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Digital Analysis of Eyelid Features and Eyebrow Position Following CO2 Laser-assisted Blepharoptosis Surgery



Plastic and Reconstructive Surgery - Global Open:
doi: 10.1097/GOX.0000000000001063
Original Article

Digital Analysis of Eyelid Features and Eyebrow Position Following CO2 Laser-assisted Blepharoptosis Surgery

Zheng, Xiaodong MD, PhD; Kakizaki, Hirohiko MD, PhD; Goto, Tomoko MD, PhD; Shiraishi, Atsushi MD, PhD

Open Access
Japan
Article Outline
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Author Information

From the *Department of Ophthalmology, Ehime University School of Medicine, Toon City, Ehime, Japan; Hanamizuki Eye Clinic, Matsuyama, Ehime, Japan; and Department of Ophthalmology, Aichi Medical University, Nagakute, Aichi, Japan.
Received for publication June 1, 2016; accepted August 10, 2016.
Disclosure: The authors have no financial interest to declare in relation to the content of this article. The Article Processing Charge was paid for by the authors.
Xiaodong Zheng, MD, PhD, Department of Ophthalmology, Ehime University School of Medicine, Toon City, Ehime 791-0295, Japan, E-mail: xzheng@m.ehime-u.ac.jp
This is an open-access article distributed under the terms of the Creative Commons Attribution-Non Commercial-No Derivatives License 4.0 (CCBY-NC-ND), where it is permissible to download and share the work provided it is properly cited. The work cannot be changed in any way or used commercially.
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Abstract

Background: To compare the margin reflex distance of the upper (MRD-1) and lower (MRD-2) eyelids and the eyebrow height (EBH) in patients with involutional and hard contact lens wear--induced blepharoptosis before and after ptosis surgery.
Methods: Sixty patients with acquired blepharoptosis were studied. Group 1 consisted of 30 patients with involutional ptosis (age, 75.8 ± 6.4 years), and group 2 consisted of 30 patients with hard contact lens wear–induced ptosis (age, 50.2 ± 7.1 years). All patients underwent bilateral, CO2 laser–assisted levator aponeurosis advancement surgery. A digital image was taken in the primary position before and 2 months after the surgery. The image was analyzed by the ImageJ (NIH, Bethesda, Md.) software. Parameters included MRD-1, MRD-2, EBH, and ocular surface area (OSA).
Results: After surgery, all patients had a significant increase in the MRD-1 and OSA and a decrease in the EBH (all P < 0.001). The increase in MRD-1 was significantly larger in group 1 than in group 2 (P = 0.028). The decrease of EBH was significantly greater in group 1 than in group 2 (P = 0.007). Group 1 had a slight decrease in the MRD-2, but group 2 had a significant increase after surgery (P = 0.026). The change in the OSA was not significantly different between the 2 groups.
Conclusions: Digital image analyses can be used for precise measurements of the eyelid features. The disparity in the changes of eyelid and eyebrow features between the 2 groups may suggest different responses of the external eyelid muscles to surgery between cases of different etiology.
Blepharoptosis is an abnormal drooping of the upper eyelid that is observed when the eye is at primary position. Levator advancement surgery is a commonly used method to effectively treat this disorder.1–4 A restoration of the upper visual field and an improvement and rejuvenation of the facial appearance after levator advancement surgery are true and precious clinical targets and the outcomes are greatly appreciated by our patients.
At present, studies on the effectiveness of ptosis repair surgery typically use the height of the palpebral aperture in the midpupillary line as a measure of success. The conventional measure used to quantify the palpebral aperture is the margin reflex distance (MRD) which is defined as the vertical distance between the corneal light reflex and the upper (MRD-1) and lower (MRD-2) eyelid margins. However, this parameter is 1-dimensional, and the measurement of the MRD relies on the examiner’s experience. Detailed analyses of the eyelid contour including the ocular surface area (OSA) and eyebrow position, which are known to change after eyelid surgery, are important for the characterization of not only the features of the eyelid and ocular surface but also the facial appearance.5–7 Information of these parameters is necessary for both patients and surgeons to evaluate the outcome of ptosis repair surgery.
With the development of digital imaging technology and the analyzing software, the eyelid features can be assessed more accurately and quantitatively. There have been several studies using digital analyses of external photographs of the eye for the evaluation of the preoperative and postoperative eyelid and eyebrow features.568–10 Koushan et al5 reported using the Photoshop software to analyze the OSA of patients who had undergone ptosis repair surgery. They concluded that this simple method can quantify the OSA and was a good method to evaluate the postoperative changes. Prado et al8 used the ImageJ software to measure the angle of the eyebrow before and after blepharoplasty, and reported that the eyebrow tended to move down after surgery. To the best of our knowledge, there have been no reports in a single study documenting the changes of OSA, MRD, and eyebrow position, and no comparative studies focused on these changes between involutional and contact lens wear--induced ptosis.
Thus, the purpose of this study was to analyze the upper eyelid position, MRD-1, the lower eyelid position, MRD-2, the OSA, and the eyebrow height (EBH) before and after ptosis repair surgery. To accomplish this, we studied 2 groups of patients: the first group consisted of 30 patients with involutional ptosis, and the second group consisted of 30 patients with contact lens wear--induced ptosis. All the subjects underwent bilateral, CO2 laser–assisted levator aponeurosis advancement surgery.
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PATIENTS AND METHODS

Subjects
Patients who were examined at the Department of Ophthalmology, Ehime University Hospital or Hanamizuki Eye Clinic with bilateral involutional or contact lens wear–induced blepharoptosis between December 2014 and June 2016 were studied. Patients with an MRD-1 <2.5 mm were included. The exclusion criteria were corneal changes precluding accurate measurements, use of sympathomimetic drugs or eye drops, prior eyelid surgery, other types of ptosis, for example, congenital, traumatic, or mechanical, and myopathies.
All subjects were informed on the procedures to be used and the possible complications, and a signed informed consent was obtained. This study was approved by the Ethics Committee of Ehime University Hospital and Hanamizuki Eye Clinic.
The patients were separated into 2 groups according to the etiology of blepharoptosis. Group 1 consisted of 30 patients with involutional ptosis (mean age, 75.8 ± 6.4 years), and group 2 consisted of 30 patients with contact lens wear–induced ptosis (mean age, 50.2 ± 7.1 years).
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Surgical Procedures
All patients underwent standard bilateral, CO2 laser–assisted levator aponeurosis advancement surgery by the same surgeon (X.Z.). In brief, an incision was made at about 5 mm above the upper eyelid margin. Redundant skin was resected for 5–10 mm in width if necessary. The subcutaneous tissue was dissected, and the levator aponeurosis was isolated and advanced by 8–10 mm using 6-0 Asflex suture (polyvinylidene fluoride, CROWNJUN KONO CO., LTD, Chiba, Japan). The upper eyelid margin was fixed at approximately 1 mm lower from the upper corneal limbus and the proper eyelid position was confirmed while the patient was in a sitting position. Finally, interrupted sutures using 6-0 nylon were made to close the skin (Fig. 1). All subjects were examined on the first day after the surgery and again 1 week later, and the sutures were removed at 7–10 days after the surgery. Ofloxacin ophthalmic ointment (0.3%; Tarivit, Santen Co., Osaka, Japan) was applied twice a day onto the wound for 2 weeks.
Fig. 1
Fig. 1
Image Tools
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Image Processing and Measurements
Frontal photographs were taken preoperatively and at 2 months postoperatively with the eyes in the primary position. A Nikon 5500 digital camera (Nikon, Osaka, Japan) with strobe light was used. The digital images were analyzed with the ImageJ software (version 1.45, NIH, Bethesda, Md.), with the Java platform version 1.6.
The following parameters were measured and evaluated: MRD-1, the vertical distance between upper eyelid margin and corneal light reflex; MRD-2, the distance between lower eyelid margin and corneal light reflex; EBH, the distance between the center of eyebrow and the corneal light reflex; and OSA, the area surrounded by the upper and lower margins of the eyelid which was manually traced, and the area was automatically calculated by the software (Fig. 2). If the upper eyelid covered the corneal light reflex, the putative center of a circle overlapping the corneal limbus was deemed as the corneal light reflex. Then, the MRD-1 was measured and expressed as a negative value. The measurements were made by 2 of the authors (X.Z. and T.G.), and the average was used for statistical analyses.
Fig. 2
Fig. 2
Image Tools
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Statistical Analysis
All data were analyzed by JMP, version 9.1 (Japan). Data are expressed as the means ± SD. The significance of the difference in the sex distribution in group 1 and group 2 was analyzed by Tukey’s test. For all other parameters, significance of the differences between the preoperative and postoperative values for the 2 groups was determined by Student’s t tests. A P <0.05 was taken to be statistically significant.
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RESULTS

Outcome of Levator Aponeurosis Advancement Surgery
Both groups had 30 subjects (60 eyes), and the sex distribution between the 2 groups was not significantly different (P = 0.732, Tukey’s test). The patients in group 1 with involutional ptosis were significantly older than the patients in group 2 (P < 0.0001, Student’s ttest). None of the patients had any complications during and after the surgery. The average operating time was 51.5 ± 13.8 minutes for group 1 and 48.2 ± 10.6 minutes for group 2 (P = 0.376, Student’s t test). The time of suture removal was also not significantly different between the 2 groups (P = 0.884, Student’s t test). There was no difference of sex in all the parameters (MRD, OSA, and EBH) analyzed for each group. A reoperation was not needed for all subjects during the observation period. Photographs of representative cases are shown inFigure 3.
Fig. 3
Fig. 3
Image Tools
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Changes in Eyelid Features and Eyebrow Position
Before the surgery, MRD-1 was −0.56 ± 1.82 mm in group 1, which was significantly smaller than 0.64 ± 1.71 mm in group 2 (P = 0.016, Student’s t test). After surgery, MRD-1 was 3.14 ± 0.67 mm in group 1 and 3.66 ± 0.54 mm in group 2. Both values were significantly larger than the preoperative values (both P < 0.001, paired t tests). There was no significant difference in MRD-1 between the 2 groups after surgery (P = 0.742, Student’s t tests).
MRD-2 was 4.48 ± 1.26 mm in group 1 and 4.36 ± 0.75 mm in group 2 before surgery, and it was 4.15 ± 0.68 mm in group 1 and 4.68 ± 0.67 mm in group 2 after the surgery. The difference in MRD-2 between the 2 groups before surgery was not significant (P = 0.692, Student’s ttest); however, MRD-2 was significantly larger in group 2 than group 1 after the surgery (P = 0.008, Student’s t test). In addition, MRD-2 after the surgery in group 2 was significantly larger than that before surgery (P = 0.026, paired t test).
The OSA was 58.26 ± 19.04 mm2 for group 1 and 63.71 ± 17.25 mm2for group 2. The OSA increased to 100.17 ± 20.63 mm2 in group 1 and 103.15 ± 19.69 mm2 in group 2 after the surgery. The increase in the OSA was statistically significant for both groups (both P < 0.001, paired t test), and the differences between the 2 groups before and after the surgery were not significant.
The EBH was 30.16 ± 8.25 mm for group 1 and 22.09 ± 3.88 mm for group 2 before the surgery. The EBH was 25.71 ± 7.33 mm in group 1 and 19.64 ± 3.82 mm in group 2 after the surgery. The EBH was significantly larger in group 1 than in group 2 before and after surgery (all P < 0.001, Student’s t test). Both groups had a significant decrease in the EBH after the surgery (all P <0.001, paired t test). Also, the decrease of the EBH was significantly greater in group 1 than in group 2 (P = 0.007, Student’s t test).
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Correlation of EBH and MRD-1 Corrected
To eliminate the effect of the difference in the corrected volume between the 2 groups, we also evaluated the ratio of the EBH to the MRD-1 (EBH/MRD-1) of both groups. The EBH/MRD-1 was 1.17 ± 1.09 for group 1 and 1.12 ± 0.84 for group 2. The difference between the 2 groups was not significant (P = 0.863, Student’s t test).
The correlation between the MRD-1 corrected and EBH change was analyzed in all subjects. The EBH change was significantly and positively correlated with the MRD-1 corrected (P = 0.0003; r = 0.4528, Spearman correlation coefficient; Fig. 4). The correlation between the EBH change and MRD-1 corrected volume is
Fig. 4
Fig. 4
Image Tools
Equation (Uncited)
Equation (Uncited)
Image Tools
where R = MRD-1 corrected.
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DISCUSSION

Blepharoptosis not only reduces the extent of the superior visual field but can impair reading and other close-work activities.1112 Also, the asymmetry and aging appearance can compromise the quality of vision and quality of life of the patients. The advancement of levator aponeurosis is an effective surgical approach to restore the levator palpebral function and rejuvenate the facial appearance.1–4
Our results showed that computerized image analyses can be used to determine the outcome of ptosis surgery quantitatively. The analysis is simple and precise, and images of the 2 eyes can be analyzed in less than 5 minutes. The interobserver correlation coefficient of the parameters measured varies between 0.91 and 0.95 (data not shown).
Another advantage of using the ImageJ software to analyze the image is that the digital photographs and data can be permanently stored in a computer and recalled when consulting with a patient on the outcome of the surgery, and for following the postoperative course of recovery or planning a repeated surgery.
The involutional ptosis (group 1) had a significantly lower MRD-1 than the contact lens wear–induced ptosis (group 2) preoperatively. This may be because the eyelids of patients with involutional ptosis were more sagged; hence, they required a larger resection of the eyelid skin. As a result, the position of the eyebrow, the EBH, decreased more in group 1 than in group 2. This change is reasonable because the decrease in the upper eyelid volume can reduce the need of the frontalis muscle contraction leading to a lowering of the eyebrow.
The changes in the lower eyelid height (MRD-2) were significantly different between the 2 groups. Group 1 had a slight and not significant decrease in the MRD-2, whereas in group 2 this parameter was significantly increased after surgery. Coupled with the MRD-1 alterations, the OSAs between the 2 groups were not significantly different before and after surgery.
One possible mechanism for the difference in the MRD-2 changes is that there is a reduction in the neural stimulation to the orbicularis oculi caused by the ptosis repair. Another reason for this phenomenon is aging, which causes an attenuation, dehiscence, or looseness of the lower eyelid retractors.1314 The lower eyelid may be elevated slightly in older patients (decreased MRD-2), whereas the younger patients had the effect of lower eyelid traction (increased MRD-2) after the surgery.
In contrast, Matsuo et al15 reported that there is an additional contraction of the inferior rectus muscle in eyes with blepharoptosis which pulls the inferior suspensory ligament of Lockwood and the capsulopalpebral fascia downward. This contraction retracts the lower eyelid resulting in inferior scleral show, which is a sign of a disinsertion of the levator aponeurosis from the tarsus.15
Although our findings of the decrease of MRD-2 in group 1 were consistent with the findings of Matsuo et al,15 the MRD-2 in the group 2 was significantly increased. This discrepancy may be due to the differences in the age, etiology of the cause, and the methodology of the measurements. The age difference may account for different responses of orbicularis oculi muscle and/or lower eyelid retractors after surgery. One of the etiological factors in contact lens ptosis has been reported to be due to the Müller’s muscle fibrosis.16 We evaluated the MRD with an imaging analysis software, whereas Matsuo et al15 measured the area enclosed by the lower eyelid margin and medial and lateral canthi.
There are some limitations in this study. Our measurements using the corneal light reflex could be influenced by a slight rotation of the eye. However, all photographs were taken under the same conditions, and the image analyses were conducted in the same manner for both groups preoperatively and postoperatively. Under these conditions, the differences found must be valid. Changes of the lower eyelid could be slight and variable according to the evaluation method applied; future studies using more accurate and objective techniques are needed. Furthermore, difference may also exist in other types of blepharoptosis and it is known that there is a considerable anatomical difference in the eyelid and surrounding tissue of Orientals and Westerners.17 This also warrants future studies on patients of different origin to determine the intrinsic changes of the eyelid features.
In conclusion, our results showed that digital image analysis is feasible and useful in quantifying the changes of the eyelid and eyebrow after ptosis surgery. The external eyelid muscles, including the orbicularis oculi muscle and lower eyelid retractor, may respond differently after surgery for blepharoptosis of different etiology.
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ACKNOWLEDGMENTS

The authors thank Dr. Tomoyuki Kamao (Ehime University School of Medicine) and Dr. Eri Ishikawa (Ehime Prefecture Hospital) for their invaluable advice on this work.
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PATIENT CONSENT

Patients provided written consent for the use of their images.
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REFERENCES

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Copyright © 2016 The Authors. Published by Wolters Kluwer Health, Inc. on behalf of the American Society of Plastic Surgeons. All rights reserved.


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2. Jastreboff PJ, Jastreboff MM. Tinnitus Retraining Therapy (TRT) as a method for treatment of tinnitus and hyperacusis patients. J Am Acad Audiol. 2000 Mar;11(3):162-77. [Abstract]

3. Marcondes RA, Sanchez TG, Kii MA, Langguth et al. Repetitive transcranial magnetic stimulation improve tinnitus in normal hearing patients: a double-blind controlled, clinical and neuroimaging outcome study. Eur J Neurol. 2009. [Epub ahead of print] ) [Abstract]

4. Cannon SC Pathomechanisms in channelopathies of skeletal muscle and brain. Annu Rev Neurosci. 2006;29:387-415. [Abstract]

5. Davies E, Knox E, Donaldson I. The usefulness of nimodipine, an L-calcium channel antagonist, in the treatment of tinnitus. Br J Audiol. 1994;28:125-129. [Abstract]

6. Baguley DM, Jones S, Wilkins I, Axon PR, Moffat DA. The inhibitory effect of intravenous lidocaine infusion on tinnitus after translabyrinthine removal of vestibular schwannoma: a double-blind, placebo-controlled, crossover study. Otol Neurotol. 2005;26:169-176. [Abstract]

Eggermont JJ. Cortical tonotopic map reorganization and its implications for treatment of tinnitus. Acta Otolaryngol Suppl. 2006;9-12. [Abstract]

Hoke ES, Muhlnickel W, Ross B, Hoke M. Tinnitus and event-related activity of the auditory cortex. Audiol Neurootol. 1998;3:300-331. [Abstract]

Mirz F, Pedersen B, Ishizu K et al. Positron emission tomography of cortical centers of tinnitus. Hear Res. 1999;134:133-144. [Abstract]

Muhlnickel W, Elbert T, Taub E, Flor H. Reorganization of auditory cortex in tinnitus. Proc Natl Acad Sci U S A. 1998;95:10340-10343. [Abstract]

Norena AJ, Eggermont JJ. Enriched acoustic environment after noise trauma abolishes neural signs of tinnitus. Neuroreport. 2006;17:559-563. [Abstract]

Schlee W, Hartmann T, Langguth B, Weisz N. Abnormal resting-state cortical coupling in chronic tinnitus. BMC Neurosci. 2009;10:11. [Full text]

Schlee W, Mueller N, Hartmann T, Keil J, Lorenz I, Weisz N. Mapping cortical hubs in tinnitus. BMC Biol. 2009;7:80. [Full text]

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HIPPOCRATE'S OATH

"I swear by Apollo, the healer, Asclepius, Hygieia, and Panacea, and I take to witness all the gods, all the goddesses, to keep according to my ability and my judgment, the following Oath and agreement:

To consider dear to me, as my parents, him who taught me this art; to live in common with him and, if necessary, to share my goods with him; To look upon his children as my own brothers, to teach them this art.

I will prescribe regimens for the good of my patients according to my ability and my judgment and never do harm to anyone.

I will not give a lethal drug to anyone if I am asked, nor will I advise such a plan; and similarly I will not give a woman a pessaryto cause an abortion.

But I will preserve the purity of my life and my arts.

I will not cut for stone, even for patients in whom the disease is manifest; I will leave this operation to be performed by practitioners, specialists in this art.

In every house where I come I will enter only for the good of my patients, keeping myself far from all intentional ill-doing and all seduction and especially from the pleasures of love with women or with men, be they free or slaves.

All that may come to my knowledge in the exercise of my profession or in daily commerce with men, which ought not to be spread abroad, I will keep secret and will never reveal.

If I keep this oath faithfully, may I enjoy my life and practice my art, respected by all men and in all times; but if I swerve from it or violate it, may the reverse be my lot."

MAIMONIDE'S PRAYER

"Almighty God, Thou has created the human body with infinite wisdom. Ten thousand times ten thousand organs hast Thou combined in it that act unceasingly and harmoniously to preserve the whole in all its beauty the body which is the envelope of the immortal soul. They are ever acting in perfect order, agreement and accord. Yet, when the frailty of matter or the unbridling of passions deranges this order or interrupts this accord, then forces clash and the body crumbles into the primal dust from which it came. Thou sendest to man diseases as beneficent messengers to foretell approaching danger and to urge him to avert it.

"Thou has blest Thine earth, Thy rivers and Thy mountains with healing substances; they enable Thy creatures to alleviate their sufferings and to heal their illnesses. Thou hast endowed man with the wisdom to relieve the suffering of his brother, to recognize his disorders, to extract the healing substances, to discover their powers and to prepare and to apply them to suit every ill. In Thine Eternal Providence Thou hast chosen me to watch over the life and health of Thy creatures. I am now about to apply myself to the duties of my profession. Support me, Almighty God, in these great labors that they may benefit mankind, for without Thy help not even the least thing will succeed.

"Inspire me with love for my art and for Thy creatures. Do not allow thirst for profit, ambition for renown and admiration, to interfere with my profession, for these are the enemies of truth and of love for mankind and they can lead astray in the great task of attending to the welfare of Thy creatures. Preserve the strength of my body and of my soul that they ever be ready to cheerfully help and support rich and poor, good and bad, enemy as well as friend. In the sufferer let me see only the human being. Illumine my mind that it recognize what presents itself and that it may comprehend what is absent or hidden. Let it not fail to see what is visible, but do not permit it to arrogate to itself the power to see what cannot be seen, for delicate and indefinite are the bounds of the great art of caring for the lives and health of Thy creatures. Let me never be absent- minded. May no strange thoughts divert my attention at the bedside of the sick, or disturb my mind in its silent labors, for great and sacred are the thoughtful deliberations required to preserve the lives and health of Thy creatures.

"Grant that my patients have confidence in me and my art and follow my directions and my counsel. Remove from their midst all charlatans and the whole host of officious relatives and know-all nurses, cruel people who arrogantly frustrate the wisest purposes of our art and often lead Thy creatures to their death.

"Should those who are wiser than I wish to improve and instruct me, let my soul gratefully follow their guidance; for vast is the extent of our art. Should conceited fools, however, censure me, then let love for my profession steel me against them, so that I remain steadfast without regard for age, for reputation, or for honor, because surrender would bring to Thy creatures sickness and death.

"Imbue my soul with gentleness and calmness when older colleagues, proud of their age, wish to displace me or to scorn me or disdainfully to teach me. May even this be of advantage to me, for they know many things of which I am ignorant, but let not their arrogance give me pain. For they are old and old age is not master of the passions. I also hope to attain old age upon this earth, before Thee, Almighty God!

"Let me be contented in everything except in the great science of my profession. Never allow the thought to arise in me that I have attained to sufficient knowledge, but vouchsafe to me the strength, the leisure and the ambition ever to extend my knowledge. For art is great, but the mind of man is ever expanding.

"Almighty God! Thou hast chosen me in Thy mercy to watch over the life and death of Thy creatures. I now apply myself to my profession. Support me in this great task so that it may benefit mankind, for without Thy help not even the least thing will succeed."

Information for Health Professionals

Information for Patients

Modern challenged parts of the oath:

  1. To teach medicine to the sons of my teacher. In the past, medical schools gave preferential consideration to the children of physicians.
  2. To practice and prescribe to the best of my ability for the good of my patients, and to try to avoid harming them. This beneficial intention is the purpose of the physician. However, this item is still invoked in the modern discussions of euthanasia.
  3. I will not give a lethal drug to anyone if I am asked, nor will I advise such a plan. Physician organizations in most countries have strongly denounced physician participation in legal executions. However, in a small number of cases, most notably the U.S. states of Oregon,[10] Washington,[11]Montana,[12] and in the Kingdom of the Netherlands,[13] a doctor can prescribe euthanasia with the patient's consent.
  4. Similarly, I will not give a woman a pessary to cause an abortion. Since the legalization of abortion in many countries, the inclusion of the anti-abortion sentence of the Hippocratic oath has been a source of contention.
  5. To avoid violating the morals of my community. Many licensing agencies will revoke a physician's license for offending the morals of the community ("moral turpitude").
  6. I will not cut for stone, even for patients in whom the disease is manifest; I will leave this operation to be performed by practitioners, specialists in this art. The "stones" referred to are kidney stones or bladder stones, removal of which was judged too menial for physicians, and therefore was left for barbers (the forerunners of modern surgeons). Surgery was not recognized as a specialty at that time. This sentence is now interpreted as acknowledging that it is impossible for any single physician to maintain expertise in all areas. It also highlights the different historical origins of the surgeon and the physician.
  7. To keep the good of the patient as the highest priority. There may be other conflicting 'good purposes,' such as community welfare, conserving economic resources, supporting the criminal justice system, or simply making money for the physician or his employer that provide recurring challenges to physicians
http://www.worldallergy.org/educational_programs/world_allergy_forum/barcelona2008/rabe/

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