Phacoanaphylaxis Workup

  • Author: Robert H Graham, MD; Chief Editor: Hampton Roy Sr, MD   more...
 
Updated: Feb 15, 2012
 

Laboratory Studies

  • Aqueous paracentesis in subtle or early cases may reveal inflammatory cells and particulate lens proteins without bacteria. This procedure is performed more efficiently at the time of anterior chamber washout and vitrectomy to remove the inciting lenticular antigens. In cases of suspected bacterial endophthalmitis, intraoperative aqueous and vitreous specimens may establish the diagnosis of phacoanaphylaxis in the absence of positive cultures.
Next

Imaging Studies

  • If the media opacity prevents an appropriate fundus examination, echography with A-scan and B-scan may be helpful when evaluating the posterior pole.[63]
    • Suspicion for acute endophthalmitis, intraocular foreign body, dropped lens nucleus, thickening of the choroid, retinal detachment, and choroidal effusion are all indications for echography if the anterior segment changes hinder examination of the posterior segment.
    • The shape, position, and thickness of the traumatized lens; the presence of focal echogenic areas; and, sometimes, even the entrance and exit wounds are recognizable by ultrasound. It is clinically important to diagnose the isolated rupture of the posterior capsule of the lens by echography. Such ruptures are characterized by the irregular extension of the highly reflective posterior capsule toward the vitreous with significantly increased thickness of the lens.
  • Ultrasound biomicroscopy (UBM) may have an important role in the evaluation of lens-induced uveitis after extracapsular cataract extraction, revealing hidden lens particles in the posterior chamber causing inflammation as well as lens-particles creating secondary glaucoma.[64, 65]
Previous
Next

Histologic Findings

Histopathology of phacoanaphylactic endophthalmitis is characterized by a zonal granulomatous inflammatory reaction consisting of polymorphonuclear neutrophils, numerous epithelioid cells, and occasional giant cells. The inflammatory reaction is around the lens material or lens capsule (see the images below). Associated cells include eosinophils, plasma cells, and histiocytes containing phagocytized lens material.

Gross photomicrograph for eye enucleated with peneGross photomicrograph for eye enucleated with penetrating injury. Gross photomicrograph for eye enucleated with peneGross photomicrograph for eye enucleated with penetrating injury. Note marked inflammatory reaction consisting of polymorphonuclear cells around lens capsule and lens fibers (hematoxylin and eosin X100). Low (X25) photomicrograph of phacoanaphylactic reaLow (X25) photomicrograph of phacoanaphylactic reaction to lens protein in eye enucleated with penetrating injury. Note polymorphonuclear leucocytes around lens protein (hematoxylin and eosin).

Minimal histopathologic diagnostic criteria include neutrophil-associated lens damage accompanied by a granulomatous response associated with the lens material. A paucity of neutrophils may be present in late cases. Isolated giant cells without neutrophils and associated lens damage may create difficulty in distinguishing phacoanaphylactic endophthalmitis from a foreign body granuloma since lens material or the Descemet membrane may induce giant cells.

Previous
Proceed to Treatment & Management
 
 
Contributor Information and Disclosures
Author

Robert H Graham, MD  Senior Associate Consultant, Department of Ophthalmology, Mayo Clinic, Scottsdale, Arizona

Robert H Graham, MD is a member of the following medical societies: American Academy of Ophthalmology, American Medical Association, and Arizona Ophthalmological Society

Disclosure: WebMD/eMedicine Salary Employment

Coauthor(s)

Charles C Barr, MD  Retina Service Director, Professor, Department of Ophthalmology, University of Louisville School of Medicine

Disclosure: Nothing to disclose.

Specialty Editor Board

John D Sheppard Jr, MD, MMSc  Professor of Ophthalmology, Microbiology and Molecular Biology, Clinical Director, Thomas R Lee Center for Ocular Pharmacology, Ophthalmology Residency Research Program Director, Eastern Virginia Medical School; President, Virginia Eye Consultants

John D Sheppard Jr, MD, MMSc is a member of the following medical societies: American Academy of Ophthalmology, American Society for Microbiology, American Society of Cataract and Refractive Surgery, American Uveitis Society, and Association for Research in Vision and Ophthalmology

Disclosure: Nothing to disclose.

Francisco Talavera, PharmD, PhD  Adjunct Assistant Professor, University of Nebraska Medical Center College of Pharmacy; Editor-in-Chief, Medscape Drug Reference

Disclosure: Medscape Salary Employment

R Christopher Walton, MD  Professor, Director of Uveitis and Ocular Inflammatory Disease Service, Department of Ophthalmology, Assistant Dean for Graduate Medical Education, University of Tennessee College of Medicine; Consulting Staff, Regional Medical Center, Memphis Veterans Affairs Medical Center, St Jude Children's Research Hospital

R Christopher Walton, MD is a member of the following medical societies: American Academy of Ophthalmology, American College of Healthcare Executives, American Uveitis Society, Association for Research in Vision and Ophthalmology, and Retina Society

Disclosure: Nothing to disclose.

Lance L Brown, OD, MD  Ophthalmologist, Affiliated With Freeman Hospital and St John's Hospital, Regional Eye Center, Joplin, Missouri

Disclosure: Nothing to disclose.

Chief Editor

Hampton Roy Sr, MD  Associate Clinical Professor, Department of Ophthalmology, University of Arkansas for Medical Sciences

Hampton Roy Sr, MD is a member of the following medical societies: American Academy of Ophthalmology, American College of Surgeons, and Pan-American Association of Ophthalmology

Disclosure: Nothing to disclose.

Additional Contributors

The authors and editors of eMedicine gratefully acknowledge the contributions of previous coauthor, Judith Mohay, MD, to the development and writing of this article.

References

  1. Bloch-Michel E, Nussenblatt RB. International Uveitis Study Group recommendations for the evaluation of intraocular inflammatory disease. Am J Ophthalmol. Feb 15 1987;103(2):234-5. [Medline].

  2. Brinkman CJ, Broekhuyse RM. Cell mediated immunity in relation to cataract and cataract surgery. Br J Ophthalmol. May 1979;63(5):301-5. [Medline].

  3. Luntz MH, Wright R. Lens-induced uveitis. Exp Eye Res. 1962;1:317-323.

  4. Zimmerman LE. Lens induced inflammation in human eyes. In: Maumenee AE, Silverstein AM, eds. Immunopathology of Uveitis. Lippincott Williams & Wilkins; 1964:221-232.

  5. Sheppard JD, Nozik RA. Clinical Ophthalmology. In: Duane TA, Jaeger EW eds. Practical Diagnostic Approach to Uveitis. 4, chapter 33. Philadelphia: JB Lippincott; 1989.

  6. Verhoeff FH, Lemoine AN. Endophthalmitis phacoanaphylactica. Am J Ophthalmol. 1922;5:737-745.

  7. Apple DJ, Mamalis N, Steinmetz RL, Loftfield K, Crandall AS, Olson RJ. Phacoanaphylactic endophthalmitis associated with extracapsular cataract extraction and posterior chamber intraocular lens. Arch Ophthalmol. Oct 1984;102(10):1528-32. [Medline].

  8. Blodi BA, Flynn HW Jr, Blodi CF, Folk JC, Daily MJ. Retained nuclei after cataract surgery. Ophthalmology. Jan 1992;99(1):41-4. [Medline].

  9. Bai HQ, Yao L, Wang DB, Jin R, Wang YX. Causes and treatments of traumatic secondary glaucoma. Eur J Ophthalmol. Mar-Apr 2009;19(2):201-6. [Medline].

  10. Emery JM, Wilhelmus KA, Rosenberg S. Complications of phacoemulsification. Ophthalmology. Feb 1978;85(2):141-50. [Medline].

  11. Fine HI. Small incision cataract surgery. In: Yanoff M, Duker JS. Ophthalmology. ed. Mosby Inc; 1999:23.1-10.

  12. Gifford SR. Allergic and toxic properties of lens protein. JAMA. 1925;85:351-356.

  13. Goodner EK. Experimental lens-induced uveitis in rabbits. In: Maumenee AE, Silverstein AM, ed. Immunopathology of Uveitis. Lippincott Williams & Wilkins; 1964:233-242.

  14. Hektoen L, Schulhof K. Further observations on lens precipitins. Antigenic properties of alpha and beta crystallins. J Infect Dis. 1924;34:433-439.

  15. Little J, Langman J. Lens antigens in the intraocular tissues of the human eye. Arch Ophthal. 1964;72:820-825.

  16. Mehta PD, Cooper SN, Rao SS. Identification of species -specific and organ-specific antigens in lens proteins. Exp Eye Res. 1964;3:192-199.

  17. Kida H. Experimental endophthalmitis phacoanaphylactica in rabbits sensitized with the purified bovine alpha-crystallin. Folia Ophthalmol Jpn. 1961;12:304-311.

  18. Rahi AH, Garner A. Immunopathology of the Eye. Oxford, England: Blackwell Scientific Publications; 1976.

  19. Woods AC. An adventure in ophthalmic literature: Manuel Straub and the tradition of toxicity in lens protein. Am J Ophthalmol. 1959;48:463-472.

  20. Maisel H, Goodman M. Analysis of mammalian lens proteins by electrophoresis. Arch Ophthal. 1964;71:671-675.

  21. Halbert SP, Manski W. Biological aspects of autoimmune reactions in the lens. Invest Ophthal. 1965;4:516-530.

  22. Friedlander MH. Allergy and Immunology of the Eye. Lippincott-Raven Publishers; 1979:24-203.

  23. Kincses E, Szabo G. Human and cellular immune response after injury of the lens . In: Ocular Immune Responses: Proceedings of the International Symposium on Immunology & Immunopathology of the Eye. Strasbourg: S Karger AG Basel Publisher; 1974:16.

  24. Marak GE Jr. Phacoanaphylactic endophthalmitis. Surv Ophthalmol. Mar-Apr 1992;36(5):325-39. [Medline].

  25. Schubert HD. Postsurgical hypotony: relationship to fistulization, inflammation, chorioretinal lesions, and the vitreous. Surv Ophthalmol. Sep-Oct 1996;41(2):97-125. [Medline].

  26. Gass JD, Norton EW. Follow-up study of cystoid macular edema following cataract extraction. Trans Am Acad Ophthalmol Otolaryngol. Jul-Aug 1969;73(4):665-82. [Medline].

  27. Ellant JP, Obstbaum SA. Lens-induced glaucoma. Doc Ophthalmol. 1992;81(3):317-38. [Medline].

  28. Toris CB, Pederson JE. Aqueous humor dynamics in experimental iridocyclitis. Invest Ophthalmol Vis Sci. Mar 1987;28(3):477-81. [Medline].

  29. Thach AB, Marak GE Jr, McLean IW, Green WR. Phacoanaphylactic endophthalmitis: a clinicopathologic review. Int Ophthalmol. Jul 1991;15(4):271-9. [Medline].

  30. Besen G, Freeman WR. Intraoperative recognition of retinal vasculitis in a patient with early lens-induced uveitis. Ophthalmic Surg Lasers. Jan 1997;28(1):67-8. [Medline].

  31. Chishti M, Henkind P. Spontaneous rupture of anterior lens capsule (phacoanaphylactic endophthalmitis). Am J Ophthalmol. Feb 1970;69(2):264-70. [Medline].

  32. Perlman EM, Albert DM. Clinically unsuspected phacoanaphylaxis after ocular trauma. Arch Ophthalmol. Feb 1977;95(2):244-6. [Medline].

  33. Perlman EM, Albert DM. Clinically unsuspected phacoanaphylaxis after ocular trauma. Arch Ophthalmol. Feb 1977;95(2):244-6. [Medline].

  34. Habil I, Cohen E, Karshai I, BenEzra D, Behar-Cohen F. Spontaneous involution of autologous lenses and phacoanaphylaxis reaction in Stickler syndrome. Br J Ophthalmol. Nov 2005;89(11):1532-3. [Medline].

  35. Inomata H, Yoshikawa H, Rao NA. Phacoanaphylaxis in Behçet's disease: a clinicopathologic and immunohistochemical study. Ophthalmology. Oct 2003;110(10):1942-5. [Medline].

  36. McCluskey P, Harrisberg B. Long-term results using scleral-fixated posterior chamber intraocular lenses. J Cataract Refract Surg. Jan 1994;20(1):34-9. [Medline].

  37. McMahon MS, Weiss JS, Riedel KG. Clinically unsuspected phacoanaphylaxis after extracapsular cataract extraction with intraocular lens implantation. Br J Ophthalmol. Nov 1985;69(11):836-40. [Medline].

  38. Muccioli C, Belfort R Jr. Cataract surgery in patients with uveitis. Int Ophthalmol Clin. Spring 2000;40(2):163-73. [Medline].

  39. Truhlsen SM. Approaching nucleus slippage. Arch Ophthalmol. May 1991;109(5):627. [Medline].

  40. Habil I, Cohen E, Karshai I, BenEzra D, Behar-Cohen F. Spontaneous involution of autologous lenses and phacoanaphylaxis reaction in Stickler syndrome. Br J Ophthalmol. Nov 2005;89(11):1532-3. [Medline].

  41. Inomata H, Yoshikawa H, Rao NA. Phacoanaphylaxis in Behçet's disease: a clinicopathologic and immunohistochemical study. Ophthalmology. Oct 2003;110(10):1942-5. [Medline].

  42. Ritch R. Exfoliation syndrome and exfoliative glaucoma. In: Eid TM, Spaeth GL. Glaucomas: Concepts and Fundamentals. Lippincott Williams & Wilkins: 2000:114-120.

  43. Thompson JT, Parver LM, Enger CL, Mieler WF, Liggett PE. Infectious endophthalmitis after penetrating injuries with retained intraocular foreign bodies. National Eye Trauma System. Ophthalmology. Oct 1993;100(10):1468-74. [Medline].

  44. Winward KE, Pflugfelder SC, Flynn HW Jr, Roussel TJ, Davis JL. Postoperative Propionibacterium endophthalmitis. Treatment strategies and long-term results. Ophthalmology. Apr 1993;100(4):447-51. [Medline].

  45. Speaker MG, Smolin G, Menikoff JA, Friedlaender MH, eds. Postoperative endophthalmitis: Pathogenesis, prophylaxis and management. In: International Ophthalmology Clinics. Vol 33. 1993:51-70.

  46. Meltzer DW. Sterile hypopyon following intraocular lens surgery. Arch Ophthalmol. Jan 1980;98(1):100-4. [Medline].

  47. Kraff MC, Sanders DR, Lieberman HL, Peyman GA, Levine RA. Membrane formation after implantation of polyvinyl alcohol-coated intraocular lenses. J Am Intraocul Implant Soc. Apr 1980;6(2):129-36. [Medline].

  48. Stark WJ, Rosenblum P, Maumenee AE, Cowan CL. Postoperative inflammatory reactions to intraocular lense sterilized with ethylene-oxide. Ophthalmology. May 1980;87(5):385-9. [Medline].

  49. Allen JC. Sympathetic uveitis and phacoanaphylaxis. Am J Ophthalmol. Feb 1967;63(2):280-3. [Medline].

  50. Blodi FC. Sympathetic uveitis as an allergic phenomenon: with a study in association with phacoanaphylactic uveitis and a report on the pathological findings in sympathizing eyes. Trans Am Acad Ophthal Otolaryng. 1959;63:642-649.

  51. Chan CC. Relationship between sympathetic ophthalmia, phacoanaphylatic endophthalmitis, and Vogt-Koyanagi-Harada disease. Ophthalmology. May 1988;95(5):619-24. [Medline].

  52. Sheppard JD. Seminars in Ophthalmology. In: Beatty RL, ed. Sympathetic Ophthalmia. Philadelphia: JB Lippincott; 1994.

  53. Ishikawa Y, Kawata K. Three cases of endophthalmitis phacoanaphylactica in the fellow eye after extracapsular lens extraction. Folia Ophthalmol Jpn. 1977;28:1260-1265.

  54. Lubin JR, Albert DM, Weinstein M. Sixty-five years of sympathetic ophthalmia. A clinicopathologic review of 105 cases (1913--1978). Ophthalmology. Feb 1980;87(2):109-21. [Medline].

  55. Sisk RA, Davis JL, Dubovy SR, Smiddy WE. Sympathetic ophthalmia following vitrectomy for endophthalmitis after intravitreal bevacizumab. Ocul Immunol Inflamm. Sep-Oct 2008;16(5):236-8. [Medline].

  56. Easom H, Zimmerman LE. Sympathetic ophthalmia and bilateral phacoanaphylaxis. A clinicopathologic correlation of the sympathogenic and sympathizing eyes. Arch Ophthalmol. Jul 1964;72:9-15. [Medline].

  57. Easom HA, Zimmerman LE. Sympathetic ophthalmia and bilateral phacoanaphylaxis. A clinicopathological correlation of the sympathogenic and sympathizing eyes. Arch Ophthalmol. 1964;72:9-15.

  58. Croxatto JO, Rao NA, McLean IW, Marak GE. Atypical histopathologic features in sympathetic ophthalmia. A study of a hundred cases. Int Ophthalmol. Feb 1982;4(3):129-35. [Medline].

  59. Muller H. Phacolytic glaucoma and phacogenic ophthalmia (lens-induced uveitis). Trans Ophthal. Soc. UK. 1963;83:689-704.

  60. Epstein DL. Diagnosis and management of lens-induced glaucoma. Ophthalmology. Mar 1982;89(3):227-30. [Medline].

  61. Fisher D. Glaucoma associated with uveitis (Inflammatory glaucoma). In: Eid TM, Spaeth GL. The Glaucomas: Concepts and Fundamentals. Lippincott Williams & Wilkins; 2000:190-198.

  62. Irvine SR, Irvine AR Jr. Lens-induced uveitis and glaucoma: Endophthalmitis phacoanaphylactica. Am J Ophthalmol. 1952;35:177.

  63. Alward WL, Byrne SF, Hughes JR, Hodapp EA. Dislocated lens nuclei simulating choroidal melanomas. Arch Ophthalmol. Oct 1989;107(10):1463-4. [Medline].

  64. Pavlin CJ, Harasiewicz K, Sherar MD, Foster FS. Clinical use of ultrasound biomicroscopy. Ophthalmology. Mar 1991;98(3):287-95. [Medline].

  65. Sampaolesi R. Three-dimensional scan using a single transducer and image construction. In: Tomita M, Sugata Y, Yamamoto Y, eds. Ultrasonography in Ophthalmology 12, Documenta Ophthalmologica Proceedings. Kluwer Academic Publishers; 1990:455-460.

  66. Fastenberg DM, Schwartz PL, Shakin JL, Golub BM. Management of dislocated nuclear fragments after phacoemulsification. Am J Ophthalmol. Nov 15 1991;112(5):535-9. [Medline].

  67. Gilliland GD, Hutton WL, Fuller DG. Retained intravitreal lens fragments after cataract surgery. Ophthalmology. Aug 1992;99(8):1263-7; discussion 1268-9. [Medline].

  68. Kim JE, Flynn HW Jr, Smiddy WE, et al. Retained lens fragments after phacoemulsification. Ophthalmology. Nov 1994;101(11):1827-32. [Medline].

  69. Lambrou FH Jr, Stewart MW. Management of dislocated lens fragments during phacoemulsification. Ophthalmology. Aug 1992;99(8):1260-2; discussion 1268-9. [Medline].

  70. Smiddy WE, Flynn HW. Management of retained lens fragments and dislocated posterior chamber intraocular lenses. In: Albert DM, Jakobiec FA. Principles and Practice of Ophthalmology. WB Saunders Co;2000:2485-2494.

  71. Schaal S, Barr CC. Management of retained lens fragments after cataract surgery with and without pars plana vitrectomy. J Cataract Refract Surg. May 2009;35(5):863-7. [Medline].

  72. Stewart MW. Managing retained lens fragments: raising the bar. Am J Ophthalmol. Apr 2009;147(4):569-70. [Medline].

  73. Ho LY, Doft BH, Wang L, Bunker CH. Clinical predictors and outcomes of pars plana vitrectomy for retained lens material after cataract extraction. Am J Ophthalmol. Apr 2009;147(4):587-594.e1. [Medline].

  74. Endophthalmitis Vitrectomy Study Group. Results of the Endophthalmitis Vitrectomy Study. A randomized trial of immediate vitrectomy and of intravenous antibiotics for the treatment of postoperative bacterial endophthalmitis. Endophthalmitis Vitrectomy Study Group. Arch Ophthalmol. Dec 1995;113(12):1479-96. [Medline].

  75. Greve MD, Peyman GA, Mehta NJ, Millsap CM. Use of perfluoroperhydrophenanthrene in the management of posteriorly dislocated crystalline and intraocular lenses. Ophthalmic Surg. Sep 1993;24(9):593-7. [Medline].

  76. Borne MJ, Tasman W, Regillo C, Malecha M, Sarin L. Outcomes of vitrectomy for retained lens fragments. Ophthalmology. Jun 1996;103(6):971-6. [Medline].

  77. Schechter RJ. Glass-slide vitrectomy for use by the cataract surgeon. Am J Ophthalmol. Jul 15 1991;112(1):100. [Medline].

  78. Weinstein GW, Charlton JF, Esmer E. The "lost lens": a new surgical technique using the Machemer lens. Ophthalmic Surg. Mar-Apr 1995;26(2):156-9. [Medline].

  79. Vilar NF, Flynn HW Jr, Smiddy WE, Murray TG, Davis JL, Rubsamen PE. Removal of retained lens fragments after phacoemulsification reverses secondary glaucoma and restores visual acuity. Ophthalmology. May 1997;104(5):787-91; discussion 791-2. [Medline].

  80. Jaffe NS. Cataract Surgery & Its Complications. St. Louis: Mosby Inc; 1976:367-370.

  81. Aaberg TM Jr, Rubsamen PE, Flynn HW Jr, Chang S, Mieler WF, Smiddy WE. Giant retinal tear as a complication of attempted removal of intravitreal lens fragments during cataract surgery. Am J Ophthalmol. Aug 1997;124(2):222-6. [Medline].

  82. Bourke RD, Gray PJ, Rosen PH, Cooling RJ. Retinal detachment complicating scleral-sutured posterior chamber intraocular lens surgery. Eye. 1996;10 (Pt 4):501-8. [Medline].

  83. Burky EL, Woods AC. Lens extract: its preparation and clinical use. Arch Ophthalmol. 1931;6:548-553.

  84. Epstein E. Suture problems. J Cataract Refract Surg. Jan 1989;15(1):116. [Medline].

  85. Kronenthal RL. Nylon in the anterior chamber. Ophthalmology. Sep 1981;88(9):965-7. [Medline].

  86. Leaming DV. Practice styles and preferences of ASCRS members--1994 survey. J Cataract Refract Surg. Jul 1995;21(4):378-85. [Medline].

  87. Uhlenhuth P. Zur Lehre von der Unterscheidung verschiedener Eiweissarten mit Hilfe spezifischer Sera. In: Festschrift zum Geburstag Robert Koch. Gustav Fischer Verlag;1903:49-74.

  88. Volcker HE, Naumann GO. Morphology of uveal and retinal edemas in acute and persisting hypotony. Mod Probl Ophthalmol. 1979;20:34-41. [Medline].

 
Previous
Next
 
Gross photomicrograph for eye enucleated with penetrating injury.
Gross photomicrograph for eye enucleated with penetrating injury. Note marked inflammatory reaction consisting of polymorphonuclear cells around lens capsule and lens fibers (hematoxylin and eosin X100).
Low (X25) photomicrograph of phacoanaphylactic reaction to lens protein in eye enucleated with penetrating injury. Note polymorphonuclear leucocytes around lens protein (hematoxylin and eosin).
High (X50) photomicrograph of phacoanaphylactic reaction to lens protein in eye enucleated with penetrating injury. Note polymorphonuclear leucocytes around lens protein (hematoxylin and eosin).
Phacoanaphylactic reaction to penetrating injury of lens. This patient was a 25-year-old woman whose eye was penetrated with a 27-gauge needle during an attempt to anesthetize the eyelid for chalazion removal. One week later, a marked uveitis was present. Notice perforation site and posterior synechiae.
Same patient as in Media file 5. Notice cortical cataract at perforation site.
Typical clinical picture of retained lens material following cataract surgery. White cortical material is easily visible in the pupillary space.
Patient with persistently elevated intraocular pressure after cataract surgery was found to have retained lens material and low-grade inflammation. Eye is white and quiet with anterior chamber lens.
Patient with persistently elevated intraocular pressure after cataract surgery was found to have retained lens material and low-grade inflammation. Retained lens material is visible in retroillumination on downgaze.
Typical appearance of retained lens fragments in posterior vitreous cavity. Lens material is a whitish substance that obscures fundus details.
Another view of a retained lens fragment, noted inferiorly.
 
 
 
All material on this website is protected by copyright, Copyright © 1994-2012 by WebMD LLC.
This website also contains material copyrighted by 3rd parties.

DISCLAIMER: The content of this Website is not influenced by sponsors. The site is designed primarily for use by qualified physicians and other medical professionals. The information contained herein should NOT be used as a substitute for the advice of an appropriately qualified and licensed physician or other health care provider. The information provided here is for educational and informational purposes only. In no way should it be considered as offering medical advice. Please check with a physician if you suspect you are ill.