Eye Disorders in Primary Care

Transcription

1 Texas Academy of Family Physicians San Antonio, TX June 8, 2018 Eye Disorders in Primary Care Robert D. Gross, MD, FACS Clinical Professor of Ophthalmology UT Southwestern Medical Center Dallas, Texas USA

2 Speaker Disclosure Dr. Gross has disclosed that he is a consultant for R&D Consultants and Shire.

3 Learning Objectives By the end of this activity, the participant should be better able to: Discuss the anatomy and physiology of the eye. Determine the differential diagnosis of the red eye. Manage ocular conditions utilizing concepts in treatment.

4 Which is responsible for the highest utilization of topical ophthalmic agents? 1. Surgical post-op care 2. Red eye conditions 3. Glaucoma 4. Retinal conditions Insufficient data

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6 The best initial management for a patient newly diagnosed with pink eye is: 1. Sulfacetamide drops qid x 7d 2. Moxifloxacin ointment bid x 3d 3. Prednisolone drops 1% tid x 5d 4. Visine or Naphcon tid x 3 days 5. TobraDex drops qid x 7 days Insufficient data

7 The Red Eye Pink Eye is a descriptive term, not a diagnosis. >> The History is the Key to diagnosis!

8 The Red Eye Conjunctivitis Lid Disease Foreign body Trauma Uveitis Neoplasm Structural Change Bacterial Viral Inclusion Irritative Allergic Contact lenses

9 The Red Eye Bacterial Conjunctivitis Community acquired May be contagious Matting & discharge Self-limited: ~10 days Many pathogens: Culture not required

10 Ophthalmic Antibiotics Sulfacetamide Bacitracin Polysporin Polymyxin B/Bacitracin Neosporin PolymyxinB/ Bacitracin/Neomycin Achromycin Tetracycline Chloroptic Chloramphenicol Ilotycin Erythromycin Polytrim Polymyxin B/Trimethoprim Gentamicin Tobrex Tobramycin Fluoroquinolones Chibroxin Norfloxacin Ciloxan Ciprofloxacin Ocuflox Ofloxacin Quixin Levofloxacin Zymar Gatifloxacin Vigamox Moxifloxacin

11 Ophthalmic Antibiotics Three days treatment should suffice Consider ointments for children Moxifloxacin drops tid or gel drops bid Ciprofloxacin drops qid or ointment bid Neomycin/Polymyxin B/Bacitracin* ung tid Tobramycin drops qid or ointment bid Polymyxin B/Bacitracin* ointment tid Gentamicin drops qid or ointment bid *Clearly specify Ophthalmic ung

12 The Red Eye Viral Conjunctivitis Commonly associated with viral upper respiratory tract infection Contagious Resolves with URI, but may persist for weeks if adenovirus Cocksackievirus & enterovirus 70 may cause hemorrhagic disease Bacterial super-infection common Adenovirus infection may involve the cornea types 8, 11, 19 [consider povidone-iodine]

13 Viral Conjunctivitis Herpes Simplex Primary occurrence in children: Average age of onset = 19 yrs Initial cases associated with vesicular lesions of the eyelids Follicular conjunctivitis, uveitis, sightthreatening dendritic corneal lesions Recurrences common Exacerbated by steroids Ganciclovir gel 0.15% to eye 5x/d Acyclovir ung 5% to skin lesions

14 Usually affects adults Unilateral herpetiform skin lesions in V1 dermatomal distribution Keratitis/uveitis Older patients at risk for post-herpetic neuralgia Initiate PO acyclovir, valacyclovir or famciclovir within 72 hours of diagnosis Viral Conjunctivitis Herpes Zoster

15 Viral Conjunctivitis Varicella Unilateral/bilateral Associated with clinical chickenpox Papular lesions of the lid margin and conjunctiva, usually at the limbus Lesions are not sight-threatening Conjunctival signs resolve as systemic disease improves

16 Molluscum Contagiosum Unilateral or bilateral Umbilicated nodule(s) on lid margin Follicular onjunctivitis and keratitis Treatment directed at removal of skin lesions

17 Inclusion Conjunctivitis Chronic follicular conjunctivitis caused by chlamydia Children and sexually-active young adults Epithelial keratitis Prolonged time course Discharge uncommon Kids: PO Erythromycin, Azithromycin Adults: PO Tetracycline, Fluoroquinolone

18 Irritative Conjunctivitis Irritation Conjunctival hyperemia No itching, discharge or URI Environmental pollutants, smoke Occupational exposure HP-guar-based artificial tears

19 Who s treating the most patients for ocular allergy? 1. Pediatricians 2. Ophthalmologists 3. Family Physicians 4. Optometrists None of the above

20 Allergic Conjunctivitis If it doesn t itch, it s probably not Allergy.

21 Patients with the most common forms of ocular allergy rarely complain of changes in vision. 1. True 2. False

22 Allergic Conjunctivitis Seasonal (SAC)/ Perennial (PAC) Main symptom is itching Chemosis, tearing, and hyperemia Vision unaffected Histamine Treatment enhances quality of life

23 Vernal Keratoconjunctivitis (VKC) Presents from early spring until fall Seen in children, usually boys Palpebral and limbal forms Intense itching, tearing, photophobia Ropy mucous discharge Ptosis Corneal ulcers 4-6% have permanent visual change

24 Atopic Keratoconjunctivitis (AKC) Conjunctivitis may be cicatrizing Swollen eczematous lids Superficial punctate keratitis/ulcers Superficial corneal infiltrates Keratoconus Anterior polar cataracts

25 The majority of allergy patients with systemic control of symptoms with nasal steroids and oral antihistamines have good control of ocular symptoms. 1. True 2. False

26 Ocular Allergy Treatment Considerations Determine the primary source of symptoms Non-sedating antihistamines not non-drying Control allergic rhinitis: steroid nose spray Topical therapy is preferred: Eye and nose Avoid ocular vasoconstrictors and steroids Start with artificial tears on a schedule Move to olopatadine if tears unsuccessful Use the safest, most effective agent Refer vernal and atopic conjunctivitis cases

27 Soft contact lenses are safer and healthier for the eye than rigid gas permeable (hard) contact lenses and provide better visual acuity. 1. True 2. False

28 Giant Papillary Conjunctivitis (GPC) Irritation, mucus discharge, hyperemia Deposits on soft contact lenses Ocular prosthesis, exposed suture, scleral buckle Enlarged papillae in superior tarsal conjunctiva Pannus formation

29 The Red Eye Contact Lenses Novelty lenses popular in children Poor hygiene Lenses worn & traded Overwear Keratitis, GPC

30 The Red Eye Lid Disease Meibomianitis chronic inflammation of the Meibomian glands Internal hordeolum Blepharitis chronic inflammation of the lash follicles External hordeolum Seborrhea

31 Blepharitis Anterior lamellar inflammation involving the lash follicles and accessory sebaceous glands of Zeis and Moll Over-colonization of staph Redness, grittiness & burning Scaly, crusting of debris on the lid margins Common in Down Syndrome Seborrhea a common cause

32 Meibomianitis Posterior lamellar blepharitis due to chronic infection and inflammation Burning, foreign body sensation, tearing, redness Internal hordeola Associated with acne rosacea Lid hygiene (Q-tip & baby shampoo), artificial tears, antibiotic ointment Doxycycline 100mg PO QD (adults)

33 Meibomianitis/Blepharitis Tear film changes Chronic irritation, dryness Chronic hyperemia Superficial punctate keratitis (SPK) Pannus Corneal scarring Lid vascularization, scar formation, trichiasis, lash loss

34 Phlyctenular Keratoconjunctivitis Unilateral Localized hyperemia around a nodule Inflammatory response to staph Common with lid disease Conjunctival nodule stains with fluorescein and may be tender Associated with tuberculosis

35 Ocular Manifestations of Dry Eye PATIENT SYMPTOMS Dryness Itchiness or scratchiness Photophobia Contact lens intolerance Burning or stinging Foreign body sensation Grittiness Fluctuating visual acuity Tired eyes General discomfort CLINICAL SIGNS Hyperemia Low tear meniscus Tear debris Abnormal tear osmolarity Fast tear break up time Conjunctival staining Stringy mucus, filaments Blepharitis Increased cytokines Corneal surface damage

36 Lacrimal Glands Dry Eye Aqueous Insufficiency Rapid Tear Break-up Secretomotor Nerve Impulses Tears Support and Maintain Ocular Surface Ocular Surface Neural Stimulation Evaporative Blepharitis Lid abnormalities Contact lens wear Meibomianitis (lipid deficiency) Blinking abnormalities Lagophthalmos Rapid tear break-up time

37 Managing Dry Eye The majority of patients will improve with physician-directed intervention Physician recommendation and follow-up care are important for good outcomes HP-guar-based artificial tear tid A specific administration schedule to be continued despite symptomatic improvement is required for resolution of structural changes.

38 The Red Eye Uveitis HSV, corneal ulcer Contact lens overwear Trauma Rheumatologic disease Juvenile arthritis (JIA) Sarcoidosis HLA-B27 { *Pain *Photophobia *Tearing } Reticulum cell sarcoma

39 Neoplasm/Structural Abnormality Management Considerations Conjunctival Nevus Nevus, pterygium, pingueculum most common Observation for Growth Change Encroachment on visual axis Lubricants & sunglasses Surgical management

40 In cases of ocular trauma, when a ruptured globe has been excluded topical anesthetic may facilitate the ocular trauma evaluation. 1. True 2. False

41 Ocular Trauma Careful Eye Examination is Required to Determine the Degree of Injury It s a Ruptured Globe until proven otherwise Carefully ballotte the eye and compare its firmness to the uninjured eye Visualize the eye Irregular pupil Shadows in the cornea Blood in the anterior chamber Foreign body Corneal or conjunctival abrasion / laceration Evert eyelids

42 Ocular Trauma Examination Topical anesthetic may be applied after ruptured globe is excluded Improved cooperation with evaluation Aids in diagnosis Facilitates vision testing Makes irrigation more comfortable Proparacaine 0.5% or Tetracaine 0.5%

43 Ocular Trauma Examination A complete eye exam is mandatory Visual Acuity Pupils; afferent defect Motility Fluorescein Ophthalmoscopy: Optic nerves Facial sensory exam Infraorbital nerve Gums over incisors

44 Subconjunctival Hemorrhage Non-painful red eye Blood blocks visualization of the sclera Normal vision Caused by valsalva (coughing, sneezing, straining) Resolves without treatment in days

45 Corneal Abrasion Pain Tearing Photophobia Blurred vision Trauma Fingernail, paper cut, tree branch Rule out foreign body Topical antibiotics & cycloplegic +/- patch

46 Foreign Body/Trauma Management Considerations Rule out ruptured/ penetrated globe Fluorescein exam Evert eyelids and check conjunctival fornices Remove foreign bodies and rust rings Appropriate antibiotic coverage

47 Corneal Foreign Body Associated with history of drilling, grinding, etc. Evert upper lid, especially if vertical linear defects present Topical anesthetic Fluorescein examination

48 Corneal Foreign Body Treatment Irrigation Avoid applicators 25g. needle or spud Alger Brush for rust rings Refer if foreign body in visual axis or for removal of rust ring

49 Hyphema Management Strict bedrest with eyeshield Sickle prep or screen No aspirin or NSAID-containing products Topical steroids if no abrasion Long-acting cycloplegic agent Children: Atropine 1% ointment qd Adults: Cyclopentolate 1% drops bid Risk of re-bleed days 1-5 Flashlight checks bid and for pain

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51 When a patient presents with a possible chemical injury, the first action taken should be: 1. Contact Poison Control 2. Check the visual acuity 3. Irrigate with one liter of saline 4. Rule out conjunctival foreign bodies 5. All of the above 6. None of the above

52 Chemical Burn A true ophthalmic emergency Check the ph Alkaline worse than acidic Remove any foreign material Prompt copious irrigation Recheck ph after 20 minutes Manage as corneal abrasion Ophthalmology referral for alkaline or other severe exposure

53 Ruptured Globe Prompt ophthalmology referral No medication or patch Avoid pressure on the globe Metal shield NPO Endophthalmitis / Hypopyon

54 Timing of events Witnessed Eye protection Glasses wearer Protective eyewear Ocular Trauma History Projectile possible Chemical exposure Past ocular and medical history Any initial therapy already administered Conjunctival Laceration

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57 The Standard of Care for Family Physicians who treat children is the same as that for Pediatricians. 1. True 2. False

58 Which Patient Sees Double? Patient #1 Patient #2 1. Patient #1 2. Patient #2 3. Neither patient 4. Insufficient data

59 Which Patient has Lazy Eye? Patient #1 Patient #2 1. Patient #1 2. Patient #2 3. Neither patient 4. Insufficient data

60 Lazy Eye = Amblyopia Anatomically normal eye Wearing best spectacle correction Vision remains subnormal Strabismic Deprivation Refractive

61 Strabismic Amblyopia [Suppression]

62 Deprivation Amblyopia

63 Refractive Amblyopia (myopia)

64 Refractive Amblyopia

65 Amblyopia Diagnosis Age-appropriate vision test

66 Stereo Tests Cover Uncover Test

67 Guidelines of the American Academy of Pediatrics require children to have their first vision screen with their primary care physician at age 4 years. 1. True 2. False

68 Vision Screening Referral Criteria (AAP, AAO, AAPOS, AACO) Ages months: < 20/50 Ages months: < 20/40 Age 60 months and older: < 20/30 Each eye must pass individually Two line difference or inability to test Any movement on cover/uncover test < 4 / 6 correct on Randot E stereo test

69 Vision Screening Purpose: To distinguish between different populations of patients Screening tests do not: Quantify visual acuity Diagnose or treat Make timely referral based on criteria Refer to age-appropriate level of care AAFP supports U.S. Preventive Services Task Force (USPSTF)

70 Treatment Overview Bacterial Conjunctivitis Ciprofloxacin ung bid x 3 days Corneal Abrasion: Ciprofloxacin ung bid, no patch, consider cyclopentolate Ocular Allergy: Systane Ultra; Olopatadine Corneal Infection: Moxifloxacin drops 4-6x daily Dry eye / irritation: Systane Ultra on scheduled basis Ophthalmology referral as appropriate

71 Examination Aids Welch-Allyn #11720 ophthalmoscope Bluminator ( Vision Testing Book # (

72 Eye Disorders in Primary Care References Procedures for the Evaluation of the Visual System by Pediatricians. Pediatrics 2016; 137:1. The Eye Examination in the Evaluation of Child Abuse. Pediatrics 2010; 126:2, Recommendations for Preventive Pediatric Health Care, Pediatrics 2017; 139: Harper RA[Ed]. Basic Ophthalmology, 10 th edition. American Academy of Ophthalmology [product # U]

73 Texas Academy of Family Physicians San Antonio, TX June 8, 2018 Eye Disorders in Primary Care Robert D. Gross, MD, FACS Clinical Professor of Ophthalmology UT Southwestern Medical Center Dallas, Texas USA abceyes.com