@HUHEYE in Haiti 2018

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1 @HUHEYE in Haiti 2018 Eye Evaluation and Common Eye Diseases Leslie S. Jones, MD Associate Professor and Interim Chair Residency Program Director Glaucoma Services Director Department of Ophthalmology Howard University

2 Blindness Legal blindness is a VA in the better eye worse than or equal to 20/200 or VF < 20 degrees in diameter Vision impairment is defined as having 20/40 or worse vision in the better eye even with eye glasses Preventable Blindness Largely a Public Health solution Vitamin A Deficiency Trachoma Onchocerciasis Treatable Blindness Largely an Ophthalmologic solution Cataract Diabetic Retinopathy Glaucoma Congenital/Heritable Disorders Surgically Amenable Refractive Errors

3 Vision Problems in the U.S. US Census ,386,252 : 11,798,940 Black & 8,884,286 Hispanic Visual Impairment : 3,406,280 Blindness: 1,046,920 D 7,095 D 2,608 M 56,701 M 18,385 V 73,714 V 23,594 AMD: 1,651,335 Cataract: 20,476,040 D 2,731 D 38,335 M 27,370 M 356,447 V 35,657 V 470,160 Diabetic Retinopathy : 5,353,233 Glaucoma: 2,227,485 D 11,508 D 7,324 M 99,193 M 45,748 V 131,032 V56,296 Vision Problems in the U.S. - Prevalence of Adult Vision Impairment and Age Related Eye Disease In America NEI & Prevent Blindness America

4 Eye Disease Prevalence and Projections (Number of Adults 40 Years and Older in The U.S.) Estimates Projections (In Millions) (In Millions) Age related Macular Degeneration ( with Associated vision loss) Glaucoma Diabetic Retinopathy Cataract *Another 7.3 million people are at substantial risk for vision loss from AMD Source: NEI

5 Haiti Lascahobas Friends of the Children of Lascahobas Saint-Marc Hospitals for Humanity Fort-Liberte HU/NOAH NY

$Eye Disease Prevalence in Retrospective 2007-2009 3,702 patients, 49% female, 6 months to 92 years Refractive error 53% 981 (26%) Cataract Lascahobas Haiti 323 Cataract surgeries 706 (19%) Glaucoma$

6 Eye Disease Prevalence in Retrospective ,702 patients, 49% female, 6 months to 92 years Refractive error 53% 981 (26%) Cataract Lascahobas Haiti 323 Cataract surgeries 706 (19%) Glaucoma Duong HV, Westfield KC, Jones LS, Mitchell J, Carr T. A survey of ocular diseases in an isolated rural Haitian community: a retrospective evaluation. J Natl Med Assoc Nov-Dec;104(11-12): PubMed PMID:

7 Normal Eye

8 Eight Part Exam 1. External Exam 2. Visual Acuity 3. Confrontational Visual Fields 4. Extraocular Motility 5. Pupils 6. Anterior Segment 7. Intraocular Pressure 8. Dilated Fundus Exam

Eight Part Exam I. External Exam Eyeballs Size Setting in the orbit Symmetry and alignment Eyelids Thickness, uniformity, lesions Location of lid to cornea and pupil Margins and lashes II.

9 Eight Part Exam I. External Exam Eyeballs Size Setting in the orbit Symmetry and alignment Eyelids Thickness, uniformity, lesions Location of lid to cornea and pupil Margins and lashes II. Visual Acuity (VA) Fraction (distance at which patient can read letters/distance at which normal eye can read letters) With correction (cc) Without correction (sc) Pinhole* Distance (V) Near (N) Hold near card inches from patient

10 Eight Part Exam 1. External Exam 2. Visual Acuity 3. Confrontational Visual Fields 4. Extraocular Motility 5. Pupils 6. Anterior Segment 7. Intraocular Pressure 8. Dilated Fundus Exam

11 Eight Part Exam III. Confrontational Visual Fields (CVFs) Only portion with left eye written first Documented from patient s perspective Examiner positioned in front of patient at equal eye level comparing their left eye to patient s right and vice versa One quadrant at a time Ask patient to count fingers

12 Eight Part Exam 1. External Exam 2. Visual Acuity 3. Confrontational Visual Fields 4. Extraocular Motility 5. Pupils 6. Anterior Segment 7. Intraocular Pressure 8. Dilated Fundus Exam

13 Eight Part Exam IV. Extraocular Motility (EOM) Versions Ductions Nine cardinal fields of gaze Esodeviation and exodeviation Hirschberg light reflex test V. Pupils Size Shape Reactivity Pay attention to symmetry >2mm requires further work-up Afferent pupillary defect

16 Eight Part Exam 1. External Exam 2. Visual Acuity 3. Confrontational Visual Fields 4. Extraocular Motility 5. Pupils 6. Anterior Segment 7. Intraocular Pressure 8. Dilated Fundus Exam

17 Not necessary for pupil to be dilated Position patient in slit lamp Dim background lights Hold lens in one hand of the examiner in front of the patient s eye. Gradually pull the lens towards you until the lens is filled with the retinal image

18 Slit-lamp Biomicroscope

19 Lids and lashes Comment on eyelid position (ex. Ptosis), Meibomian glands, unusual coloration of skin or lashes, anything notable on lid eversion

20 Conjunctiva Comment on pigment, vessels (episcleral, scleral), lesions, post-surgical changes (blebs, tubes, thinning)

21 Cornea Comment on clarity, location of lesions (corneal layer and clock hour), edema or thinning, vascularization/pannus

22 Anterior Chamber Comment on depth, presence of cells (WBC, pigment, RBC) or protein/flare, postsurgical changes (tubes, shunts, IOLs)

23 Iris Comment on reactivity, pupil shape, nodules/lesions, atrophy/illumination defects, post-surgical changes

24 Lens Comment on clarity, color, post-surgical changes, capsular changes (pigment, PCO)

25 Eight Part Exam 1. External Exam 2. Visual Acuity 3. Confrontational Visual Fields 4. Extraocular Motility 5. Pupils 6. Anterior Segment 7. Intraocular Pressure 8. Dilated Fundus Exam

26 Eight Part Exam VII. Intraocular Pressure (IOP) Goldmann applanation Applanator tip 3.06 mm in diameter Scleral rigidity is force directed away from globe, tear film surface tension is force directed toward globe, so amount of force applied to produce circular area of flattening 3.06mm in diameter will cancel out aforementioned forces

27 icare Tonometer/Tonopen

28 Eight Part Exam VII. Intraocular Pressure (IOP) Mean IOP approximately 16mmHg Non-Gaussian distribution with a skew toward higher pressures Colton T, Ederer F. The distribution of intraocular pressures in the general population Nov-Dec; 25(3):123-9

29 Eight Part Exam 1. External Exam 2. Visual Acuity 3. Confrontational Visual Fields 4. Extraocular Motility 5. Pupils 6. Anterior Segment 7. Intraocular Pressure 8. Dilated Fundus Exam

Indirect Ophthalmoscopy Pupil should be fully dilated Position patient, laying down or reclining Dim background lights Ensure that the patient s and the observer s eye are

30 Indirect Ophthalmoscopy Pupil should be fully dilated Position patient, laying down or reclining Dim background lights Ensure that the patient s and the observer s eye are aligned Hold lens in one hand of the examiner in front of the patient s eye. Gradually pull the lens towards you until the whole lens is filled with the retinal image Examination

31 Direct Ophthalmoscopy

32 Retina 9 layers of neurosensory retina Macula Ganglion cell layer is more than 1 cell thick Peripheral Retina Extends from the macula to ora serrata

33 Normal Fundus

34 Documentation

35 Pinguecula/Pterygium

36 Describe this photo

37 Cataract The lens is transparent, biconvex and responsible for diopters of convergent refractive power Cataract is a clouding of the eye s naturally clear lens Age-related cataract is the main cause of blindness and visual impairment throughout the world Cataracts cause blindness in more than 15,000,000 people worldwide and 40,000,000 by the year 2025

38 Cataract

39 Vision with a Cataract

40 Cataract Etiology Aging changes Drug-induced lens changes Trauma Metabolic cataract Nutritional Uveitis Exfoliation Cataract and skin disease

41 Signs and Symptoms Decreased visual Acuity Glare Myopic shift Monocular diplopia Diagnosis History and Physical Eight part eye examination Glare testing Contrast Sensitivity Visual Field Testing Cataract

42 Describe this photo

43 Glaucoma Glaucoma refers to a group of diseases optic neuropathy with associated visual field loss elevated intraocular pressure (IOP) is one of the primary risk factors Three factors determine the IOP: The Rate of aqueous humor production by the ciliary body Resistance to aqueous outflow across the trabecular meshwork - Schlemm s canal system The level of episcleral venous pressure Commonly accepted range for normal IOP is mmhg In most cases of > IOP is > resistance to aqueous humor outflow

44 Glaucoma Between 80,000 and 116,000 Americans are legally blind secondary to glaucoma with each year an additional 5,500 pts become legally blind Approximately 3 million Americans 40 yrs or older have POAG and other forms of glaucoma or related conditions add to these totals 50% don t know they have the disease Glaucoma is the most frequent cause of blindness in Black Americans Classifications Open Angle glaucoma Angle- closure glaucoma Combined-mechanism glaucoma Childhood glaucoma

45 Glaucoma Signs and Symptoms Blurred vision Halos Loss of vision and visual field Diagnosis History and physical Eight part eye examination Gonioscopy Visual field Ultrasonography pachymetry HRT/OCT

46 Aqueous Outflow Channels

47 Histology of Aqueous Outflow Channels

48 Normal Optic Nerve Appearance of nerve tissue ON color Disc Margin Cup to disc ratio

49 Glaucoma

50 Glaucomatous Optic Nerve

51 Glaucoma Visual Field Loss Patterns of Glaucomatous Nerve Loss Paracentral scotoma Arcuate or Bjerrum scotoma Nasal step Temporal wedge

52 Humphrey Visual Fields

53 Treatment Medical Adrengic agonists improves aqueous outflow Alpha 2 adrengic agonists reduces aqueous secretion Parasympathomimetic (miotic) agents improves aqueous outflow Prostaglandin analogs Increases uveoscleral outflow Carbonic anhydrase inhibitors- reduces aquious secretion Hyperosmotic agents reduces aqueous volume Surgical Laser Iriditomy Laser Trabeculoplasty Incisional Trabeculectomy Full thickness

54 Medications

55 Laser Iridotomy/Trabeculoplasty

56 Filtration Surgery

57 Abbreviations you may encounter DES CAM PCO NS CS PSC CEIOL TRAB Dry eye syndrome Complexion associated melanosis Posterior capsular opacification Nuclear sclerosis Cortical spoking Posterior subcapsular cataract Cataract extraction with intraocular lens placement Trabeculectomy

58 Contact Information Leslie S. Jones, MD Associate Professor and Chair Department of Ophthalmology Howard University Department Office (202)

02/03/2014. Average Length: 23mm (Infant ~16mm) Approximately the size of a quarter Volume: ~5mL

02/03/2014. Average Length: 23mm (Infant ~16mm) Approximately the size of a quarter Volume: ~5mL Identify the anatomy of the eye. Explain the basic physiology of the parts of the eye. Briefly discuss various surgeries related to different parts of the anatomy. Average Length: 23mm (Infant ~16mm) Approximately