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The prescriber need not be a physician discount 80mg geodon fast delivery, but must be licensed and authorized to prescribe by the state effective 40 mg geodon. Acamprosate Alcohol Delayed-release tablet: Not Provided by prescription best 80 mg geodon; use 333mg Scheduled acamprosate is used in the disorder under the maintenance of alcohol Controlled abstinence. The prescriber need Substances not be a physician, but must Act be licensed and authorized to prescribe by the state. Disulfram Alcohol Tablet: Not When taken in combination with use 250mg, 500mg Scheduled alcohol, disulfram causes severe disorder under the physical reactions, including Controlled nausea, fushing, and heart Substances palpitations. The knowledge that Act such a reaction is likely if alcohol is consumed acts as a deterrent to drinking. For these reasons, only appropriately trained health care professionals should decide whether medication is needed as part of treatment, how the medication is provided in the context of other clinical services, and under what conditions the medication should be withdrawn or terminated. Prescribed in this fashion, medications for substance use disorders are in some ways like insulin for patients with diabetes. Insulin reduces symptoms by normalizing glucose metabolism, but it is part of a broader disease control strategy that also employs diet change, education on healthy living, and self-monitoring. A chemical substance that use of methadone as an effective treatment for opioid use binds to and activates certain receptors disorder. Long-term methadone maintenance treatment for opioid use disorders has been shown to be more effective than short-term withdrawal management,132 and it has demonstrated improved outcomes for individuals (including pregnant women and their infants) with opioid use disorders. Under regulations dating back to the early 1970s, the federal government created special methadone programs for adults with opioid use disorders. Originally referred to as “methadone treatment programs,” these treatment facilities were created to provide special management of the medical and legal issues associated with the use of this potent, long-acting opioid. Many people, including some policymakers, authorities in the criminal justice Drug diversion. A medical and legal system, and treatment providers, have viewed maintenance concept involving the transfer of any treatments as “substituting one substance for another”85 and legally prescribed controlled substance from the person for whom it was have adhered instead to an abstinence-only philosophy that prescribed to another person for any avoids the use of medications, especially those that activate illicit use. Moreover, withholding medications greatly increases the risk of relapse to illicit opioid use and overdose death. For individuals who are already on a stable low to moderate dose of buprenorphine, the implant delivers a constant low dose of buprenorphine for 6 months. Buprenorphine is associated with improved outcomes compared to placebo for individuals (including pregnant women and their infants) with opioid use disorders,140 and it is effective in reducing illegal opioid use. As a result, there is an upper limit to how much euphoria, pain relief, or respiratory depression buprenorphine can produce. However, if the combined medication is injected, the naloxone component can precipitate an opioid withdrawal syndrome, and in this way serves as a deterrent to misuse by injection. When they frst receive their waiver, physicians can provide buprenorphine treatment for only up to 30 individuals. Although approximately 435,000 primary care physicians practice medicine in the United States,148 only slightly more than 30,000 have a buprenorphine waiver,149 and only about half of those are actually treating opioid use disorders. Naltrexone is an opioid antagonist that binds to opioid receptors and blocks their activation; it produces no opioid-like effects and is not abusable. It prevents other opioids from binding to opioid receptors so that they have little to no effect. It also interrupts the effects of any opioids in a person’s system, precipitating an opioid withdrawal syndrome in opioid-dependent patients, so it can be administered only after a complete detoxifcation from opioids. Naltrexone may be appropriate for people who have been successfully treated with buprenorphine or methadone who wish to discontinue use but still be protected from relapse; people who prefer not to take an opioid agonist; people who have completed detoxifcations and/or rehabilitation or are being released from incarceration and expect to return to an environment where drugs may be used and wish to avoid relapse; and adolescents or young adults with opioid dependence. Oral naltrexone can be effective for those individuals who are highly motivated and/or supported with observed daily dosing. Extended-release injectable naltrexone, which is administered on a monthly basis, addresses the poor compliance associated with oral naltrexone since it provides extended protection from relapse and reduces cravings for 30 days. Prescribing health care professionals should be familiar with these side effects and take them into consideration before prescribing. Thus, once disulfram is taken by mouth, any alcohol consumed results in rapid buildup of acetaldehyde and a negative reaction or sickness results. The intensity of this reaction is dependent on the dose of disulfram and the amount of alcohol consumed. Disulfram is most effective when its use is supervised or observed, which has been found to increase compliance. Thus, an individual who wants to reduce, but not stop, drinking is not a candidate for disulfram. Because it blocks some opioid receptors, naltrexone counteracts some of the pleasurable aspects of drinking. Many studies have examined the effectiveness of naltrexone in treating alcohol use disorders. Adherence to taking the medication increases under conditions where it is administered and observed by a trusted family member or when the extended-release injectable, which requires only a single monthly injection, is used. These therapies also teach and motivate patients in how to change their behaviors as a way to control their substance use disorders. Despite this, many counselors and therapists working in substance use disorder treatment programs have not been trained to provide evidence-based behavioral therapies, and general group counseling remains the major form of behavioral intervention available in most treatment programs. These therapies have been studied extensively, have a well-supported evidence base indicating their effectiveness, and have been broadly applied across many types of substance use disorders and across ages, sexes, and racial and ethnic groups. Individual counseling is delivered in structured sessions to help patients reduce substance use and improve function by developing effective coping strategies and life skills. Most studies support the use of individual counseling as an effective intervention for individuals with substance use disorders. These sessions typically explore the positive and negative consequences of substance use, and they use self-monitoring as a mechanism to recognize cravings and other situations that may lead the individual to relapse. Contingency management, which involves giving tangible rewards to individuals to support positive behavior change,85 has been found to be effective in treating substance use disorders. A group providing generic group counseling, not only because it is an individual mutual support and fellowship for therapy, but also because it involves a systematic set of people recovering from addictive 85 behaviors. All three treatments reduced the quantity and frequency of alcohol use immediately after treatment. Studies of various family therapies have demonstrated positive fndings for both adults and adolescents.

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List the possible medical risks that may occur with any surgical geodon 40mg on line, medical or diagnostic procedure order geodon 40mg without a prescription, including the potential for infection 20 mg geodon with mastercard, blood clots, hemorrhage, allergic reactions and death. List the possible medical risks that may occur with a surgical abortion, including hemorrhage, uterine perforation, sterility, injury to the bowel or bladder, a possible hysterectomy as a result of a complication or injury during the procedure and failure to remove all products of conception that may result in an additional procedure. List the possible medical risks that may occur with a medication abortion, including hemorrhage, infection, failure to remove all products of conception that may result in an additional procedure, sterility and the possible continuation of the pregnancy. The information may be given to or withheld from the spouse, parent, or guardian without the consent and over the express objection of the minor. This section shall not apply to custodial property given or held under the terms of the “Colorado Uniform Transfers to Minors Act”, article 50 of title 11, C. Such consent shall not be subject to disaffirmance because of minority, and, when such consent is given, said minor shall have the same rights, powers, and obligations as if he or she had obtained majority. Consent to organ or tissue donation may be revoked pursuant to section 12-34-106, C. The consent of a minor parent shall not be subject to disaffirmance because of minority, and, when such consent is given, said minor parent has the same rights, powers, and obligations as if he or she were of legal age. Equally important is the duty of those performing such service or providing such materials to exercise due care under the attending circumstances to the end that those receiving health care will benefit and adverse results therefrom will be minimized by the use of available and proven scientific safeguards. The imposition of legal liability without fault upon the persons and organizations engaged in such scientific procedures may inhibit the exercise of sound medical judgment and restrict the availability of important scientific knowledge, skills, and materials. It is, therefore, the public policy of this state to promote the health and welfare of the people by emphasizing the importance of exercising due care, and by limiting the legal liability arising out of such scientific procedures to instances of negligence or willful misconduct. No physician, surgeon, hospital, blood bank, tissue bank, or other person or entity who donates, obtains, prepares, transplants, injects, transfuses, or otherwise transfers, or who assists or participates in donating, obtaining, preparing, transplanting, injecting, transfusing, or transferring any tissue, organ, blood, or 32 component thereof from one or more human beings, living or dead, to another living human being for the purpose of therapy or transplantation needed by him for his health or welfare shall be liable for any damages of any kind or description directly or indirectly caused by or resulting from any such activity; except that each such person or entity remains liable for his or its own negligence or willful misconduct. The consent of the parent, parents, or legal guardian of such a minor shall not be necessary in order to authorize such donation of blood, organs, or tissue and penetration of tissue. Medical treatment also means the examination and treatment of any laceration, fracture or other traumatic injury, or any symptom, disease or pathology which may, in the judgment of the treating health care professional, if left untreated, reasonably be expected to threaten health or life. A minor giving such consent shall be deemed to have the same legal capacity to act and the same legal obligations with regard to giving such consent as if such minor were 18 years of age or over. Consent so given shall not be subject to later disaffirmance by reason of such minority and the consent of no other person or court shall be necessary for performance of the lawful procedures required to be performed in order to receive such donation. A minor giving the consent shall be deemed to have the same legal capacity to act and the same legal obligations with regard to giving consent as if the minor were of full legal age. Consent so given shall not be subject to later disaffirmance by reason of such minority; and the consent of no other person or court shall be necessary for the performance of the diagnostic and lawful therapeutic procedures, medical or surgical care and treatment rendered such minor. Constructive service of process may be used, provided the petitioning parent makes an actual, diligent search to discover the location of, and provide notice to, the nonpetitioning parent. An order removing the disabilities of nonage shall have the effect of giving the minor the status of an adult for purposes of all criminal and civil laws of the state, and shall authorize the minor thereafter to exercise all of the rights and responsibilities of persons who are 18 years of age or older. Such consent shall not be subject to disaffirmance because of minority, unless the parent or parents of such minor specifically object, in writing, to the donation or penetration of the skin. Each hospital or other health care facility, health care provider, and any other person or entity who acts in good faith reliance on any such direction or decision shall be protected and released to the same extent as though such person had interacted directly with the patient as a fully competent person. The consent of no other person or persons, including but not limited to a spouse, parent, custodian, or guardian, shall be necessary in order to authorize the provision to such minor of such medical or surgical care or services as are described in this subsection. Such information may be given to or withheld from the spouse, parent, custodian, or guardian without the consent of the minor patient and even over the express refusal of the minor patient to the providing of such information. If the minor patient is not diagnosed as being pregnant or afflicted with venereal disease, such information as well as the application for diagnosis may be disclosed, at the discretion of the treating physician after consulting with the minor patient. A minor who consents to the provision of medical care and services under this section shall assume financial responsibility for the costs of such medical care and services. As used in this chapter, “primary medical care and services” does not include invasive care, such as surgery, that goes beyond standard injections, laceration care, or treatment of simple abscesses. A minor without support who consents to the provision of primary medical care and services under this chapter shall assume financial responsibility for the costs of the primary medical care and services. The plan may require that the request for confidential communication be made in writing and that it contain a statement that disclosure of all or part of the information to which the request pertains could endanger 45 the minor. The plan shall have fourteen days to make any changes necessary to comply with the request for confidentiality. The plan may accommodate requests by the minor or the licensed health care practitioner to receive communications related to the primary medical care and services by alternative means or at alternative locations. The court shall provide her with counsel unless she appears through private counsel. All records contained in court files of judicial proceedings arising under the provisions of this section shall be confidential and exempt from disclosure pursuant to section 9-340G, Idaho Code. Dockets and other court records shall be maintained and court proceedings undertaken so that the names and identities of the parties to actions brought pursuant to this section will not be disclosed to the public. If the court fails to issue its ruling at the conclusion of the hearing, the petition is deemed to have been granted and the consent requirement is waived. A minor shall file her notice of appeal within five (5) days, excluding weekends and holidays, after her petition was denied by the district court. The appellate court shall hold the hearing within forty- eight (48) hours, excluding weekends and holidays, after the notice of appeal is filed and shall issue its ruling at the conclusion of the hearing. If the appellate court fails to issue its ruling at the conclusion of the hearing, the petition is deemed to have been granted and the consent requirement is waived. Filing fees are not required of the pregnant minor at either the district court or the appellate level. The consent of the parent, parents, or legal guardian of such minor shall not be necessary to authorize hospital, medical and surgical care related to such disease and such parent, parents, or legal guardian shall not be liable for payment for any care rendered pursuant to this section. The consent to the performance of a medical or surgical procedure by a physician licensed to practice medicine and surgery executed by a married 47 person who is a minor, by a parent who is a minor, by a pregnant woman who is a minor, or by any person 18 years of age or older, is not voidable because of such minority, and, for such purpose, a married person who is a minor, a parent who is a minor, a pregnant woman who is a minor, or any person 18 years of age or older, is deemed to have the same legal capacity to act and has the same powers and obligations as has a person of legal age. Any parent, including a parent who is a minor, may consent to the performance upon his or her child of a medical or surgical procedure by a physician licensed to practice medicine and surgery or a dental procedure by a licensed dentist. The consent of a parent who is a minor shall not be voidable because of such minority, but, for such purpose, a parent who is a minor shall be deemed to have the same legal capacity to act and shall have the same powers and obligations as has a person of legal age.

When this has all been done safe 80mg geodon, you have to write out all the answers and add them together: 2 3 3 4 4 + –––––––––––––––––– 3 –––––––––––––––––– 1 As before discount geodon 20 mg on-line, carry over numbers (if necessary) when adding together order geodon 80 mg otc. These are: dividend = quotient (answer) divisor or quotient (answer) divisor ) dividend The process is as follows. If you are having trouble, a quicker method would be to write down the 14 times table before starting the division. Repeat the process until there is no remainder or enough decimal places have been reached: 18 Basics 17×1=17 1. Mathematical tricks and tips An in-depth study of mathematics would reveal that certain patterns occur which can be used to our advantage to make calculations a lot easier. Multiplication tips Multiplying by 5 • Multiplying an even number by 5: • Halve the number you are multiplying and add a zero to give the answer. For example: 5×7 Subtract 1 from the 7 (7 – 1) to get 6; halve the 6 to get 3, then place 5 after the number for an answer of 35. Multiplying by 9 • Take the number you are multiplying and multiply by 10; then subtract the original number. For example: 9 × 6 Multiply 6 by ten (6 × 10) which gives 60; subtract 6 from 60 (60 – 6) for an answer of 54. Basic maths 19 9 × 1,234 Multiply 1,234 by ten (1,234 × 10) which gives 12,340; subtract 1,234 from 12,340 (12,340 – 1,234) for an answer of 11,106. Note: adding up the digits of your answer together will equal 9 (not 11 × 9 = 99, but 9 + 9 = 18; 1 + 8 = 9) e. For example: 5 × 11 repeat the 5 for an answer of 55 7 × 11 repeat the 7 for an answer of 77 • Multiplying a 2-digit number by 11: simply add the first and second digits and place the result between them. For example: 36 × 11 3 + 6 = 9; place the 9 between the two digits (3 and 6) for an answer of 396. The answer is less than ten, so there is no number to carry over; write it down next to the 4, i. The answer is less than ten, so there is no number to carry over; write it down next to the 64, i. Once again, the answer is greater than 9, so carry over 1; write down 2 next to the 27, i. Once again, the answer is greater than 9, so carry over 1; write down 1 next to the 227, i. Then add those two results together with the number itself to get your final answer. Dividing by 3 • Add up the digits: if the sum is divisible by 3, then the original number will be too. For example: 111,111 Addupthedigits:1+1+1+1+1+1=6;6canbedivided by 3, so it follows that 111,111 can too: 111,111 ÷ 3 = 37,037. Dividing by 4 • If the last 2 digits of the number are divisible by 4, then the whole number is divisible by 4. Basic maths 21 For example: 259,812 The last two digits are 12 which is divisible by 4; so 259,812 is divisible by 4 as well. Dividing by 6 • If the number is divisible by 3 and by 2, then it will be divisible by 6 as well. For example: 378 It is an even number so it is divisible by 2; 3 + 7 + 8 = 18, which is divisible by 3; so 378 will be divisible by 6: 378 ÷ 6 = 63. Dividing by 7 • Take the last digit, double it, then subtract the answer from the remaining numbers; if that number is divisible by 7, then the original number is too. Dividing by 9 • If the sum of all the digits is divisible by 9, then the number will be too. For example: 270 Add up the digits: 2 + 7 + 0 = 9; 9 can be divided by 9, so it follows that 270 can too: 270 ÷ 9 = 30. Dividing by 10 • Numbers ending in a 0 are always divisible by 10 (simply remove the zero at the end). Consider the sum: 3 + 4 × 6 • Do we add 3 and 4 together, and then multiply by 6, to give 42? There are two possible answers depending upon how you solve the above sum – which one is right? Rules for the order of operations The processes of adding (+), subtracting (–), multiplying (×) and dividing (/ or ÷) numbers are known as operations. When you have complicated sums to do, you have to follow simple rules known as the order of operations. Initially (a long time ago) people agreed on an order in which mathematical operations should be performed, and this has been universally adopted. E Next, any exponentiation (or powers) must be done – see later for a fuller explanation of exponentiation or powers. It is important to know how to multiply and divide fractions and decimals, as well as to be able to convert from a fraction to a decimal and vice versa. Fractions Before we look at fractions, a few points need to be defined to make explanations easier. Definition of a fraction A fraction is part of a whole number or one number divided by another. Thus in the above example, the whole has been divided into 5 equal parts and you are dealing with 2 parts of the whole. To reduce a fraction, choose any number that divides exactly into the numerator (number on the top) and the denominator (number on the bottom). A fraction is said to have been reduced to its lowest terms when it is no longer possible to divide the numerator and denominator by the same number. This process of converting or reducing fractions to their simplest form is called cancellation. Remember – reducing or simplifying a fraction to its lowest terms does not change the value of the fraction. If you have a calculator, then there is no need to reduce fractions to their lowest terms: the calculator does all the hard work for you! Equivalent fractions Consider the following fractions: 1 3 4 12 2 6 8 24 Each of the above fractions has the same value: they are called equivalent fractions. If you reduce them to their simplest forms, you will notice that each is exactly a half. Now consider the following fractions: 1 1 1 3 4 6 If you want to convert them to equivalent fractions with the same denominator, you have to find a common number that is divisible by all the individual denominators. For each fraction, multiply the numbers above and below the line by the common multiple.

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Remember that wet areas a hospital operating theatre should have a minimum of 20 are easily contaminated with Pseudomonas aeruginosa geodon 20mg on line, an air changes per hour in order to reduce airborne bacterial organism that can lead to devastating endophthalmitis buy geodon 80 mg amex. Research on ultra-clean common cause of endophthalmitis outbreaks were air for hip surgery shows that a fast laminar fow of air in contaminated solutions (37%) and contaminated the operating theatre can remove airborne bacteria within phacoemulsifcation machines (22 buy discount geodon 80 mg online. Gram-negative bacteria outnumbered Gram- Nevertheless, it is unclear whether this degree of ultra positive bacteria as pathogens in these cases of external clean air would be required for phacoemulsifcation surgery contamination sources, with Ps. This microorganisms was identifed in an ultraclean air systems utilizing either horizontal or vertical outbreak in India, found in the phacoemulsifer’s internal laminar fows. Isolated strains were multi-drug postoperative endophthalmitis is not yet established. Ten of the 20 patients involved had enucleation or phthisis of the infected eye [Pinna 2009]. Two recent large series of acute endophthalmitis cases after cataract surgery describe substantially different mean times to presentation - 5 days [Pijl 2010] vs 13 days Table 17. Presenting clinical characteristics of [Lalwani 2008] - with the latter possibly refecting an altered postoperative endophthalmitis mechanism of onset associated with clear cornea surgery. If a patient presents involvement and rule out complications such as retinal with sudden decrease in visual acuity early after cataract detachment, especially in an eye with opaque media. The clinician should proceed immediately to 18 collect an intraocular sample and administer empirical Microbiology, Cultures antibiotic treatment by intraocular injection. Presumed endophthalmitis should be considered a medical Ideally, samples should be plated directly onto culture emergency because bacteria are replicating exponentially media but, if not possible, blood culture bottles (particularly and their toxic by-products, with associated infammation, paediatric ones) offer a useful option [Joondeph 1989, are destroying visual potential. Note perception only, but we also favor this technique for acute that cultures must be retained for at least 15 days to detect cases presenting with better vision as it allows a larger any slow growing microorganisms. In the outpatient clinic, we recommend the availability of a cutting device for the vitreous biopsy because a needle tap is too frequently dry, and sucking material from the vitreous cavity in a severely infamed eye may lead to complications. Gram Stain Stains, Gram for bacteria and others such as calcofuor when fungi or other pathogens are suspected, are useful because they can offer immediate confrmation of the infectious nature of this postoperative infammation. It offers much Institute for Medical Microbiology and Hygiene, University improved pathogen detection, especially in the case of Hospital, 93053 Regensburg, Germany (udo. Clinical applications are currently samples can be deep frozen for identity of the limited but may become more of an option in the future microorganism at a future time (i. It is often • Irritants on instruments that have accumulated due to confused with endophthalmitis because of a similar clinical inadequate instrument cleaning and/or sterilization (eg. However, with technical advances in vitrectomy, activates the cutter until an adequate sample (at least more recent retrospective series have shown better 0. Some clinicians favour performing only a vitreous tap, 5) The syringe now contains 0. It should be aspiration control and a light pipe is inserted through the noted that direct comparisons between such studies cannot pars plana. With this setup in place, only a small amount be made due to differences in study design, inclusion/ of extra time is needed to complete a standard three port exclusion criteria and reported microbial spectrum. Reality is, therefore, a balance of time performing a total vitrectomy with posterior vitreous over completeness. Consider reducing the An antibiotic combination is injected separately intravitreally dose by 50 per cent if a full vitrectomy has been performed. Intravitreal dexamethasone (preservative free) is then antibiotic injection between 36-60 hours). It is mandatory to have available the drugs and recipe for their dilution in both operating and emergency rooms used Intravitreal antibiotic doses must be highly accurate for this purpose (see preparation guide). Since initial therapy in the appropriate dilution for intravitreal injection, is of should cover both Gram-positive and Gram-negative beneft during the normal working day but is rarely available microorganisms, the most common antibiotic combinations after-hours. Despite the synergy between vancomycin and room, in order to avoid delays, an appropriate option is amikacin for Gram-positive microbes, many surgeons are to perform a vitreous biopsy with injection of intravitreal abandoning the use of aminoglycosides for treating Gram- antibiotics without further therapeutic vitrectomy (our “silver negative bacteria because of the risk of retinal toxicity. As simple aspiration with a needle is frequently unsuccessful, it can be performed using a portable vitrector Antibiotics that have been used relatively safely for (eg: the Intrector, commercially available from Insight intravitreal injection are shown in Table 20 opposite. In addition, silicone oil and gas-flled eyes require a transconjunctival small gauge probes, incision frequently substantial dose reduction (1/4-1/10 of the standard dose does not require suture closure. Every cataract surgeon and has been suggested) taking into account the reduced fuid duty resident must have the skills to perform the biopsy and distribution volume that remains in the eye [Hegazy 1999]. The antibiotics for intravitreal injection should be supplied, It is also important, after surgery, to continuously chase the freshly diluted, by the hospital pharmacy department. Following emergency room tap/antibiotics, the patient Due to potential antibiotic physical or chemical should be reviewed clinically after six hours. Patients incompatibility issues, it is important to use separate often get worse before they get better, but always get syringes and needles for each drug to be injected worse before they get worse! Following core or complete (antibiotics and steroid) and not mix the drugs together in vitrectomy, review is at 12 hours. Most incompatibilities are physical in nature - that is, they produce a precipitate (as opposed to Topical antibiotics (fortifed), steroids and mydriatics invisible chemical inactivation or degradation) - and the (atropine) are initiated after the surgery. Dilating the pupil more concentrated the solutions, the more likely they are to at the end of the surgery to avoid permanent synechiae is produce a precipitate when mixed. Once intravitreal antibiotics are administered there is doubt about the role of topical antibiotics, but they may be Always draw up a suffcient volume of drug to fll about half especially useful in cases with surface problems. Then place the needle you will use to inject into the vitreous (30G) onto the syringe. Subconjunctival antibiotics probably don’t give any Take care not to leave any air in the syringe and needle additional beneft and in many cases are withheld. This adjunctive regimen will help maintain meaningful intravitreal levels of the drug In this way, the surgeon will inject only what is in the syringe for a longer period of time by counterbalancing the diffusion and will not need to look continuously at the barrel to of injected drug out of the eye. It vancomycin levels should be monitored if administered produces, accompanied with antimicrobial therapy, a more intravenously. However, negative effect [Shah 2000] to no effect [Das 1999] to a the ocular infammation usually becomes worse before benefcial effect [Gan 2005, Albrecht 2011]. The use of intravitreal dexamethasone may reduce the Consider referral to a vitreoretinal surgeon for an opinion need for systemic (oral) corticosteroids in elderly patients, on a full vitrectomy if response is poor after a partial/mini thereby avoiding the side effects of these systemic agents.

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