Faculty Financial Disclosure. Learning Objectives: Office Ophthalmology. Basic Eye Exam: What s in your pocket/office? Office Ophthalmology

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1 Faculty Financial Disclosure Office Ophthalmology Lynn K. Gordon, MD, PhD, has no financial relationships to disclose. Lynn K. Gordon, MD, PhD Professor and Vernon O Underwood Family Chair Department of Ophthalmology David Geffen School of Medicine at UCLA Learning Objectives: Office Ophthalmology Describe how a careful history will identify the likely etiologies for transient vision loss Understand the urgency of referral to an ophthalmologist or an emergency facility for specific sight or lifethreatening conditions Describe the differential diagnosis of the red eye When to refer to an ophthalmologist? Red flag in history or examination Screening evaluations for disease prevention Diabetic Retinopathy Age related macular degeneration Diagnostic dilemma Need for specific surgical expertise Consideration for use of topical steroids Identify the components of an office-based screening evaluation for eye disease 5 Minute Screening Exam Basic Eye Exam: What s in your pocket/office? Measure visual acuity Penlight exam Assess pupils Ocular alignment and versions Examine lids and adnexa Ocular surface Assess anterior chamber depth Perform confrontation visual fields Direct ophthalmoscopy Confirm red reflex Distinguish normal from abnormal disc Identify optic disc edema, atrophy, and cupping See retinal hemorrhages Recognize macular degeneration Near vision card Pinhole Penlight Direct ophthalmoscope Mydriatic Topical anesthetic Fluorescein strips 1

2 RAPD (Relative Afferent Pupillary Defect) Possible Red Flags Eye Pain Floaters and flashes Vision loss Double vision Red eye Eye trauma Droopy eyelid What questions to ask? What examination to do? What not to miss.. Goal is to prevent loss of vision, permanent morbidity, or mortality Eye Pain Eye Pain Lids and periorbita Uveitis Hordeolum Preseptal cellulitis Cornea Abrasion Infectious ulcer Conjunctivitis may cause discomfort but not pain!!! Scleritis Orbit Cellulitis Inflammatory disease Headache Severe? yes Vision Loss? yes Red eye? yes Contact lenses? yes Call and Refer to Ophthalmology for Urgent Evaluation and Management Floaters and Flashes Is this a new symptom? YES New floaters and flashing lights require urgent evaluation by ophthalmology Today or maybe tomorrow Possibilities include posterior vitreous detachment, retinal tear, retinal detachment, uveitis Is this a new symptom? NO Are there changes in prior floaters? YES: Same evaluation as if this is a new complaint!! No: non-urgent evaluation Case 1: What is that floater in my vision Posterior vitreous detachment (PVD) Often described as a fly or circle or dust May interfere with central vision, bothersome but not dangerous Typically occurs in older individuals, myopes Major concern: vitreous hemorrhage, retinal tear or detachment Must refer, seen within a day 2

3 Case 2 What is that floater in my vision? Retinal tear +/- limited detachment May have peripheral floater May only complain of flashing lights Painless Often occurs at time of PVD Increased in myopes Worry about detachment Must refer, seen within a day Vision loss: Characteristics Is it permanent or transient? Is it monocular or binocular? Was it gradual or sudden? If gradual, what is the duration and tempo? Was it really sudden or just noticed suddenly? If permanent Is it decreased visual acuity? Is it loss of visual field? Is it an inability to read or interpret text? Vision loss: transient or permanent Are they older than 50? Do they have associated systemic symptoms? Unexpected weight loss, decreased energy Jaw or tongue claudication, new neck pain New onset headache Consider Giant-Cell Arteritis (GCA) This is an emergency!!! Transient Visual Loss Monocular vs Binocular Time course Seconds Think TVOs (Transient visual obscuration) Consider optic disc edema, IIH (Idiopathic intracranial hypertension) Minutes Consider vascular disease Greater than 15 minutes Scintillating scotoma Consider migraine Case 3 Every time I stand up my vision blurs for a few seconds Red flag symptom Caused by disc edema until proven otherwise Does not help determine cause Increased intracranial pressure from any reason Examine optic discs today If any question then refer I noticed that part of my vision is missing in my right eye I used eyewash but it didn t help What parts of the eye could be responsible for this complaint? 3

4 Is there a problem in one eye or both? One eye Consider retina, vitreous, optic nerve Is this a new problem? REFER NOW Both eyes: Glaucoma Neurologic causes Try to formally define the defect and then proceed Case 4 Retinal detachment May have flashing lights (retinal traction), new floaters (rbc s in vitreous) May have history of myopia Will not complain of pain Case 5 55-year-old male History of hypertension and diabetes Suddenly noticed the defect this morning when he awoke No pain Case 5: Non-arteritic ischemic optic neuropathy Common cause for acute (abrupt) monocular vision loss in adults Typical: Painless Associated with systemic vascular risk factors Fellow eye has disc at risk (a small cup) Associated with sleep apnea? Affected disc is swollen No therapy, yet Risk of fellow eye ~15% Case 6: Case 6: This patient complained of bumping doorways Name the defect: Junctional Scotoma Where is the localization? Anterior to and involving the chiasm When to Image? NOW, today MRI with and without contrast Surprisingly no headache Urgent neurosurgical referral Complete recovery of left eye visual field and partial recovery of right eye visual field 4

5 Double vision Case 7: Double Trouble What to consider if the patient sees double First: is it really double or just blurry Second: is it monocular or binocular? Cover one eye: is the image single? Cover the other eye: is the image single? If the answer to both is yes = binocular double vision If NEW, then urgent evaluation If the answer to one is yes and the other is no = monocular double vision Non-urgent evaluation for a local eye problem Patient with a six month history of increasing neck pain She needs to turn her head to avoid double vision Left abduction deficit Either the left 6 th nerve is weak (i.e., palsy) or the left medial rectus is causing restriction (thyroid eye disease or rarely medial wall orbital fracture) Chronic cranial nerve palsy When do you image? Now. Red Eye: Specify Involvement The Red Eye: When to Refer Eyelid Conjunctiva Episclera Sclera Cornea Anterior chamber Orbit Pain? yes Vision Loss? yes Duration? > 1 week Call and Refer to Ophthalmology for Evaluation and Management Discharge? purulent Red Eye: Eyelid Abnormalities Conjunctivitis Regional disease Chalazion, hordeolum, dermatitis Preseptal cellulitis Hemangioma Systemic disease Orbital cellulitis Thyroid orbitopathy Arteriovenous fistula Symptoms and Signs Discharge, itching/irritation, pain, changes in vision, photophobia Time course Exam Visual acuity Eye exam Lids/lashes Conjunctiva Cornea How long? Anterior chamber One eye or both? Systemic history? Trauma, contact lens use (REFER), skin lesions, allergy, prior episodes? Culture If neonatal conjunctivitis If suspect gonoccocal or chlamydia 5

6 Conjunctivitis Allergy: watery discharge, itching Cool compresses, remove allergen if possible Rx: over the counter antihistamine/vasoconstrictor (but only for a few days); if chronic then use a histamine H1-receptor antagonist or mast cell stabilizer if recurrent/persistent Infectious Bacteria: Purulent discharge Gonorrhea or chlamydia: Systemic antibiotics (patient and partner) Other: topical antibiotic, should improve within 24 hours Virus: Mucoid discharge Do not use antibiotics! They can make things take longer (adenovirus) or make things worse (herpes), may last 7-10 days Case 8:My eyes are red My child had red eyes last week. Now mine are red and tearing, I feel like something is there and they are uncomfortable. There is not much discharge but I have some tenderness in front of my ear. Examination: Conjunctival follicles Preauricular node Non-purulent discharge Diagnosis? Viral conjunctivitis Treatment? Supportive care: artificial tears, vasoconstrictor/ antihistamine If corneal infiltrates then may require topical steroids (REFER) Home hygiene, prevent spread Red Eye: Other Diagnoses Sub-conjunctival hemorrhage Elevated orbital venous pressure Angle closure glaucoma Episcleritis Scleritis Uveitis/Iritis Keratitis Always Worry About Possible Herpes Keratitis Remember: If you are considering topical steroids then send patient to ophthalmologist Do not send patient home with topical anesthetic Eye trauma Droopy eyelid Is the globe ruptured? Is there a hyphema? Is there a lid laceration? Does it involve the eyelid margin? Is the canalicular system compromised? If the answer to any of the above is YES then refer to ophthalmology for urgent evaluation and repair Is this new? Gravitational? Neurologic? Is there variability? Could this be myasthenia gravis? Associated symptoms? Could this be a 3 rd nerve palsy? URGENT IMAGING Diplopia Pupil 6

7 Case: I can t read This symptom can reflect an urgent or serious problem or just require a change in glasses.. Is this a problem with the visual acuity? Maybe they just need glasses Is this a problem with the visual field? Maybe they had a stroke or a tumor! Is this a problem with muscle balance? Maybe they have convergence insufficiency (non urgent) Maybe they have a cranial nerve palsy or thyroid eye disease? Do they have problems with making smooth eye movements (pursuits) or fast eye movements (saccades) Maybe they have Parkinson s Disease or PSP (Progressive supranuclear palsy) Could this be secondary to visual processing? Maybe they have dementia? Office Ophthalmology: Keys to Success Careful history Appropriate physical examination Comfort with procedures Appropriate differential diagnosis Referral criteria and patterns Suggested Readings Papers Caylor, T. L. & Perkins, A. Recognition and management of polymyalgia rheumatica and giant cell arteritis. American family physician 88, (2013). Cronau, H., Kankanala, R. R. & Mauger, T. Diagnosis and management of red eye in primary care. American family physician 81, (2010) Friedlaender, M. H. Ocular allergy. Current opinion in allergy and clinical immunology 11, , 2 (2011). Hollands, H. et al. Acute-onset floaters and flashes: is this patient at risk for retinal detachment? JAMA : the journal of the American Medical Association 302, , (2009). Petzold, A., Islam, N., Hu, H. H. & Plant, G. T. Embolic and nonembolic transient monocular visual field loss: a clinicopathologic review. Survey of ophthalmology 58, 42-62, (2013). Roy, F. H. The red eye. Annals of ophthalmology (Skokie, Ill.) 38, (2006). THANK YOU Book: Basic Ophthalmology, 9th Edition Published by the American Academy of Ophthalmology and available through the internet. 7