Ophthalmology in Primary Care Claudia U. Richter, M.D. Ophthalmic Consultants of Boston, Inc.
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1 Ophthalmology in Primary Care 2015 Claudia U. Richter, M.D. Ophthalmic Consultants of Boston, Inc.
2 No financial disclosures
3 Objectives Red eye Nonvision threatening Vision threatening Cataracts Diabetes ARMD Red Flag Signs and Symptoms
4 Nonvision Threatening Red Eye Subconjunctival hemorrhage Stye/chalazion Blepharitis Conjunctivitis Dry eye
5 Vision Threatening Red Eye Corneal infections Iritis Scleritis/Episcleritis Angle-closure glaucoma
6 Subconjunctival Hemorrhage Bright red eye Normal vision No pain Usually no obvious cause No treatment
7 Stye/Chalazion Stye (hordeolum): obstruction of the perifollicular glands Chalazion: obstruction of the Meibomian glands
8 Stye/Chalazion
9 Stye/Chalazion Treatment Warm compresses +/- topical antibiotics Systemic antibiotics for associated preseptal cellulitis Incision and curettage for drainage
10 Blepharitis Chronic inflammation affecting the lash line Dysfunction of the meibomian glands Secondary infection Associated with acne rosacea
11 Blepharitis Symptoms Foreign body sensation Burning Mattering of the lashes Eyelids sticking together upon waking
12 Blepharitis Treatment Warm compresses Lubricant eye drops Mechanical cleansing of lids Omega-3 fatty acid supplements (flaxseed oil, fish oil) Counseling that this may be a chronic or recurring problem
13 Blepharitis Treatment Topical antibiotics Azasite (azithromycin in DuraSite) Topical steroids for inflammatory component (only for short duration) Restasis Systemic doxycycline for refractory problems
14 Diagnosis of Conjunctivitis Stringy white mucus: allergic Purulent discharge: bacterial Watery: viral
15 Allergic Conjunctivitis Symptoms: ITCHING Clinical findings Normal exam Lid or conjunctival edema Stringy white discharge
16 Allergic Conjunctivitis Treatment Cold compresses Topical antihistamines (over the counter) Topical mast cell stabilizers Combination topical antihistamines and mast cell stabilizers
17 Topical Antihistamines Over the counter (use QID) Vasocon-A Naphcon-A Opcon-A Visine-A
18 Allergic Conjunctivitis Treatment Mast cell stabilizers with anitihistamine action BID use Azelastine (Optivar) Epinastine (Elestat) Ketotifen (Alaway) Ketotifen (Zaditor --over the counter) Nedocromil (Alocril) Olopatadine (Patanol) Pemirolast (Alamast) Once daily use Olopatadine (Pataday) Alcaftadine (Lastacaft)
19 Viral Conjunctivitis Adenovirus Highly contagious
20 Viral Conjunctivitis Symptoms Burning discomfort Associated systemic symptoms: URI, sore throat, fever, malaise Clinical findings Redness Watery discharge Palpable preauricular lymph node
21 Viral Conjunctivitis Diagnosis AdenoPlus is immunoassay to detect adenoviral antigens Compared to cell culture 90% sensitivity, 96% specificity Cost $15-$25 per test Reimbursable Accurate diagnosis reduces treatment with unnecessary and ineffective antibiotics
22
23 Viral Conjunctivitis
24 Viral Conjunctivitis Treatment: symptomatic Cold compresses Iced artificial tears Acetaminophen Topical betadine
25 Viral Conjunctivitis Duration is 1-3 weeks Contagious period is for 1 week after onset of symptoms Postconjunctivitis dry eye syndrome may persist for several months
26 Bacterial Conjunctivitis Caused by all common bacteria Symptoms: purulent discharge Clinical findings Conjunctival injection Purulent discharge
27 Bacterial Conjunctivitis Treatment: topical antibiotics QID for 7-10 days
28 Ophthalmic Antibiotic Ointments Erythromycin Bacitracin Sulfacetamide sodium Gentamicin Tobramycin Ciprofloxacin Polymyxin B/Bacitracin Polymyxin B/Neomycin/Bacitracin Polymyxin B/Oxytetracyclin
29 Ophthalmic Antibiotic Solutions Sulfacetamide sodium Polymixin B/trimethoprim (Polytrim) Polymixin B/Neomycin/Gramicidin (Neosporin) Gentamicin Tobramycin Azithromycin (Azasite)
30 Ophthalmic Antibiotic Solutions Ofloxacin (Ocuflox) Ciprofloxacin (Ciloxan) Levofloxacin (Quixin) Gatifloxacin (Zymar, Zymaxid) Moxifloxacin (Vigamox) Besifloxacin (Besivance)
31 Hyperpurulent Bacterial Conjunctivitis Copious discharge may indicate infection with pseudomonas or gonorrhea and requires urgent referral
32 Dry Eyes Symptoms Burning Foreign body sensation Grittiness Tearing
33 Dry Eyes Associated conditions Aging Sjogren s syndrome Rheumatoid arthritis Stevens-Johnson syndrome Systemic medications: antihistamines, diuretics, antidepressants
34 Dry Eyes Treatment Lubricant eye drops (artificial tears) Lubricating ointment at bedtime Protective glasses and hat outdoors Flaxseed oil 1000 mg daily Restasis (topical cyclosporine) Punctal plugs or occlusion
35 Punctal Plugs
36 Vision Threatening Red Eye Corneal infections Scleritis/episcleritis Iritis/uveitis Acute angle-closure glaucoma
37 Vision Threatening Red Eye Indications for Referral Decreased vision Severe eye pain Light sensitivity Opacity on cornea
38 Corneal Infections Viral keratitis Herpes simplex most common Bacterial keratitis Frequently related to soft contact lens wear Fungal keratitis
39 Herpes Simplex Keratitis Primary HSV Conjunctivitis with watery discharge Skin vesicles on lids Enlarged preauricular lymph nodes +/- corneal involvement with single or multiple dendrites Recurrent HSV
40 Primary HSV Recurrent HSV
41 Bacterial Keratitis Most common in soft contact lens wearers Red painful eye Opacity on the cornea Requires ophthalmologic referral
42 Bacterial Keratitis
43 Iritis/Uveitis Inflammation in the anterior chamber (iritis) or involving the entire eye (uveitis) Symptoms Pain Photophobia Decreased vision
44 Iritis/Uveitis Clinical findings: Circumcorneal redness Pupil is smaller than normal Cell and flare in the anterior chamber
45 Iritis/Uveitis Etiology Nongranulomatous: Idiopathic Traumatic Ankylosing spondylitis Behcet s disease Inflammatory bowel disease Herpes Lyme disease Postoperative Psoriatic arthritis Reiter s syndrome Lupus Wegener s granulomatosis JRA Granulomatous: Sarcoidosis Tuberculosis Syphilis Toxoplasmosis Brucellosis
46 Episcleritis Benign, self-limited inflammation of episclera (Tenon s capsule) Rarely associated with systemic disease Mild eye pain and tenderness Treatment:Oral NSAIDs
47 Scleritis Inflammation of the wall of the eye. Severe destructive disease, underlying systemic disease Severe boring eye pain Treatment with systemic steroids, NSAIDs, and/or immunosuppressives
48 Scleritis
49 Angle Closure Glaucoma Obstruction of aqueous outflow due to occlusion of the trabecular meshwork by the iris. Occurs in patients anatomically predisposed with shallow anterior chambers.
50 Angle Closure Glaucoma Screening for susceptible patients: penlight held temporal and parallel to the iris reveals a shadow on the nasal iris in at risk patients.
51 Angle Closure Glaucoma Symptoms Severe ocular pain Blurred vision Halos around lights Headache Nausea and vomiting Clinical findings High intraocular pressure Mid-dilated sluggish pupil Corneal epithelial edema Conjunctival injection Shallow AC
52 Angle Closure Glaucoma Medical treatment to lower IOP Pilocarpine Topical aqueous humor suppressants: timolol, brimonidine, carbonic anhydrase inhibitors Definitive therapy: Iridectomy
53 Cataract Clouding of the lens which may result in decreased vision Leading cause of treatable blindness worldwide In US accounts for 50% of low vision cases in adults > 40 Cataract surgery with IOL implantation one of most common surgeries performed under Medicare
54 Risk Factors Smoking Lifetime exposure to UV-B radiation Diabetes Inhaled, topical, and oral corticosteroid use Hypertension Myopia Obesity No significant delaying effect on cataract development with vitamin supplementation
55 Cataract
56 Treatment of Cataracts Cataract extraction with intraocular lens implant Indicated when patients are having difficulty with their vision due to cataracts Typically small incision phacoemulsification
57 Intraocular Lenses Posterior chamber intraocular lens inserted into the lens capsule Anterior chamber or sutured IOL used in certain cases
58 Intraocular lenses Multifocal IOL Accommodative IOL
59 Preoperative Preparation Decide based on patient s needs if cataracts are visually significant Measurements for IOL calculation Preoperative physical examination EKG in patients older than 65 Laboratory studies as medically necessary Preoperative topical antibiotics and NSAIDS Anticoagulation frequently may be continued, but consult with ophthalmologist
60 Tamsulosin Precautions Alpha blocker therapy may cause intraoperative floppy iris syndrome and increase the risk of surgical complications Discontinuation of alpha blockers for weeks to years does not reverse the effect If a patient has a cataract and requires tamsulosin or other therapy, consider cataract surgery before initiating therapy Tell ophthalmologist of any history of alpha blocker use
61 Benefits of Cataract Surgery Better optically corrected vision Better uncorrected vision with reduced spectacle dependence Increased ability to read or do near work Reduced glare Improved ability to function in dim light Improved depth perception and binocular vision (reduced risk of motor vehicle accidents and falls with broken hips and shoulders)
62 Diabetes Leading cause of blindness under age 65 Prevalence increases with duration of disease Intensive control of blood glucose reduces the risk of retinopathy in both type I and II diabetics
63 Nonproliferative Diabetic Retinopathy: Characteristics Microaneurysms Leakage of intravascular fluid Intraretinal hemorrhage Retinal ischemia due to capillary dropout
64 NPDR
65 NPDR
66 NPDR
67 NPDR: Treatment Intravitreal anti-vegf (Diabetic Retinopathy Clinical Research Net) Bevcizumab (Avastin) Ranibizumab (Lucentis) Aflibercept (Eyelea) Focal laser photocoagulation for clinically significant macular edema (CSME) reduces rate of vision loss by more than 50% (EDTRS) Intravitreal steroids
68 Proliferative Diabetic Retinopathy: Characteristics All of the findings of NPDR PLUS formation of neovascular tissue from the optic nerve or the retinal surface
69 PDR
70 PDR
71 PDR: Treatment Intravitreal anti-vegf Panretinal photocoagulation Involute neovascularization Reduce risk of vitreous hemorrhage and/or reduce traction retinal detachment Vitrectomy Remove nonclearing vitreous hemorrhage Repair traction retinal detachment
72 Pitfalls in Diagnosis More difficult if pupils undilated CSME not visible without stereoscopic view IRMA difficult to distinguish from neovascularization Neovascularization unapparent or outside field of direct ophthalmoscope
73 Screening Recommendations Type I diabetics 5 years after onset, then yearly Type II diabetics at time of diagnosis, then yearly Diabetics who are pregnant early in the pregnancy and every trimester
74 Age-Related Macular Degeneration A leading cause of severe, irreversible vision impairment Characterized by Drusen RPE abnormalities Geographic atrophy Neovascular maculopathy
75 Age-Related Macular Degeneration Risk factors Smoking doubles risk of AMD +/-hypertension, cardiovascular disease, inflammation Low levels of anti-oxidants
76 Dry ARMD
77 Wet ARMD
78 Dry ARMD ARMD Treatment Diet rich in green leafy vegetables, no smoking, weight control Anti-oxidant supplements for intermediate AMD or advanced AMD in one eye Wet ARMD Intravitreal anti-vegf (bevacizumab,ranibizumab, aflibercept) Anti-oxidant supplements (AREDS 2 formula)
79 Amsler Grid
80 New Onset Diplopia Is this a neurologic emergency? Diplopia that is not improved by covering one eye requires a neuro-ophthalmic or neurologic evaluation
81 Diplopia Monocular: abnormalities in the refractive media Corneal (high astigmatism) Lenticular cataract or dislocated lens Retinal (rarely) Binocular: misalignment of the visual axis Cranial nerve palsy Giant cell arteritis Demyelinating disease Myasthenia gravis Thyroid orbitopathy Orbital myositis Other causes
82 Flashes and Floaters Patients need to be examined to detect and treat retinal holes and detachments.
83 What is the differential diagnosis? Posterior vitreous detachment Retinal hole/detachment Vitreous hemorrhage Posterior segment inflammation Trauma Migraine
84
85 Red Flag Signs and Symptoms Require urgent referral Decreased vision Metamorphopsia (distorted vision) Severe eye pain Red eye with light sensitivity Corneal opacity Flashes and floaters Binocular double vision
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