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Epilepsy Mansour A: Feasibility and effectiveness of treat Behav 2000; 1:100–105 [B] ments for post-stroke depression in elderly in 858 menstruation urinalysis buy discount tamoxifen 20 mg on-line. J Geriatr Psychiatry interictal depression with citalopram in patients Neurol 2001; 14:37–41 [E] with epilepsy menopause knee joint pain tamoxifen 20mg visa. Schmitz B: Antidepressant drugs: indications and itors and increased bleeding risk: are we missing guidelines for use in epilepsy breast cancer blog cheap 20 mg tamoxifen with amex. Neurology 1999; overview of warfarin and its drug and food interac 53:1503–1511 [E] tions menopause neuropathy buy tamoxifen 20mg without prescription. Neurology 1984; 34:1092– A, Pollmacher T: Epidemiology, implications and 1094 [C] mechanisms underlying drug-induced weight gain 850. Rasmussen K, Abrams R: Treatment of Parkinson’s Bolden-Watson C, Donahue R, Metz A: Effect on disease with electroconvulsive therapy. Psychiatr body weight of bupropion sustained-release in pa Clin North Am 1991; 14:925–933 [F] tients with major depression treated for 52 weeks. Psychosomatics eating disorders in bariatric surgery patients: a 2005; 46:250–253 [G] cross-sectional study using structured interview 885. Zimmerman M, Francione-Witt C, Chelminski I, patients: the relationship between mood and glycemic Young D, Boerescu D, Attiullah N, Pohl D, Roye control. Int J laborative care in patients with diabetes and depres Psychiatry Med 2007; 37:69–79 [B] sion. Obes Surg prevention of depression recurrence in diabetes 2008; 18:314–320 [B] mellitus: a randomized, double-blind, placebo 881. Arch Gen Psychiatry 2006; 63:521– Senf W, Hebebrand J: Does obesity surgery im 529 [A] prove psychosocial functioning Practice Guideline for the Treatment of Patients With Major Depressive Disorder, Third Edition 141 itriptyline and paroxetine. 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They often result from inadvertent of operation or in the adjacent segment (due to pregnancy depression order tamoxifen 20 mg on line alteration meningeal tear or inadequate closure during surgery of load distribution) [76] breast cancer kills generic 20 mg tamoxifen overnight delivery. Another condition known as “bat to menstruation during menopause purchase 20mg tamoxifen free shipping try and form the basis for such guidelines to women's health clinic limerick buy generic tamoxifen 20 mg online better tered root syndrome” may cause persistent radicular pain direct when spinal surgery should be undertaken following lumbar spine surgery [94]. Surgery may produce arachnoiditis, months with conservative medical management in 75% of which may result in persistent irritation of the nerve roots patients [100]. For those patients suffering from radicular as the inammation of the arachnoid persists [88]. This pain longer than 3 months, current evidence shows process may produce pain in both the spine and lower surgery for herniated lumbar disc has a high success rate limbs [88]. On the other hand, for nonradicular low back pain with degenerative spine, there is moderate the paraspinal muscles are a potential source of back evidence that spinal fusion is no better than an intensive pain post-lumbar spine surgery. Continuing research will muscular pain probably occur during and after the surgical hopefully identify which cases of degenerative spine procedure [88,95–98]. In cases of spinal stenosis with evidence of insults to the muscles may be compounded by postural degenerative spondylolisthesis, simple laminectomy alone changes in the postoperative period. With lumbar lordosis has provided good to excellent outcomes in 82% of lost due to pedicle screw xation, the paraspinal and patients, with fusion only necessary for 2. Typically, the patient may compensate with hyperexten sion of the thoracolumbar spine, which exacerbates poor While prevention may be partly achieved by determining posture and pain in the long-term period [88]. This myo which surgical procedure is indicated, preoperative iden fascial pain is known as “fusion disease” [88,95–98]. First, failure rates for spinal should be applied for those patients at high risk. The surgery have not changed in the past several decades effects of psychological intervention for those patients at [1,99]. Second, spinal surgery rates have increased in that high risk have not been investigated in high-quality time [11–13]. However, these surgery does not meet the pre-surgical expectations of studies can be difcult to undertake in the practical sense the patient and surgeon” [2], communication and educa and are associated with ethical concerns [104]. Alterna tion of the patient on probable success rate is obviously tively, implementation of patient registries has been pro paramount. Presumably, patients’ expectations are inu posed as a method by which to gain valuable data on enced largely by their discussion with the surgeon about surgical rates and outcomes and consequently identify the planned spinal surgery. Therefore, this discussion which spine surgical operations provide benet and in must be realistic for the patient and the objective and likely which type of patients [25,26]. For the substantial improvement in outcomes post-spine example, if spinal surgery is indicated for preservation of fusion for spondylolisthesis but reduced improvement for limb function, this should be communicated clearly to the patients with degenerative disc and axial back pain [105]. Limitations of registries are the hazards of making nonran domized comparisons and problems with uncontrolled While there is consensus that patients with major motor confounding factors [26]. Furthermore, for validity, the reg decits and major spine trauma require surgery [19], the istry must obtain follow-up on every patient which is a criteria for operating in cases of persistent pain are less huge undertaking [26]. The need for guidelines for spinal surgery, in particu lar, fusion surgery, is apparent [21,22,24–26] and in recent In our current state of knowledge, spinal surgery for per years, high-quality reviews and trials have been published sistent pain should only be proposed after a period of 581 Chan and Peng intensive rehabilitation including psychological intervention management and investigations. Patients with psychologi cal and social stressors should receive further psychologi Based on the initial assessment, an individualized interdis cal intervention to complement the proposed surgery. Obviously, if surgery proceeds, meticulous attention to surgical technique is needed to reduce complications. History Patient Evaluation A detailed description of the pain characteristics must be obtained (Figure 1A). While a comprehensive history and examination should be performed, special attention is given to the pain history and how this compares with pre-surgical pain. Red ags should be assessed, and if present, an early surgical opinion should be sought. If there is evidence of a surgical cause of pain that may be reversed, such as a misplaced pedicle screw compressing a nerve root, referral to a spine surgeon would be appropriate. The assessment should also focus on psychological and social factors that may contribute to both pain and impaired function. In patients who have identied yellow ags (signicant psychosocial stressors), more intensive psychological and occupational therapy should be provided. If magnetic resonance imaging is contraindicated, computed tomography myelogram is a suitable alternative. Patients should be managed by an interdisciplinary team with medications, psychological therapy, exercise therapy, interventional procedures, and surgical proce dures playing a role. A suggested guide on interventional procedures and surgical options are provided in Figure 1B. For those patients with predominantly axial pain, diagnostic blockade may be performed to determine if the pain is arising from the zygapophysial joints or the sacroiliac joints. If there is positive response to lumbar medial branch blocks, radiofrequency rhizotomy may then be performed for longer lasting analgesia. For suspected discogenic pain, the clinician may consider lumbar provocation discography. However, the result cannot be interpreted alone and must be interpreted in the context of the interdisciplinary assessment. Furthermore, there is uncertainty regarding the best treatment for discogenic pain. For those patients with severe axial pain not responding to more conservative medical measures, intrathecal drug delivery systems may be considered (refer to text). Revision surgery should only be undertaken if a lesion amenable to surgical intervention is present, and in this case, review by an expert spine surgeon is recommended. For those patients with predominantly radicular pain, epidural injection of steroids under uoroscopic guidance may be achieved via several routes. If there is a positive response, repeated injections may occur with an appropriate time interval. If epidural injection is unsuccessful, percutaneous epidural adhesiolysis may be considered. Percutaneous epidural adhesiolysis is considered before spinal cord stimulation due to the less invasive nature and therefore reduced risks associated with the former. A trial of spinal cord stimulation is to be strongly considered in all patients with radicular pain who have failed the more conservative measures. The demonstrated efcacy for spinal cord stimulation in randomized control trials makes this a better option than an intrathecal drug delivery system or revision surgery. Intrathecal drug delivery system Intrathecal drug delivery revision surgery: recommend system expert spine surgeon opinion Revision surgery: Recommend expert spine surgeon opinion Figure 1 Continued in the lower back (axial) or the leg (radicular) [5,106]. If centralization is brosis, or recurrent disc herniation or residual disk or present, this is suggestive of discogenic pain [107,108]. Leg pain, which is different in character this refers to pain moving centrally toward the lumbar and appears shortly after surgery, is more suggestive of an spine or peripherally from the lumbar spine in response instrumentation issue, such as a pedicle screw compress to repeated lumbar movements [109,110]. It is important to determine if the pain may be of the patient to undress and of any associated pain due to a cause other than spinal pathology. During the examination period, much can be observed including pain behavior and the presence of Red ags should be identied if present (Figure 1A). The interpretation of Waddell’s signs are con patient should be questioned to rule out possible abdomi troversial, but recent research suggested their presence nal or pelvic inammatory disease, infectious of malignant as indicative of psychological distress [114]. The lumbar spine is inspected, and surgical scars and Other red ags, such as bowel and bladder paralysis, alignment of vertebrae are taken note of. If red ags are present early, surgical referral cally increase with hyperextension of the spine and reduce should be sought (Figure 1A). This includes preoperative anatomical distribution is usually viewed as “non-organic” and postoperative investigations and operative reports. The pain treatments Muscle power is assessed by resistance testing of each the patient has tried thus far including pharmacological muscle group with comparison with the corresponding and non-pharmacological should be identied. If a reduction in power is ration of medication efcacy and adverse effects is man detected, the clinician should attempt to determine if datory. An assessment of addiction and drug abuse risk is whether the reduction is global or focal and whether it also recommended [111] considering that opioids. This will assist in reducing sustained release morphine or oxycontin) are commonly the zones of interest, which will be of interest if further prescribed [112]. Similarly, sensation is tested in the lower limbs and an attempt to see whether any posi Comorbid medical history and treatment should be tive or negative phenomena follow a dermatomal or obtained as this may inuence choice of treatments.

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The teaching menopause over the counter cheap 20mg tamoxifen with amex, learning and assessment structures in Irish schools were considered to women's health center medina ny generic tamoxifen 20 mg line be narrow women's health clinic varsity lakes order 20mg tamoxifen with amex, focusing mainly on intelligences in the academic realm (Logical-mathematical and Verbal-Linguistic) menopause 10 years after hysterectomy 20mg tamoxifen fast delivery. These inquiries suggested that teachers are receptive to the theory and that benefits could accrue to both teachers and learners if methodologies were broadened and intelligence-fair instruments were devised in accordance with this. The research proposal emphasised that inquiry would be ongoing throughout the research project. The action plan outlined in the proposal involved “the development, piloting, dissemination and evaluation of methodological and assessment techniques over a three-year period” of which evaluation would be an integral part. The Action Research Phase of the Project was launched in January 1997 at an all-day colloquy. Teachers were asked to plan and teach, assess and evaluate at least three lessons before the next meeting. A strong sense of commitment and enthusiasm could be gleaned from the participating teachers. Among the practical concerns raised were reaction from colleagues, level of classroom noise, time factors (especially for planning) and the fear that some active learning strategies might not be as effective as existing didactic approaches. Teachers in the group were quite experienced, some having recently pursued post-graduate studies, others being active in curriculum development projects in various subjects. Strategies were “used as starting points, very few people took them in raw form without adapting them” (Hanafin 1997b). For some teachers these were new and innovative ways of approaching pedagogy: One teacher commented: “there is an awareness of students’ intelligences/strengths and respect for all intelligences. I use/exploit several intelligences in any class period” (Second-level teacher, Teacher questionnaire). For others, the new element was the naming of the various intelligences: “I have used these approaches in my teaching previously but I didn’t realise they were multiple intelligences approaches. Multiple Intelligences strategies affirmed existing practice and provided a structure and language for teachers to articulate their approaches to pedagogy and make explicit their intuitive theories about the differing strengths of their students. This provided a base from which to move forward, allowing the movement from surface application to more complex interpretation, from tentative initial explorations to deeper and more fundamental questions around the theory of Multiple Intelligences. These approaches provided an accessible, tangible, easily applicable and perhaps necessary form of what is a complex theory. Gardner (1995) agrees with this view: Initially, all applications of a novel education concept will be surface; that is necessary and not in itself bad. However, if applications remain at the superficial level, then educational progress will be limited (1995, p16). Hanafin (1997c) argues that: ‘ it may well be necessary to interpret the theory at a level of ‘new strategies’ or ‘more mental acrobatics’ before or in addition to interpreting the theory at a level which constructs intelligence more equally’ (p6). From an experimental point of view, teaching strategies allowed teachers to confirm intuitive beliefs about students diverse learning profiles and see how diverse intelligence profiles might be activated using these approaches. From a developmental point of view, these strategies provided the initial inroads into the theory and a base from which to explore the theory at a deeper level. The following is a selection of some of the approaches used by teachers in the early stages of the project in an attempt to activate learners’ diverse intelligences. Similarly students were given dates of historical events and asked to arrange them sequentially. Identifying sequences in musical passages: Students were divided into groups and given a set of cards with pictures of animals on them. They listened to a recording of ‘Carnival of the Animals’ and had to sequence the cards in the order in which they ‘heard’ the animals. Designing questionnaires on the value of travelling abroad: using brainstorming to generate questions for the survey, the students then organised the questions into a sequence. The data from the survey was presented using information grids, block graphs, line graphs and pie charts. Use of triangular graphics: to show the social differentiation of different classes during the French Revolution. Using codes to communicate messages: As part of a project on the French Revolution, Fifth students had to design a code to escape from the Bastille. A Sixth class group explained the Braille alphabet and used it to communicate messages. These included a Snakes & Ladders type game for explaining the concept of income and expenditure and an Irish language game with questions and answers on the European union. Other Visual Spatial strategies included: 3D models of the physical features of France: Sixth class students were divided into four groups – rivers, mountains, cities and borders and constructed pulp models of each with labels attached Constructing paper models of various body systems: Groups of First years and Third years cut out, assembled and constructed paper models of the skeletal and breathing systems. Names and functions of each part were then attached Teaching vocabulary using concrete objects: First years learned the names of rooms and items of furniture using a doll’s house Making a short video presentation of project undertaken: A number of groups undertook project work and presented their work to the camera Board games – One teacher used the game of snakes and ladders to explain the concepts of income and expenditure. Another used it in the exploration of the French Revolution Use of graphic organisers to help structure and present essay content – use of terms such as topic, supporting sentence, supporting details. One teacher commented that “initially pupils found it difficult to make such a detailed plan of the essay. Classes were broken into small groups or pairs to work together on the same set of problems or just as a means of sharing information and ideas about a particular topic. Students teaching and examining each other Gardner (1983) defines the Interpersonal intelligence as “the ability to notice and make distinctions among other individuals and, in particular, among their moods, temperaments, motivations and intentions and to be able to act accordingly”. It seems from the lesson data that some of the methods employed by teachers valid ways of activating the Interpersonal intelligence. One teacher commented that one of her “highest achievers or most academic” did not like working with her classmates on projects. In the same class two students who would be considered less able in traditional areas, needing a “push or encouragement”, produced far superior work than the rest. One second-level teacher remarked that some children felt “threatened” in the group situations which might lead to the conclusion that these students preferred the “anonymity” of whole group approaches or a preference to work by themselves. Another teacher was worried about the prospect of developing a selfishness in children who like to work by themselves. These comments highlight the tension for some between the need to respect an individual’s learning style and at the same time activate or develop areas where learners were less comfortable. Bodily-Kinesthetic Pupils physically representing the composition and movement of solids, liquids and gases. Exercise is repeated at different speeds to gauge differences in pulse and heartbeat. Students singing the multiplication tables Using Music to convey mood – one teacher focused specifically in one lesson on the value of music for expressing different moods and emotions. The students picked pieces of music to suit particular poems and discussed the suitability of the piece of music to the poem. Oral and written presentation of material for project work Using texts as sources of information Brainstorming Use of courtroom type procedures to present content Intrapersonal: the main way in which teachers worked on the intrapersonal intelligences was through the completion of reflective templates, logs and journals. Project work proved to be extremely valuable for incorporating most of the intelligence areas. Some teachers expressed concern at “only using a few intelligences” while others were concerned about trying to incorporate them all. While most topics can be approached in a number of ways, every subject does not lend itself to being viewed with equal clarity through th the lens of each of the eight intelligences. One 5 class teacher in the above example commented that “It was difficult to set up logical-mathematical activities that would really integrate. I’m not so sure about dragging in a puzzle or artwork just to have that intelligence included” (ibid. His comments on the use of strategies for the sake of using them echoes Gardner’s (1995) remarks about it being a waste of time and effort to attempt to approach every topic in as many ways as there are intelligences. Therefore trying to drag in an intelligence for the sake of it would inevitably lead to a cosmetic treatment of that intelligence and consequently a reductionist interpretation of the theory. One second-level teacher writes: the students in this particular class spend a lot of time watching T. They also spend a lot of time ‘doodling’ in class, and so, are ready and willing to draw. The teacher describes her 2 year class as mixed-ability, preparing for Junior Certificate and attempting ordinary level paper: “They find the ‘studied’ poetry section very difficult.

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While it may be tempting • the mere fact that a lens is subluxed [updated 2017 Feb 2] womens health 50 years old 20 mg tamoxifen amex. Weill-Marchesani syndrome and secondary sequela may occur years after the initial glaucoma associated with ectopia lentis Clin Exp Optom womens health 8 veggie burgers 20mg tamoxifen fast delivery. Bilateral posterior dislocation of advanced glaucoma and corneal endothelial dysfunction: a case sidered when functional visual acuity the crystalline lens after a head injury sustained during a seizure menstrual blood color order tamoxifen 20mg free shipping. Challenging/Complicated Cataract Surgery reous womens health 6 month subscription purchase tamoxifen 20mg without a prescription, intervention depends upon the sta Case Rep. Surgical manage of crystalline lens dislocation into the anterior chamber in a vic ment of lens subluxation in Marfan syndrome. Intracapsular lens extraction for the treat or if the retina is compromised at any 8. Intraocular ment of pupillary block glaucoma associated with anterior lens subluxation in Marfan syndrome. Management of traumatic crys a rare disease: ectopia lentis and homocystinuria, a Pakistani talline lens subluxation and dislocation. Emergency use of pilo Comparison with the fellow eye in unilat nuclear cataracts. Also in contrast to Clinical Pearls of subluxated lens with capsular tension ring implantation. Evaluation of the ent with significantly reduced vision, yet by a dense, milky nuclear opalescence that modified capsular tension ring in cases of traumatic lens sublux ation. Surgical strategies for the man that is, practitioners will have a clear view disability. Patients typically develop “milky” nuclear • When diagnosing milky nuclear sclerotic cataracts at an earlier age than Pathophysiology opalescence, remember the “M”s: male, other forms of lens opacification. Cataracts are described • Laser interferometry and glare test usually developing during middle age, from generalized nuclear sclerosis, cortical ing may help with diagnosis. Males changes, anterior and posterior subcapsu this type of lens opacity will complain that are often more affected than females, and lar cataracts, and polar cataracts, among visual acuity and nighttime driving are patients are typically moderately to highly others. Prevalence of myopic shifts Patients will often complain of declin as having nuclear opalescence or “milky” among patients seeking cataract surgery. Monocular type of cataract that is not often described cataract types, and cataract grades on vision-specific function diplopia occurs, although most patients in the literature as a distinct clinical entity, ing using Rasch analysis. Lens testing relieves monocular diplopia and ties and behaviors as described above. As the myopia when examining the retina with a biomi incident cataract and cataract surgery: the blue mountains eye study. Cataract: the relation between myopia declines to a point where the patient can A known association exists between and cataract morphology. Comparative evaluation of 1,2 femtosecond laser-assisted cataract surgery and conventional acuity or both. In contrast to generalized cataractogen prior to refractive surgery are likely those 9. Standard phacoemulsifica Signs and Symptoms tion with intraocular lens implantation Phacoanaphylaxis is a term used to describe provides excellent visual rehabilitation. Depending upon the clinical surgery is also a viable option for sur etiology, sequelae and area of impact, gical rehabilitation. As such, these situations require glaucoma, retained lens fragment and lens surgical removal of the fragments. In the majority of and the eye is quiet, there is no emergent cases, the patient has undergone cataract need to proceed to extraction; many cases extraction, often seemingly without com never convert to the inflammatory disease, plications. If There exists no well-explained patho ments from the anterior chamber is best penetrating lens trauma is the inciting physiologic process accounting for the accomplished with surgical irrigation and factor, then the term lens particle glaucoma corneal edema frequently seen. In most cases, the corneal Retained lens fragments may be bio fragment resting against the cornea is edema and inflammation resolve with microscopically visible in the anterior or obvious in some cases. However, in many absence of direct contact with the cornea medications and surgical removal of the cases, the fragment is elusive, and gonios in this area, it is difficult to account for lens fragment. Prolonged duration of lens copy may be necessary to locate the mate the wedge-shape or inferior location of fragments in the setting of an inflamma rial. Some eyes will continue In addition to persistent inflammation, endothelial cells could explain this phe to decompensate even after surgical another hallmark feature is corneal edema. Pathophysiology Often, the inclination in managing per • Gonioscopy should be performed Phacoanaphylaxis is an autoimmune phe sistent postoperative inflammation is to on all eyes with persistent postoperative nomenon in response to release of seques continue or increase steroid usage. While inflammation and corneal edema to look tered antigens consisting of lens nuclear this may be done initially to temporarily for retained lens fragments. The ameliorate the condition, the approach is • Though most cases of phacoanaphy antigens are more likely to induce the rarely effective in providing a cure. Clinically with a non-granulomatous macrophage nuclear fragments, as virtually all of the unsuspected phacoanaphylaxis after extracapsular cataract 14 extraction with intraocular lens implantation. The etiopathology of phacoantigenic uveitis and been found with vascular and perfusion the optic disc is characteristically seen. Retained lens fragments: nucleus fragments are associated with worse prog and hypotension have been implicated riorly and inferiorly on the optic disc; it nosis than cortex or epinucleus fragments. Spontaneous anterior lens cap betes, medication usage and Alzheimer’s rhages) may emanate from the neuroreti sular dehiscence causing lens particle glaucoma. Late-onset lens particle glaucoma patients may complain of poor peripheral widespread diffuse atrophy. In early as a consequence of posterior capsule rupture after pars plana vision and missing things in their visual disease, the neuroretinal rim may appear vitrectomy. Diagnosis of phaco anaphylactic endophthalmitis by fine needle aspiration biopsy. Complications of retained nuclear 11-13 fragments in the anterior chamber after phacoemulsifica level. Therefore, it is better said that show abnormalities in the visual field cor tion with posterior chamber lens implant. Sudden corneal edema due to the pressure value is elevated beyond what may consist of paracentral defects, nasal retained lens nuclear fragment presenting 8. Thus, the tolerability of intra instances, thinning within the macular gauge pars plana vitrectomy for retained lens fragments after cataract surgery. Timing of dislo individuals; it can be quite high in persons 24-2 automated perimetry. Eur J to normal pressure disease with visual eyes may manifest characteristic optic disc Ophthalmol. Any other finding is lamina cribrosa, which serves as organizer million, increasing to 76 million in 2020 defined by the nomenclature as “second of axons of the ganglion cells that form and 111. Mechanical compression of the nerve head occurs early enough to be considered a primary pathogenetic event in glauco matous damage. This scenario leads there will be patients who may not show Apoptosis is triggered by oxidative to an overall stiffening of the inner wall progression for a considerable amount of stress via mitochondrial damage, inflam region modulated by transforming growth time, even without treatment. Stiffening of juxtacanalicular below a level thought to slow progres triggered erroneously by genetically pro trabecular meshwork and Schlemm’s sion and, ultimately, reduce risk of visual grammed messages (genetic mechanism). As thin corneas have sistently falls within a statistically normal it is a direct participant or an epiphenom been shown to be a risk factor for disease range. The frequency of repeat the compensatory drainage through the immunity to stress, excitotoxicity, oxida testing is typically contingent upon disease trabecular meshwork and uveoscleral tive stress, chronic ischemia, structural severity. Unfortunately, there is no way these medications enhance uveoscleral complications. Consideration must be timolol/dorzolamide or timolol/brimo procedures are less invasive than tradi taken for the patient’s health, age and life nidine) offer two agents in one bottle to tional filtering surgery and tube implants, expectancy, adverse effects imparted by ease use and enhance compliance. In rare don’t suffer from blebs, are technically any therapy and risk of visual disability in instances, topical miotics. Laser trabec tine examination identify patients at risk for primary open-angle uloplasty can be used in conjunction with Clinical Pearls glaucoma The role of ocular perfu sion pressure in the course of primary open angle glaucoma in for aqueous to escape the anterior cham evaluation. A randomized trial determines that topical ocular hypotensive medication delays or prevents filtration.


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