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Am Fam Physician. 2000;61(9):2878

Treating Patients with Acute Angle-Closure Glaucoma

(Canada—Canadian Family Physician, February 2000, p. 303.) When the trabecular mesh-work is blocked at the junction of the cornea and iris, the resulting rise in intraocular pressure can reach dangerously high levels and damage the optic nerve. Acute closed-angle glaucoma occurs most frequently in eyes that are structurally predisposed to pupillary blockage. With age, the lens enlarges and the anterior chamber of the eye becomes narrower, setting the stage for blockage of aqueous humor circulation. Acute attacks of glaucoma are usually precipitated by dilation of the pupil by medications or dark environments. Pain is initially restricted to the eye but can become generalized throughout the head. Blurred vision and rainbow lights may result from corneal edema. In severe attacks, patients develop nausea and vomiting. Pilocarpine drops may be used to constrict the pupil and reestablish circulation of aqueous humor. Surgery remains the definitive choice to treat the condition and prevent recurrence.

Treatment of Patients with Nasal Polyps

(Great Britain—The Practitioner, February 2000, p. 84.) At least 1 percent of persons in the population have symptomatic nasal polyps and up to 42 percent may have asymptomatic polyps on careful examination of the middle meatus, middle turbinate and ethmoids. The cause of nasal polyps is unknown, but they may be associated with asthma, cystic fibrosis and aspirin allergy. The most common symptom is nasal obstruction, but rhinorrhea, loss of smell and taste, and respiratory infections are also likely. Polyps are visualized as pale, grapelike structures prolapsing into the nasal cavity from the middle meatus. First-line treatment is usually with topical nasal steroid drops, which should be applied in the “head-down and forward” position. After one month of treatment, or after symptoms have been controlled, intranasal steroid spray is used for maintenance treatment. Systemic steroids are used for polyps that are too large for topical therapy. Surgery is reserved for cases refractory to medical therapy.

Surgical Treatments for Patients with Parkinson's Disease

(Canada—Canadian Family Physician, February 2000, p. 368.) Surgical intervention in persons with Parkinson's disease is usually reserved for patients with severe disability who have ceased to benefit from medical therapy. New techniques and careful patient selection may provide a greater role for surgery. Patients and families may have unrealistic expectations of surgery; therefore, the selection and counseling of surgical patients are essential. Unilateral limb tremor is reported to improve in nearly 90 percent of patients following thalamotomy or thalamic stimulation. Resting and postural tremor may be ablated. Kinetic tremors may not respond as dramatically to surgery. The greatest benefit from pallidotomy is reported to be in patients with bradykinesia. In approximately one third of patients, the benefits are dramatic. The benefits of thalamectomy and pallidotomy appear to last for several years. Even with stereotactic techniques, the risk of serious adverse effects from surgery is about 2 percent. The risks of adverse outcomes are higher with older patients and bilateral procedures. Patients may experience seizures, cognitive dysfunction and neurologic problems following surgery.

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