TOP 5 EYE CONDITIONS NOT TO BE MISSED

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Sheryl Beasley
6 years ago
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1 TOP 5 EYE CONDITIONS NOT TO BE MISSED Dr Kolin Foo Consultant Ophthalmologist Senior Lecturer in Ophthalmology Wellington Hospital Terrace Eye Centre

2 Financial disclosure No financial interest in the products or services mentioned in my presentation

3 Case 1 JB, 2 year old male toddler Parental concern with abnormal pupil on photos Leukocoria = white pupillary reflex

5 Red Reflex Test

6 Red Reflex Test leukocoria Urgent referral to an ophthalmologist Needs to be seen within 1 week

7 Retinoblastoma (Rb) Rb is a fast growing eye cancer of the retinal cells in early childhood (< 5 years of age) accounts for 3-4% all childhood cancers 1 in 17,500 live births (2-3 cases in NZ per year)

8 Caused by mutations on chromosome 13 (RB1 gene) Tumour suppressor gene 40% heritable and 60% non-heritable (sporadic) 1/3 bilateral (100% heritable), 2/3 unilateral (10-20% heritable) Autosomal dominant pattern of inheritance in heritable cases

10 Treatments Aim : save life & preserve vision Depends on size and staging of the tumour laser, cryotherapy, thermotherapy, radiotherapy, chemotherapy, enucleation High cure rate due to infrequent metastasis 2-5% mortality Death due to metastases, trilateral tumours and second malignancy (sarcomas)

11 Screening of family members In hereditable cases Screen other children in the family up to age of 5 years old Genetic counselling for parents

12 Key points Listen to the parents Do the red reflex test in all infants at 6 week post-natal check Use 1% Tropicamide dilating drops if pupils are too small to perform the red reflex test Refer if red reflex is abnormal or unsure

13 Case 2 AJ, 28 year old male builder Hammering a nail and felt something his his R eye 3 weeks ago; used drops from chemist c/o- floaters and blurred vision (6/12)

14 Dilated fundal examination reviewed mild vitreous haemorrhage and an intraocular foreign body (IOFB)

15 Intraocular Foreign Body (IOFB) Vague history, eye can look normal externally History of metal vs metal eg. hammering nails, chiselling No protective eyewear Feeling of something hitting the eye +/-pain, +/-floaters

17 Urgent referral Vitrectomy with removal of IOFB

18 Key Points Take a good history (metal vs metal) Eye can appear normal Refer urgently if IOFB is highly suspected or unsure Eye protection

19 Case 3 Miss Y, a 34 year old female day care worker 3 weeks history of bilateral red, gritty, watery eyes with slightly blurred vision (6/9) URTI symptoms 1 week prior to red eyes Tried OTC antiseptic drops, chloramphenicol drops and fucithalmic ointment without relief

21 Adenoviral Keratoconjunctivitis 65% of conjunctivitis are viral 90% of viral conjunctivitis are caused by Adenovirus Common cause of acute follicular conjunctivitis in children and adults Can be bilateral or unilateral (initially)

2 forms: pharyngoconjuctival fever (PCF) and epidemic keratoconjunctivitis (EKC) follicular conjunctivitis pinpoint subconjunctival haemorrhage

22 2 forms: pharyngoconjuctival fever (PCF) and epidemic keratoconjunctivitis (EKC) follicular conjunctivitis pinpoint subconjunctival haemorrhage watery, mucoid discharge crusting oedematous lids palpable preauricular lymphadenopathy pseudomembranes and subepithelial (stromal) infiltrates +/- URTI

23 Diagnosis Clinical RPS Adeno Detector Plus

24 Treatments There are no antiviral drugs approved for adenoviral conjunctivitis 2-3 week self-limiting course cool compress, artificial tears and eye toileting prevent contagious spread (washing sheets and pillowcases, hand washing, avoid sharing towels) Take sick leave (highly contagious) Antibiotic drops in secondary bacterial infection Topical corticosteroids for corneal infiltrates to prevent scarring pseudomembranes should be peeled.

25 Key points Suspect adenoviral conjunctivitis in conjunctivitis that is out of character ie. duration >3 weeks, vision involvement, corneal spots or pseudomembrane Treat with antibiotic drops if mucopurulent discharge is present Refer is vision is affected or unsure Prevent contagious spread

26 Case 4 Mrs B, a 76 year old lady Blurred vision in her R eye for 1 week (6/18) kink in the power line Smoker

27 Age-related macular degeneration (AMD) Leading cause of blindness among people age 50 or older A chronic disease that causes loss of central vision

28 1 in 7 people over 50 Risk factors: age (>50), smoking (2x), race (Caucasians > Africans), family history

29 Dry AMD 6/6-6/9 6/36-CF

30 Wet AMD Vascular endothelial growth factor (VEGF) upregulation

31 Diagnosis Check VA (pin hole) Amsler grid Dilated fundal examination Refer urgently if symptoms are acute and +ve Amsler test

32 Optical Coherence Tomography (OCT scan) Normal Dry AMD Wet AMD

green vegetables, fruits, fish (3x a week), nuts,

33 Treatment- Dry AMD No effective treatment High dose antioxidant supplements (AREDS formula) Diet: leafy green vegetables, fruits, fish (3x a week), nuts, avoid saturated fats Sun protection Amler grid self-monitoring

34 Treatment-wet AMD Early detection and early referral Intravitreal anti-vegf (vascular endothelial growth factor) injections Aim of treatment is to halt the deterioration of, and improve vision (not a cure)

Anti-VEGF agents Available agents in NZ:

35 Anti-VEGF agents Available agents in NZ: Bevacizumab (Avastin), Ranibizumab (Lucentis) & Aflibercept (Eylea) None subsidized by Pharmac All require long term, regular and repeated injections (monthly to 3 monthly) Cost: Avastin ($150), Lucentis & Eylea ($2000)

36 Avastin (Bevacizumab) Only approved for treatment of certain cancers Requires compounding pharmacies to draw into multiple syringes Contamination risk

37 video

38 Results In general, regular anti-vegf injections will prevent further loss of vision in majority cases (95%) 30% cases significant visual improvement

39 Key points Perform Amsler gird test if suspect AMD High index of suspicion in patients with documented AMD in fellow eye Refer immediately if symptoms are acute Wet AMD requires long term regular intravitreal injections to maintain vision Avoid smoking (stand 22)

40 Case 5 Mr J, a 70 year old male patient transient diplopia over 2 days; getting worse Intermittent blurring in R eye darkness crossing over Mild R sided headache Feeling off colour for a few weeks Loss of appetite, low energy levels and muscle aches all over

42 Further questioning: painful gums with difficulty chewing (seen by dentist), sensitive scalp when combing hair

43 Gian Cell Arteritis (GCA) Age over 60 New onset of headache (temporal) Acute or transient loss of vision (amaurosis fugax) Diplopia (acute or transient) Jaw claudication Unexplained weight loss Fever Myalgia (pain & stiffness in neck, shoulders or hips in PMR 50%)

44 Ocular Complications Central retinal artery occlusion Severe vision loss: PL-NPL Afferent pupillary defect

45 Arteritic anterior optic neuropathy Partial sight loss with field defect

46 Investigations & Treatements Neuro-ophthalmological emergency If high index of suspicion Start high dose systemic steroids (oral prednisone 1mg/kg) Urgent ESR, CRP and FBC (platelets) ESR normal in 15-20% CRP and platelets more sensitive and specific

47 Refer for temporal artery biopsy (TAB) (ophthalmologist, neurologist, rheumatologist)

48 Corticosteroid treatment for GCA Start high (i.v methylprednisolone 15mg/kg or oral prednisone 1mg/kg) Taper slowly (monitor ESR & CRP)

49 Key Points Suspect GCA in patients with headaches and eye symptoms +/- PMR Start steroids immediately is GCA is highly suspected ESR can be normal (10%); CRP and platelets more sensitive All cases require TAB to confirm GCA Corticosteroid therapy, start high, taper slowly

50 Thank you

Age-Related Macular Degeneration (AMD)

Age-Related Macular Degeneration (AMD) What is the Macula? What is Dry AMD (Age-related Macular Degeneration)? Dry AMD is an aging process that causes accumulation of waste product under the macula leading