Ophthalmology for Primary Care: Do I Really Need to See It? Jennifer R. Olbum, DO

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Ophthalmology for Primary Care Jennifer Olbum, DO CCOM 1988 (Midwestern U.) Medical Retina subspecialist jenolbum@aol.com Daniel J.

com 93 million miles in 8½ minutes If you are reading in sunshine, the photons reaching your retina were born just 8 ½ minutes ago through nuclear

..That [photon] is funneled by the cornea and the lens of the eye...tumbling onto the safety net of the retina. The energy of that impact.

..leads to the firing of a single retinal nerve, and the perception of a single scintilla of light We can taste what s in our mouths, touch what s

1 Ophthalmology for Primary Care Jennifer Olbum, DO CCOM 1988 (Midwestern U.) Medical Retina subspecialist Daniel J. Nadler, MD LLC Beaver, PA Everett & Hurite Ophthalmic Assoc. Belle Vernon, PA McMurray, PA everett hurite.com 93 million miles in 8½ minutes If you are reading in sunshine, the photons reaching your retina were born just 8 ½ minutes ago through nuclear fusion in the core of the sun. 5 minutes ago they were streaking past the orbit of Mercury, 2 ½ minutes ago they outran Venus...That [photon] is funneled by the cornea and the lens of the eye...tumbling onto the safety net of the retina. The energy of that impact...starts a chain reaction, which...leads to the firing of a single retinal nerve, and the perception of a single scintilla of light We can taste what s in our mouths, touch what s within our reach, smell within hundreds of meters and hear within tens of miles. But it s only through our vision that we are in communication with the sun and stars -Dr. Gavin Francis Adventures in Human Being Common ocular conditions you will likely address Special attention to diabetic retinopathy Interesting cases and new horizons January 25 28,

Why is this important? 35 40 million adults >50y/o have some degree of vision loss 5.

Diabetes Glaucoma *NEI AMD = leading cause in USA Cataracts = leading cause worldwide DM = leading cause of new blindness ages 20 74 in USA Leads to: loss of depth perception fall risk mood changes

2 Why is this important? million adults >50y/o have some degree of vision loss 5.5 million will be affected by low vision or legal blindness by 2020* PCPs are critical in helping to identify those at risk 4 major causes of vision loss in adults: Macular degeneration Cataracts Diabetes Glaucoma *NEI AMD = leading cause in USA Cataracts = leading cause worldwide DM = leading cause of new blindness ages in USA Leads to: loss of depth perception fall risk mood changes loss of independence Parameters: Low vision = worse than 20/70 Legal blindness = at best 20/200 or < 20 degree VF Profound vision loss = worse than 20/400 or < 10 degree VF 120 degrees side vision needed for legal driving Visual Fields/Driving Normal VF 160 horizontally 135 vertically Legal Driving 120 combined VF 20/40 night 20/70 daylight Legal blindness VF of 20º or less January 25 28,

Treatable, not curable How would the PCP

No pain Family hx Increased likelihood in

A) Stop smoking No sugar, more green leafy

3 What is this? 30 million worldwide, 10 mill in USA Chromosome 1q32 is the locus 90 % dry Incidence of wet increases to from 10% to 25% in 2 nd eye Leading cause of vision loss >60 y/o (USA) Sudden vision loss Treatable, not curable How would the PCP know? CC: sudden loss of vision (central) No pain Family hx Increased likelihood in smokers > 60 Bilateral but not often symmetrical Age Related Macular Degeneration Treatment AREDS 2 (no vitamin A) Stop smoking No sugar, more green leafy vegetables Anti VEGF therapy Avastin (bevacizumab) Eylea (aflibercept) Cost/FDA approval January 25 28,

to changes in the configuration of lens proteins Leading cause

Diabetic retinopathy and glaucoma combined.

Etoh, obesity, UV, trauma Glaucoma Recognize the risk factors

American Diabetes Age Can be congenital Asymptomatic until late

4 Nobody wants them..everybody gets them CATARACTS Clouding of our natural lens due to changes in the configuration of lens proteins Leading cause of blindness in the world More cases worldwide than AMD, Diabetic retinopathy and glaucoma combined. More than 22 million Americans > 40 y/o Risk factors: age, DM, Etoh, obesity, UV, trauma Glaucoma Recognize the risk factors for referral High myopia (near sighted) Family history African American Diabetes Age Can be congenital Asymptomatic until late stage Peripheral VF loss Diabetic eye disease 30+ million U.S. adults have DM Another 70 million are pre diabetic January 25 28,

Signs/Symptoms of Diabetic Retinopathy How would you, the PCP know?

or bilateral (carotid dx) > 15 20 years of DM New floaters (rarely flashes)

Type 1: 5 yrs after diagnosis Type 2: same time as diagnosis All pregnant

leukocytes in the retinal vasculature This leads to a loss of vascular

cytokines produced by these leukocytes cause inflammation, breakdown of

ischemia (Hypoxic RPE cells then release VEGF) Treatments What I do with

Anti VEGF therapy (reduces macular edema and retinal neovascularization)

5 Signs/Symptoms of Diabetic Retinopathy How would you, the PCP know? None (sometimes) Chronic or sudden, painless, blurred vision in Unilateral or bilateral (carotid dx) > years of DM New floaters (rarely flashes) When to refer? Type 1: 5 yrs after diagnosis Type 2: same time as diagnosis All pregnant diabetics Pathophysiology Chronic hyperglycemia causes an increase in leukocytes in the retinal vasculature This leads to a loss of vascular endothelial cells and pericytes resulting in retinal vascular leakage The cytokines produced by these leukocytes cause inflammation, breakdown of retinal capillaries leading to non perfusion of the retina and retinal ischemia (Hypoxic RPE cells then release VEGF) Treatments What I do with your patients Retinal photocoagulation (laser) reduces vision loss >50% Anti VEGF therapy (reduces macular edema and retinal neovascularization) Can IMPROVE vision Intravitreal corticosteroids (down regulates cytokine expression, inhibits macrophages which release angiogenic growth factors) January 25 28,

Specific complaints in your offices Floaters Red eye HZV (nasolacrimal nerve)

) RED EYE How do you know when it s emergent?

non reactive) Corneal alkali burns (pain, hx) Penetrating injury Treatment:

Conjunctivitis (viral, bacterial, chemical, allergic) Scleritis/episcleritis

6 Specific complaints in your offices Floaters Red eye HZV (nasolacrimal nerve) Eyelid edema (chalazion?, cellulitis?) RED EYE How do you know when it s emergent? True emergencies: Acute angle closure glaucoma (red, painful, mid dilated, non reactive) Corneal alkali burns (pain, hx) Penetrating injury Treatment: refer immediately Pilocarpine gtts (for glaucoma) Irrigation until normal ph (for burns) To ER? Cover and immobilize (open globe) Non Emergent Red Eye Mild or NO pain Conjunctivitis (viral, bacterial, chemical, allergic) Scleritis/episcleritis Subconjunctival hemorrhage Dry eye Most are self limiting Treat: Healthcare prof, school kids, immunocompromised Azosite (Azythromycin), Ilotycin ointment (Erythromycin), Ciloxan (ciprofloxacin) January 25 28,

Non Emergent Red Eye Moderate to severe pain (corneal involvement) REFER

) Iritis (blurred vision, recurrent, photophobia) Trauma (blunt)

foreign body (history) Herpes Zoster Ophthalmicus Reactivation of the

divides: frontal, lacrimal, nasociliary nn Keratitis, uveitis,

Tx: antivirals (acyclovir) Most effective if within first 72 hours Start

Ectropion Blepharitis Chalazion Dacryocysitis Cellulitis Cellulitis:

7 Non Emergent Red Eye Moderate to severe pain (corneal involvement) REFER Vesicular rash (Herpetic keratitis) Corneal ulcer (CLs?, white lesion?) Iritis (blurred vision, recurrent, photophobia) Trauma (blunt) Chemical burn (other than alkali) Thermal burn Corneal abrasions & foreign body (history) Herpes Zoster Ophthalmicus Reactivation of the varicella zoster virus in the trigeminal ganglion Trigeminal nerve (V1) divides: frontal, lacrimal, nasociliary nn Keratitis, uveitis, conjunctivitis. Can become chronic. Tx: antivirals (acyclovir) Most effective if within first 72 hours Start oral antivirals, Refer Lid Edema When to be concerned? Ectropion Blepharitis Chalazion Dacryocysitis Cellulitis Cellulitis: Preseptal Retroseptal (orbital)* *Lift lid. Look for proptosis, chemosis, loss of ocular movement. Usually no loss of vision. +febrile January 25 28,

8 Research what s new? Gene therapy (FDA approve 12/17) *Luxturna Uses a virus to insert a normal copy of the gene into the retina Leber s Stargardt Choroideremia Stem Cell Therapy AMD, Stargardt *first gene therapy approved in the USA that targets a dx caused by a specific gene mutation Retinal Prosthesis chip Enables ambulatory vision We often share patients Colon Cancer mets Breast Cancer mets MS Arteritis begin oral steroids Lyme dx January 25 28,

9 Please remember Always check for a red reflex in babies! children annually develop Retinoblastoma Hereditary or gene mutation Death rate was 100% until recent decades January 25 28,

OPHTHALMOLOGY REFERRAL GUIDE FOR GPS

OPHTHALMOLOGY REFERRAL GUIDE FOR GPS A guidebook to support general practitioners in the management and referral of a range of common eye problems. Contents 3 Introduction 4 Ophthalmic Workup 6 Acute Visual