Common Eye Conditions Every Primary Care Clinician Should Know Disclosure I have no financial interest in any of the products mentioned in this presentation Cynthia S., MD, FACS Professor UCSF Department of Ophthalmology UCSF Family Medicine Board Review March 21, 2018 http://www.timandjeni.com/images/cookiemonster.jpg The Eye Exam Pupils Eye Vital Sign Near Vision Card Held at 14 inches Glasses as needed Look for afferent pupillary defect Swinging flashlight test +APD indicates optic nerve or large retinal lesion http://www.drbanker.com/images/nearvision.gif http://img.tfd.com/elmill/thumb/f0p-24-s2958.jpg Motility Confrontational Visual Fields Six extraocular muscles Test cardinal fields of gaze Cover eyes on same side Hold fingers midway between Normal per eye: 60-60-60-90 http://www.opsweb.org/opphoto/extern/motility/muscle.jpg http://www.opsweb.org/opphoto/extern/motility/9gazedwg.jpg http://www.ncbi.nlm.nih.gov/bookshelf/br.fcgi?book=cm&part=a3460&rendertype=figure&id=a3464 1
Penlight Exam Anterior Chamber Depth Lids Conjunctiva/Sclera Lashes Cornea Iris/Pupil Lens Puncta Deep chamber: illumination of nasal iris Shallow chamber: shadow on nasal iris Dilation: Phenylephrine 2.5%, Tropicamide 1% http://cache.heraldinteractive.com/blogs/sports/rap_sheet/wp-content/uploads/2009/11/bionic-eye.jpg http://iei.ico.edu/images/anatomy.jpg http://www.ophthobook.com/wp-content/uploads/2007/12/video-glaucoma-shallowpenlight.jpg Fundoscopy Primary Care Ophthalmology PanOptic or Direct Ophthalmoscope Evaluate optic nerve, retinal vessels, macula http://www.welchallyn.com/images/corporate/0509_wa_bmurf/011810xx1panopticredhe.jpg http://webvision.med.utah.edu/imageswv/retina.jpeg http://www.factzoo.com/sites/all/img/reptiles/chameleon-eyes.jpg The Red Eye Infectious Conjunctivitis VIRAL: Clear/mucoid discharge Lymphadenopathy Contagious! Treat for comfort BACTERIAL: Purulent discharge Culture: Staph, Strep, Hflu PolyTrim or Vigamox NOTTobraor Gent GC, chlamydia (IM/PO) http://i.zdnet.com/blogs/lord-of-the-rings-ii-eye-of-sauron-4900244.jpg 2
Allergic Conjunctivitis Blepharitis History of atopy Conjunctival edema Itchy! Topical antihistamines Zaditor Patanol/Pataday/Pazeo Visine tachyphylaxis Redness, itching, grit, dry eyes Rosacea, Staph, Demadex Warm compresses, baby shampoo, artificial tears Doxycycline, Azithromycin http://www.stop-rosacea.com/ Dry Eye Syndrome Herpes Simplex Burning, stinging, excess tearing (wind or cold) Blurry vision that improves with blinking Artificial tears, immunologics (Restasis, Xiidra) When to refer: V1, V2 red eye eye pain change in vision Acyclovir http://steptohealth.com/wp-content/uploads/2015/07/dry-eye.png Herpes Zoster Uveitis Hutchinson s sign: nasociliary nerve Treat Post-Herpetic Neuralgia: Lyrica, Neurontin, TCA s Inflammation of vascular tissue Auto-immune Infectious Toxic Masquerade May require immunosuppression 3
Angle Closure Glaucoma Subconjunctival Hemorrhage Headache Loss of vision Firm eye IV Diamox, Mannitol Glaucoma gtt s Surgical treatment Coughing/sneezing, HTN, anti-coagulation, eye rubbing, spontaneous Not dangerous unless vision has changed In the setting of trauma: refer http://sixfishes.com/_cache/assets/img/441-r-w320-q75-m1445457194.jpg Corneal Abrasion Corneal Foreign Body Pain! Loss of epithelium Not infected Erythromycin ung PolyTrim gtt Artificial Tears Patching Iron is toxic Surgical treatment Hyphema Ruptured Globe Severe eye trauma Risk of rebleed Risk of glaucoma Peaked pupil Brown tissue outside the eye CT scan NOT MRI Fox shield, NPO 4
Common Diseases of Aging Cataract Painless progressive loss of vision with age Also caused by DM, XRT, trauma, medications Difficulty reading, driving, glare Outpatient surgery http://www.jaredyellin.com/wp-content/uploads/2009/12/old-man-winking1.jpg Glaucoma Macular Degeneration Chronic progressive optic neuropathy Loss of visual field Risk factors: age, tobacco, race, family hx Medications may have systemic interactions http://img.medscape.com/fullsize/migrated/569/545/569545.fig2.gif http://cdn.shopmedvet.com/images/uploads/2640_7780_thumb.jpg Risk factors: age, UV, tobacco, Family Hx Loss of central vision Dry form: AREDS vitamins, stop smoking Wet form: anti-vegf injections Disorders of the Eyelid and Orbit Ptosis Loosening of eyelid muscle, extra skin Surgical repair http://greatpiercingshop.com/blog/wp-content/uploads/2009/12/eyelid-piercing-method-and-aftercare_49.jpg http://www.drduerksen.com/public/images/gallery/1366466717-1366466717-111052-(small).jpg 5
Trichiasis Ectropion/Entropion Eyelash growing inward toward the eye Epilation Electrolysis Ectropion: rotation of eyelid outward Entropion: rotation of eyelid inward Irritation of the ocular surface Surgical repair http://healthfixit.com/wp-content/uploads/2016/01/trichiasis-or-ingrown-eyelash-1.jpg http://www.shropshireeyecare.co.uk/sites/default/files/bilateral%20ll%20ectropion_2_0.jpeg http://www.lancashireeyeclinic.co.uk/wp-content/uploads/2014/09/lower-lid-entropion-6.jpg Chalazion Cellulitis Preseptal vs Orbital Blocked oil gland Inflammation Warm compresses Incision/curettage Preseptal: full EOM, no proptosis, quiet eye Treat PO Abx Orbital: proptosis, strabismus, inflamed eye Treat IV ABx Thyroid Orbitopathy Disorders of the Retina Proptosis Strabismus/Diplopia Corneal exposure Optic nerve compression 131-I may aggravate Surgical treatment http://webphysics.davidson.edu/faculty/dmb/edibleopticalmaterials/index_files/cyclops.jpg 6
Posterior Vitreous Detachment Retinal Detachment Flashes/Floaters Loss of vision/field Sudden, painless Separation of vitreous from optic nerve and retina Sudden appearance of floaters (ring/lines) Small risk of retinal tear when first occurs, otherwise benign Surgical treatment http://www.retinacarecenternj.com/images/p-pvd_diagram_100.jpg http://theretinagroup.com/wp-content/uploads/2015/06/screen-shot-2015-06-14-at-8.08.41-pm.png http://www.rameshshahmd.com/pictures/retinal%20detach.%201.jpg?nxg_versionuid=published Diabetic Retinopathy Hypertensive Retinopathy Microvascular disease Bleeding Macular edema Neovascularization Glucose/BP control Laser ablation Anti-VEGF Mild: arteriolar narrowing Mod: cotton wool spots, hemorrhages Severe: disc edema, vessel leakage, infarcts HIV/CMV Retinopathy Retinal Artery Occlusion Microvascular disease Annual exam if CD4>200 CMV retinitis Embolic: cardiac echo, carotid doppler Vasculitic (GCA) http://depts.washington.edu/hivaids/images/oit/oit_c7_d06.jpg 7
Retinal Vein Occlusion Neuro-Ophthalmology HTN/hyperlipidemia Glaucoma Young patients: hypercoagulable http://www.capitalgainsmedia.com/images/development%20news%20photos/dev-ino-issues%2002/dev-ino%20issue%200244/dsc01869.jpg Stroke Pituitary Adenoma Homonymous field defect Location of lesion is contralateral + upside-down Compression of nasal fibers at optic chiasm Bitemporal hemianopia http://www.lfhk.cuni.cz/patfyz/intranet/figures/58/18.13.jpg Temporal Arteritis Optic Neuritis Acute vision loss Headache, jaw claudication, scalp tenderness, proximal myalgias, constitutional symptoms ESR and CRP Prednisone 100mg QD Temporal artery biopsy Loss of vision Pain with EOM +/- disc edema Multiple Sclerosis Steroids http://www.djo.harvard.edu/files/2982_355.jpg 8
Pseudotumor Cerebri Horner Syndrome Headache, tinnitus Papilledema Vision loss Female, overweight Medication-induced LP: opening pressure Anisocoria in the dark Mild ptosis Acute and painful: R/O carotid dissection http://www.caleyes.com/images/papilledema-image.jpg http://www.mrcophth.com/oculoplasticgallery/traumatichorner/horner.jpg Third Nerve Palsy Thank You! Aniscoria in the light Severe Ptosis EOM paresis Microvascular PCA/PCom aneurysm http://www.nature.com/eye/journal/v18/n3/images/6700625f1.jpg http://www.revophth.com/images//2008/10/083_rpj8_f6.gif http://blog.omy.sg/dingan/files/2009/05/bob.jpg References Cynthia S., MD, FACS (510) 836-2122 Oakland, CA Dr.Cynthia.@gmail.com http://www.drgreene.com/21_1254.html http://www.bobzyeruncle.com/archives/images/conjunctivitis-gc.html http://www.ueseyecare.com/images/photos/allergic_conjunctivitis_l.jpg http://www.ueseyecare.com/images/photos/viral_conjunctivitis_l.jpg http://www.vigamox.com/images/packaging.jpg http://dro.hs.columbia.edu/ced3/conjhemb.jpg http://www.aafp.org/afp/20030401/1481_f3.jpg http://eyemicrobiology.upmc.com/images/sub/photoeyedendrite.jpg http://www.hkmj.org.hk/skin/images/108-1.jpg http://www.medicalskincare.be/images/content/herpes03.jpg http://www.tusalud.com.mx/images/herpes_zoster.jpg http://eyelearn.med.utoronto.ca/lectures04-05/redeye/images/11kera2.jpg http://www.nova.edu/~albert/scleritisweb.jpg http://www.mrcophth.com/externaleyediseases/sp.jpg http://e-learning.studmed.unibe.ch/augenheilkunde/systematik/aderhaut/images/iritis2.jpg http://www.emedicine.com/oph/images/456cmv7.jpg http://www.revoptom.com/handbook/images/62a.jpg http://images.google.com/imgres?imgurl=http://www.asoprs.org/graphics/gravesct.jpg&imgrefurl=http://www.asoprs.org/pages/thyroid.html&h=250&w= 429&sz=9&tbnid=ul6zL-4JdFYJ:&tbnh=71&tbnw=122&start=1&prev=/images%3Fq%3Dthyroid%2Beye%2Bmuscles%26hl%3Den%26lr%3D http://www.medscape.com/content/2002/00/44/63/446304/art-mop446304.coat.fig3.jpg http://www.jeremydiamond.co.uk/graphics/cataract_eye.jpg http://technology.kingston.ac.uk/dirc/medical/images/catara2.jpg http://www.drloden.com/pages/pics/cataract.gif http://www.eri.harvard.edu/faculty/peli/opthalm_mngt_0803_files/xnat.beauty.jpg http://www.avclinic.com/images/tonometry.jpg http://www.avclinic.com/glaucoma.htm http://www.lasikinstitute.org/glaucoma_whatis.html http://www.neec.com/images/photos/mitrev5.jpg http://www.rvscny.com/images/diabetic%20retinopathy.jpg http://www.tedmontgomery.com/the_eye/eyephotos/pics/diabeticretinopathyproliferative.jpg http://www.neec.com/images/photos/diabetic%20retinopathy%20figure%203.jpg http://www.tylin.com/system/uploads/gallery_image/image/681/080714_demo_burbank- 2 3 jpg 9
References http://www.gaileyeyeclinic.com/images/dr3.gif http://www.foxeyecare.com/canon/large/diabetic_retinopathy.jpg http://hubnet.buffalo.edu/ophthalmology/site/home/eye_disorders/hypertensive_retinopathy.jpg http://www.mrcophth.com/retinacases/cmv.gif http://www.opt.indiana.edu/ce/antseg/graphics/cwsaids.jpg http://www.ohiovalleyeye.com/images/macdegen_k45_dry.jpg http://www.opt.pacificu.edu/ce/catalog/10701-ps/4hemorr.jpg http://www.ttuhsc.edu/eye/faculty%20presentations/visual%20field%20testing%20tech%20seminar_files/slide0036_image002.jpg http://webeye.ophth.uiowa.edu/dept/gca/images/gcafig1b_.jpg http://www.ophthalmic.hyperguides.com/tutorials/oculoplastics/temporal_arteritis/slides/slide1.jpg http://www.mrcophth.com/pathology/gca2.jpg http://content.lib.utah.edu/ehsl-wfh/image/icon124.jpg http://www.atlasophthalmology.com/atlasimg/1396_6_low_thumb.jpg http://www.tedmontgomery.com/the_eye/eyephotos/pics/centralretinalarteryocclusion.jpg http://www.omnieyespecialists.com/images/eye_brao.jpg http://dro.hs.columbia.edu/vr3/crvob.jpg http://www.scielo.br/img/revistas/abo/v66n6/18991f1.jpg http://www.drugdigest.org/images/pillimages/a0315100.jpg http://ec1.images-amazon.com/images/i/31ityxvqypl._aa200_.jpg http://www.aafa.org/images/eye.jpg http://www.aclens.com/accessoryphotos/visine-advanced-relief-eye-drops-15-6683-v3b.jpg http://content.answers.com/main/content/wp/en-commons/thumb/6/69/420px-gray784.png http://eyelearn.med.utoronto.ca/lectures02-03/redeye/images/redeye_033.jpg http://www.varga.org/corneal_foreign_body_2.jpg http://www.permanente.net/homepage/kaiser/pictures/7945.gif http://www.medscape.com/pi/editorial/conferences/2001/747/art-aad-02.fig1.jpg http://www.opt.pacificu.edu/ce/catalog/10310-sd/trauma%20pictures/hyphema.jpg http://www.revoptom.com/handbook/images/25aa.jpg http://www.tedmontgomery.com/the_eye/eyephotos/pics/chalazion.jpg http://medicine.ucsd.edu/clinicalimg/eye-periorbital-cellulitis1.jpg http://eyelearn.med.utoronto.ca/lectures05-06/redeye/images/redeye_010.jpg 10