheath that fuse
laterally at the linea semilunaris and in the midline at linea alba.
Only the middle segment of the rectus abdominis is completely enclosed, with
the posterior sheath lacking in parts of the superior and inferior segments"

8. Which of the following is/are feature(s) of Keloid:

a. Collagen fibers are randomly arranged
b. Type IV collagen dominates
c. Lesion with healthy margin removed
d. Steroid is very useful
e. Goes beyond margin of wound
Ans. b. Type IV collagen dominates, d. Steroid is very useful & e. Goes
beyond margin of wound
"Injection of steroid preparation such as triamcinolone acetate has been found
very useful. It flatten the keloids. Intrakeloidal excision & skin grafting is to be
tried last. Recurrence is common. Care should be taken not to extend the
excision on to the normal surrounding tissues"
Scars
• The maturation phase of wound healing has been discussed above and
represents the formation of what is described as a scar. The immature scar
becomes mature over a period
lasting a year or more, but it is at first pink, hard, raised and often itchy. The
disorganised collagen fibres become aligned along stress lines with their
strength being in their weave rather than in their amount. As the collagen
matures and becomes denser, the scar becomes almost acellular as
the fibroblasts and blood vessels reduce.
• Scars are often described as being atrophic, hypertrophic and keloid.
• A hypertrophic scar is defined as excessive scar tissue that does not
extend beyond the boundary of the original incision or wound. It results from a
prolonged inflammatory phase of wound healing and from unfavourable scar
siting (i.e. across the lines of skin tension). In the face, these are known as the
lines of facial expression.
• A keloid scar is defined as excessive scar tissue that extends beyond the
boundaries of the original incision or wound . Its aetiology is unknown, but it is
associated with elevated
levels of growth factor, deeply pigmented skin, an inherited tendency and
certain areas of the body (e.g. a triangle whose points are the xiphisternum
and each shoulder tip) .
• The histology of both hypertrophic and keloid scars shows excess
collagen with hypervascularity, but this is more marked in keloids where there
is more type III collagen.
• Hypertrophic scars improve spotltaneously with time, whereas keloid
scars do not.

Table: Aetiology of Keloid

• Key factors: Surgery, burns, vaccinations
• Elevated levels of growth factor (more of type '6' collagen)
• Laceration or abrasion
• Over the sternum (incision)
• Inheritance and injection
• Deep pigmented skin
Treatment of Hypertrophic and Keloid Scars
• Pressure - local moulds or elasticated garments
• Silicone gel sheeting (mechanism unknown)
• Intralesional steroid injection (triamcinolone)
• Excision and steroid injections
• Excision and postoperative radiation (external beam or
brachytherapy)
• Intralesional excision (keloids only)
• Laser - to reduce redness (which may resolve in any event)
• Vitamin E or palm oil massage (unproven)

Hypertrophic Scars and Keloids

• Both keloids and hypertrophic scars are characterized by
excessive collagen deposition versus collagen degradation.
• Keloids are defined as scars that grow beyond the borders of the original
wounds. and these scars rarely regress with time. Keloids are more prevalent
in patients with more
darkly pigmented skin
• Keloids appear to have a genetic predisposition.
• Keloids and hypertrophic scars have stretched collagen bundles aligned
In the same plane as the epidermis, as opposed to normal'scar tissue, where
the collagen bundles are randomly arrayed and relaxed.
• In addition, keloid scars have thicker, more abundant collagen bundles
that form acellular node like structures in the deep dermal portion of the
keloid lesion. The center of keloid lesions also contains a paucity of cells in
comparison to hypertrophic scars. which have islands composed of
aggregates of fibroblasts. small vessels. and collagen fibers throughout the
dermis

9. True about paralytic ileus:

a. Postoperative ileus primarily affects the stomach and colon
b. Mostly resolve after 24-72 hours
c. Return of function occurs in the following order: stomach, large bowel and
small boweL
d. If opioid is used as postoperative analgesia, then chance increases
e. Is an anticipated complications of abdominal operations

Ans. a. Postoperative ileus primarily affects the stomach and colon, b. Mostly
resolve after 24-72 hours , d. If opioid is used as postoperative analgesia,
then chance increases & e. Is an anticipated complications of abdominal
operations
"Following most abdominal operations or injuries, the motility of the
gastrointestinal tract is transiently impaired. The return of normal motility
generally follows a characteristic temporal
sequence, with small-intestinal motility returning to normal within the first 24
hours after laparotomy and gastric and colonic motility returning to normal by
48 hours and 3 to 5 days, respectively. Resolution of ileus may be delayed in
the presence of other factors capable of inciting ileus such as the presence of
intra-abdominal abscesses or electrolyte abnormalities. Patient medication
lists should be reviewed for the presence of drugs, especially opiates, known to
be associated with impaired intestinal motility. Routine postoperative ileus
should be expected and requires no diagnostic evaluation. If ileus persists
beyond 3 to 5 days postoperatively or occurs in
the absence of abdominal surgery, diagnostic evaluation to detect specific
underlying factors capable of inciting ileus and to rule out the presence of
mechanical obstruction is warranted"
"In the immediate postoperative period, restricted oral intake and
postoperative narcotic analgesia also contribute to altered small bowel
motility. Opiates and opioid peptides in the enteric
nervous system suppress neuronal excitability. Postoperative ileus affects the
stomach and colon primarily. After laparotomy, small bowel motility returns
within several hours, gastric
motility within 24 to 48 hours, and colonic motility in 48 to 72 hours.
Secretions and swallowed air are not emptied from the stomach, and gastric
dilation and vomiting may occur. Return
of bowel activity is heralded by the presence of bowel sounds, flatus, and
bowel movements" Paralytic ileus
• Paralytic ileus may present with nausea, vomiting, loss of appetite,
bowel distension and absence of flatus or bowel movements.
• Following laparotomy, gastrointestinal motility temporarily decreases.
Treatment is usually supportive with maintenance of adequate hydration and
electrolyte levels. However, intestinal complications may present as prolonged
ileus and so should be actively sought and treated.
• Return of function of the intestine occurs in the following order: small
bowel, large bowel and then stomach. This pattern allows the passage of
faeces despite continuing lack of stomach emptying and, therefore, vomiting
may continue even when the lower bowel has already started functioning
normally.
 Paralytic Ileus
• This may be defined as a state in which there is failure of transmission of
peristaltic waves secondary to neuromuscular failure (i.e. in the myenteric
(Auerbach's) and submucous (Meissner's) plexuses) . The resultant stasis leads
to accumulation of fluid and gas within the bowel,
with associated distension, vomiting, absence of bowel sounds and absolute
constipation.
• The following varieties are recognised: Postoperative, Infection, Reflex
ileus &Metabolic
• Postoperative. A degree of ileus usually occurs after any abdominal
procedure and is self-limiting, with a variable duration of 24-72 hours.
Postoperative ileus may be prolonged in the presence of hypo pro teinaemi a
or metabolic abnormality
• Paralytic ileus takes on a clinical significance if, 72 hours after
laparotomy: there has been no return of bowel sounds on auscultation & there
has been no passage of flatus.
• Colicky pain is not a feature.

10. A child has sacrococcygeal teratoma. Following are true about this
condition:
a. Diagnosis of this condition can be done antenatally
b. β-hCGlevei is increased in maternal serum
c. AFP is elevated in maternal serum
d. Most are benign
e. More common in girls

Ans. a. Diagnosis of this condition can be done antenatally, c. AFP is elevated

in maternal serum & d. Most are benign
"Maternal serum AFP is elevated in sacrococcygeal teratoma"
"Teratoma: The serum alpha-fetoprotein (AFP) level is elevated in tumors
containing malignant endodermal sinus (yolk sac) elements. Serial AFP levels
are markers for recurrence. Beta- human chorionic gonadotropin (~-hCG) is
produced from those containing malignant choriocarcinoma tissue. Rarely,
enough
~-hCG is produced to cause precocious puberty. Elevated AFP and ~-hCG levels
in histologically benign tumors indicate an increased risk of recurrence and
malignant transformation, particularly with "immature" benign teratomas"

Sacrococcygeal Teratoma
• The majority of sacrococcygeal teratomas present in the newborn period
and can be detected by prenatal ultrasound. Females predominate; a history of
twins is common.
• Pregnancy may be complicated by fetal high-output cardiac failure via
arteriovenous shunting within the tumor, maternal polyhydramnios, and
hydrops fetalis leading to fetal demise. Fetal surgery has been utilized
successfully in those with hydrops.
• Treatment is excision of the tumor and coccyx
• The majority (97%) of newborn sacrococcygeal teratomas are benign
and do not require adjuvant therapy.
• Follow-up requires serial AFP levels and physical examinations, including
digital rectal examination. Recurrent tumors are excised. The greatest risk
factor for malignancy is age at diagnosis. The malignancy rate is approximately
50-60% after 2 months of age. Malignant tumors are often treated with
surgery and chemotherapy.

Sacrococcygeal Teratoma
• Sacrococcygeal teratoma usually presents as a large mass extendingfrom
the sacrum in the newborn period.
• Diagnosis may be established by prenatal ultrasound. In fetuses with
evidence of hydrops and a large sacrococcygeal teratoma, prognosis is poor;
thus prenatal intervention has
been advocated in such patients.
• The mass may be as small as a few centimeters in diameter or as
massive as the size of the infant.
• The tumor has been classified based on the location and degree of
intrapelvic extension. Lesions with growth predominantly into the presacral
space often present later in childhood. The differential diagnosis consists of
neural tumors, lipoma, and myelomeningoceles
• Most tumors are identified at birth and are benign. Malignant yolk sac
tumor histology occurs in a minority of these tumors.
• Complete resection of the tumor as early as possible is es- sential. The
rectum and genital structures are often distorted by the tumor, but usually can
be preserved in the course
of resection.
• Perioperative complications of hypothermia and hemorrhage can occur
with massive tumors and may prove lethal. This is of particular concern in small
preterm infants with large tumors.
 • The cure rate is excellent if the tumor is excised completely. The
majority of patients who develop recurrent disease are salvageable with
subsequent platinum-based chemotherapy

Sacrococcygeal Teratoma
• SCT accounts for 60% of all teratomas & can present as large exophytic
masses in utero. In such cases, they are detected on prenatal USG
• Teratomas occur most frequently in the neonatal period, and the
sacrococcygeal region is the most common site.
• It is four times more common in females and is most often an obvious
external presacral mass
• Although most of the tumor is usually external, with a minimal
intrapelvic presacral component, there is a spectrum of tumor distribution, to
the extent of being entirely presacral,
with no visible external component. As such, a digital rectal examination of a
neonate with care to feel the normal presacral space may be an important
screening technique.
• Most neonatal SCTs are benign.
• Treatment of SCT is complete surgical excision

11. True about esophageal adenocarcinoma:

a. Majority of cases arise in Barret's oesophagus
b. Common in upper part esophagus
c. Commonly arise in the distal esophagus
d. Tobacco exposure and obesity are risk factors
e. Incidence is increasing

Ans. a. Majority of cases arise in Barret's oesophagus, c. Commonly arise in

the distal esophagus, d. Tobacco exposure and obesity are risk factors & e.
Incidence is increasing
Esophageal Adenocarcinoma
• Adenocarcinoma now represents up to half of all esophageal cancers
reported in the United States, and the incidence has been increasing in recent
decades, particularly among white men. The majority of cases arise from the
Barrett mucosa. In rare instances, adenocarcinoma originates from heterotopic
gastric mucosa or submucosal glands.
• The lifetime risk for cancer development from Barrett esophagus is
approximately 10%. Tobacco exposure and obesity are risk factors, but there is
no close association
between alcohol ingestion and the development of adenocarcinoma of the
esophagus. Helicobacter pylori infection may be a contributing factor, but
there is no general agreement about this issue.
• Adenocarcinomas arising in the setting of Barrett esophagus are usually
located in the distal esophagus and may invade the adjacent gastric cardia.
• Microscopically, most tumors are mucin-producing glandular tumors
exhibiting intestinal-type features; less often they are made up of diffusely
infiltrative signet-ring
cells of a gastric type or even poorly differentiated small cell-type tumor.
• Adenocarcinomas arising in Barrett esophagus chiefly occur in patients
over age 40, with a median age in the sixth decade. Similar to Barrett
esophagus, adenocarcinoma is
more common in men than in women, and whites are affected more
frequently than blacks, in contrast to squamous cell carcinomas.
• As in other forms of esophageal carcinoma, patients usually present
because of difficulty swallowing, progressive weight loss, bleeding, chest pain,
and vomiting.
• Long-term symptoms of heartburn, regurgitation, and epigastric pain
related to concurrent gastroesophageal reflux disease and sliding hiatal hernias
are present in less
than half of newly diagnosed patients.
• The prognosis for esophageal adenocarcinoma is as poor as that for
other forms of esophageal cancer, with under 20% overall five-year survival.
Identification and resection
of early cancers with invasion limited to the mucosa or submucosa improves
five-year survival to over 80%.
"These adenocarcinomas behave clinically like gastric adenocarcinoma and
now account for >70% of esophageal cancers.About 10% of esophageal cancers
occur in the upper third of the esophagus (cervical esophagus), 35% in the
middle third, and 55% in the lower third"

Some Etiologic Factors Associated with Esophageal Cancer

Excess alcohol consumption
Cigarette smoking
Other ingested carcinogens
Nitrates (converted to nitrites)
Smoked opiates
Fungal toxins in pickled vegetables
Mucosal damage from physical agents
Hot tea
Lye ingestion
Radiation-induced strictures
Chronic achalasia
Host susceptibility
Esophageal web with glossitis and iron deficiency
(i.e., Plummer-Vinson or Paterson-Kelly syndrome)
Congenital hyperkeratosis and pitting of the palms and soles
(i.e., tylosis palmaris et plantaris)
Dietary deficiencies of selenium, molybdenum, zinc, and vitamin A
Celiac sprue
Chronic gastric reflux (i.e., Barrett's esophagus) for adenocarcinoma

6. True about Babcock forcep:

a. Teeth at end
b. Serration at end
c. Triangular orifice in blades
d. Used for soft delicate tubular structure
e. Curved forcep

Ans. c. Triangular orifice in blades & d. Used for soft delicate tubular
structure
Babcock's Forcep

Babcock's Forcep
• It is a non-traumatic instrument withfenestrated triangular blades & grooved
jaws.
• It is about 10 cJlllong & has small blades
• Babcock Forceps are finger ring, ratcheted, non-perforating forceps used to
grasp delicate tissue in laser procedures.
• They are frequently used with intestinal and laparotomy procedures.
• Babcock Forceps are similar to Allis forceps; however, may be considered less
traumatic due to their wider, rounded grasping surface.
• The jaws are circumferential and the tips are triangular and fenestrated. They
are particularly useful for grasping tube-shaped structures"
7. C02 is used in laproscopy for creating pneumoperitoneum in place of air
because:
a. Less absorption from peritoneal surface
b. Fast clearance from body
c. Less solubility in blood
d. Electrocauteryis safe to use
e. Less risk of gas embolism

Ans. b. Fast clearance from body, d. Electrocauteryis safe to use & e. Less risk
of gas embolism
Pneumoperitoneum
• The ideal gas for pneumoperitoneum insufflation should be non-toxic,
colorless, readily soluble in blood, easily expelled from the body or expired
through the lungs, non-flammable and inexpensive. CO2 best satisfies these
characteristics.

Pneumoperitoneum
• C02 gas insufflation is preferred by most laparoscopists because it has a
high diffusion coefficient and is a normal metabolic end product rapidly cleared
from the body.
• Also, C02 is highly soluble in blood and tissues and does not support
combustion. The risk of gas embolism is lowest with C02. Cardiac arrhythmias
can occur with C02 pneu moperitoneum .
• Because of possible C02 induced hypercarbia, N20 may be preferred in
patients with cardiac disease. With prolonged procedures, C02 retention is
possible as evidenced by tachycardia and acidosis.
• C02 is Noncombustible = safe to use with electrosurgical devices .
• Systemic absorption thought to be facilitated by C02 specific widening of
inter-cellular junctions in peritoneum ---+ buffering of C02 as above ---+
Systemic Acidification

Psm

8. True statement about air pollution:

A. Polynuclear aromatic hydrocarbons are produced by incomplete combustion
of fuels
B. Carbon monoxide concentration depends on weath- er condition
C. S02 is not a domestic pollutant
D. Lead can cross placenta

Ans. A (Polynuclear aromatic hydrocarbons are produced by incomplete

combustion of fuels) ,B (Carbon monoxide concentration depends on weath-
er condition ) & D (Lead can cross placenta)

AIR POLLUTION

1. "Polynuclear aromatic hydrocarbons(PAH) : They are formed mainly as a

result of pyrolytic processes, especially the incomplete combustion of
organic materials"

2. "Sulphur dioxide:Domestic fires(Coal, wood or oil) can also produce

emission containing S02"

3. "CO: Concentration in urban areas depend on weather & traffic density.

Variation in CO levels are also influenced by topography"

4. "Lead may be mobilized from the maternal skeleton during pregnancy

and it readily crosses the placental barrier. Hence lead exposure can
begin in utero. Similar to neurotoxicity caused by methylmercury, the
developing nervous system of the fetus and infants is extremely
susceptible to lead toxicity"
 Ortho

12. Which of the following examination is done in supine position:

a. Tredelenburg position
b. ReverseTredelenburg position
c. Sims position
d. Jack knife position
e. Lloyd-Davies position

Ans. a. Tredelenburg position , b. ReverseTredelenburg position & e. Lloyd-

Davies position
"Tredelenburg position: Lithotomy with head down"
"Reverse Tredelenburg position: The patient is supine on the operating table
with the table tilted up IS' at the head end to reduce venous engorgement"
"Most commonly, the patient is examined in the left lateral (Sims) position
with the buttocks overlying the edge of the examination couch and with the
axis of the torso crossing, rather than parallel with, the edge of the couch.
Alternatively, in younger patients, the prone jackknife or knee-elbow positions
may be used"
"Lloyd-Davies position is a medical term referring to a common position for
surgical procedures involving the pelvis and lower abdomen. The majority of
colorectal and pelvic surgery is conducted with the patient in the Lloyd-Davis
position"
"Lloyd-Davies Position: It is also known as the Trendelenburg position with legs
apart. The basic angle is a 30-degree Trendelenburg with the hips flexed at 15
degrees; this can be adjusted with leg supports"

OPHTHAL
1. Which of the following vitamin deficiency can cause centrocecal scotoma:
a. VitA
b. VitE
c. B6
d. B2
e. B12

Ans. e. B12
"Centro cecal or cecocentral scotoma: Field defect involving both the macula and the blind spot; seen in optic
nerve disease, such as Leber's hereditary optic neuropathy, toxic or nutritional optic neuropathies (said to be
typical of vitamin B12 deficiency optic neuropathy), sometimes in optic neuritis"
Ophthalmologic Manifestations
• An unusual but well-documented manifestation of cobalamin deficiency is optic neuropathy. This may
present as a subacutely progressive decrease in visual acuity with a cecocentral scotoma (I.e., a scotoma
obscuring central vision and enlarging the blind spot).
• The condition known as tobacco-ethanol amblyopia is similar, and may, at least in part, depend on
cobalamin deficiency.
"Damage to papillomacular fibers causes a cecocentral scotoma that encompasses the blind spot and macula.
If the damage is irreversible, pallor eventually appears in the temporal portion
of the optic disc. Temporal pallor from a cecocentral scotoma may develop in optic neuritis, nutritional optic
neuropathy, toxic optic neuropathy, Leber's hereditary optic neuropathy, and
compressive optic neuropathy"

2. True about primary open angle glaucoma:

a. Also kla Chronic simple glaucoma
b. Hypermeteropeas are more predisposed
c. Polygenic inheritance
d. Laser iridotomy is used for treatment
e. Fundus examination reveals large cup

Ans. a. Also kla Chronic simple glaucoma, c. Polygenic inheritance & e. Fundus examination reveals large cup
Hypermetropic eyes with shallow anterior chamber & short axial length are predisposed to primary angle
closure glauco- ma
Laser iridotomy is used for treatment of primary angle closure glaucoma

Primary Open Angle Glaucoma

• It is a type of primary glaucoma, where there is no obvious systemic or ocular cause of rise in the
intraocular pressure. It occurs in eyes with open angle of the anterior chamber.
• T is also known as chronic simple glaucoma of adult onset and is typically characterized by slowly
progressive raised intraocular pressure (>21 mmHg recorded on at least a few occasions) associated with
characteristic optic disc cupping and specific visual field defects.
• Pathogenesis: The rise in intraocular pressure in POAG is related to an increased resistance to the
outflow of aqueous at the trabecular mesh work, especially at the juxtacanalicular region. In part, this is due to
age-related changes in this tissue.
• Heredity: POAG has a polygenic inheritance. The approximate risk of getting disease is 10% in the
siblings, and 4% in the offspring of patients with POAG
• Age: The risk increases with increasing age. The POAG is more commonly seen in elderly between 5th
and 7th decades.
• Myopes are more predisposed than the normals.
• Diabetics have a higher prevalence of POAG than non- diabetics.
• Cigarette smoking is also thought to increase its risk.
• High blood pressure is not the cause of rise in lOP, however the prevalence of POAG is more in
hypertensives than the normotensives.
• Thyrotoxicosis is also not the cause of rise in lOP, but the prevalence of POAG is more inpatients
suffering from Graves' ophthalmic disease than the normals.
• Patients may experience mild headache and eyeache
• Reading and close work often present increasing difficulties owing to accommodative failure due to
constant pressure on the ciliary muscle and its nerve supply. Therefore, patients usually complain of frequent
changes in presbyopic glasses.
• Patients develop delayed dark adaptation, a disability which becomes increasingly disturbing in the
later stages.
• Anterior segment signs. Ocular examination including slit- lamp biomicroscopy may reveal normal
anterior segment.
In late stages pupil reflex becomes sluggish and cornea may show slight haze.
• Fundus examination show large cup, i.e. 0.6 or more (normal cup size is 0.3 to 0.4)