Current Topics in Ophthalmology Ophthalmology: Questions and Answers Jacque Duncan, MD Professor, Clinical Ophthalmology UCSF Primary Care Medicine: Principles and Practice October 30, 2013 With help from: Stephen D. McLeod, Professor and Chair, UCSF Department of Ophthalmology Ayman Naseri, Professor and Vice Chair for Graduate Medical Education, UCSF Department of Ophthalmology Disclosures: I have nothing to disclose Common Questions: 1. What does my patient need before undergoing cataract surgery? 2. Are vitamins really helpful in preventing vision loss? 3. What do I need to do for patients on Plaquenil? 1
Common Questions: 1. What does my patient need before undergoing cataract surgery? 2. Are vitamins really helpful in preventing vision loss? 3. What do I need to do for patients on Plaquenil? Cataract Surgery Most commonly performed ambulatory surgery in the US Numbers will increase as population ages Should I do an extensive medical evaluation to ensure my patient is safe to undergo surgery? True False Should I do routine medical testing (EKG, CBC, renal panel) to ensure my patient is safe to undergo surgery? 1. Yes 2. No No: Cochrane Review Routine pre-operative testing does not increase the safety of cataract surgery Intraoperative events (OR 1.02, 95% CI 0.85 to 1.22) Postoperative adverse events (OR 0.96, 95% CI 0.74 to 1.24). Costs estimated to be 2.55 times higher in those with preoperative medical testing compared to those without preoperative medical testing. 91.4% one year survival rate among VA pts with high disease burden Keay L, et al. Cochrane Database of Systematic Reviews 2012, Issue 3. Art. No.: CD007392 Schein O et al. NEJM 2000; 342:168-75 Greenberg PB et al. J Cataract Refract Surg 2011; 37:970-71 2
Should I discontinue my patient s anticoagulant or antiplatelet medications before cataract surgery? 1. Yes 2. No Answer: NO Most cataract surgery is done without any injections May increase medical morbidity Ophthalmologists need to communicate with primary care providers for patients with severe systemic disease, or when more invasive ocular surgery is planned. American Academy of Ophthalmology Cataract in the Adult Eye. Preferred Practice Patterns, 2006. Chen CK, Tseng VL, Wu W-C, Greenberg PB. J Cataract Refract Surg 2010; 36:1239-40. Ong-Tone L, Paluck EC, Hart-Mitchell RD. J Cataract Refract Surg 2005;31:991-6. Common Questions: 1. What does my patient need before undergoing cataract surgery? 2. Are vitamins really helpful in preventing vision loss? 3. What do I need to do for patients on Plaquenil? Age-Related Macular Degeneration Leading Cause of Severe Central Vision Loss among people over 50 in U.S. 6 million cases in U.S. 1.75 million over age 50 have advanced AMD Prevalence increasing as population ages Population >60 will double by 2030 Number with advanced AMD will increase 50% to 2.95 M by 2020 Eye Diseases Prevalence Research Group, Arch Ophthalmol 2004;122:564-72 3
Normal Retina Normal AMD Drusen Geographic Atrophy 4
Choroidal Neovascularization 10% of patients, 90% of severe vision loss Disciform Scar Nutritional Supplements in AMD Age Related Eye Disease Study (AREDS) Double-masked, placebo-controlled, multicenter, randomized clinical trial 3,640 patients, followed at least 5 years (average 6.3 years) Randomly assigned to high doses of: 1. Antioxidants Vit C 500mg, Vit E 400 IU, -carotene 15mg 2. Zinc=80mg Zn oxide + 2mg cupric oxide 3. Antioxidants + Zinc 4. Placebo AREDS Research Group, Arch Ophthalmol 2001;119:1417-36 Percent with Advanced AMD 50 40 30 20 10 0 Risk of Developing Advanced AMD Placebo Antioxidants Zinc Antioxidants+Zinc 0 1 2 3 4 5 6 7 Years 5
Age Related Eye Disease Study (AREDS) Recommend: All people > 55 years old should have dilated eye examinations If patients have medium to high-risk AMD in either eye, or advanced AMD in 1 eye: Consider supplemental vitamin C, E, zinc +copper Add -carotene if not a smoker Quit smoking if a smoker! AREDS 2 No additional benefit to adding lutein and omega-3 fatty acid supplementation Common Questions: 1. What does my patient need before undergoing cataract surgery? 2. Are vitamins really helpful in preventing vision loss? 3. What do I need to do for patients on Plaquenil? AREDS Research Group, Arch Ophthalmol 2001;119:1417-36 AREDS Study 2 Research Group, JAMA 2013:309:2005-15 63 year old woman PMH: Lupus with Sjogren s syndrome Meds: Treated with hydroxychloroquine 400 mg daily for 25 years (lifetime dose of 3,650 grams). Weight of 135 lbs = 6.52 mg/kg/d Complained of vision loss, but her ophthalmologist records visual acuity of 20/20 OU. She was told her vision was fine and not to worry. Stopped taking hydroxychloroquine in 2005 Monitored with serial Humphrey visual field tests: Visual fields: 2003 6
Visual fields: 2007 Visual fields: 2009 Fundus Photos: 2009 Retinal Toxicity and Hydroxychloroquine Rare relative to the many thousands/millions of individuals treated Of concern because even after drug cessation there is little if any visual recovery and sometimes progression of vision loss Mechanism not clearly understood Early symptoms: paracentral vision loss with foveal sparing Moderate: bull s eye maculopathy Late: loss of peripheral visual field, night vision, widespread fundus changes Toxicity can be prevented if the drug is discontinued before advanced macular outer retinal damage has occurred Marmor MF et al, Ophthalmology 2002; 109: 1377-82 7
Retinal Toxicity and Hydroxychloroquine Risk factors: Daily dose greater than 6.5 mg/kg/d IBW Obesity: drug is not retained in fat Duration of therapy greater than 5 years After 7 years: risk increases to 1% Cumulative dose > 1000 g Renal or hepatic dysfunction Age greater than 60 years Macular or retinal disease at baseline (AMD) Ideal body weight: women = 100 lbs + 5 lbs for each inch over 5 feet men = 110 lbs + 5 lbs for each inch over 5 feet Screening Protocol Patient counseling re: risk of permanent vision loss and need for periodic exams Baseline exam, then annually after 5 years Visual field testing: Sensitivity losses 2-6 degrees from fixation White: red is sensitive but not specific Even the most subtle change should prompt objective testing and referral to an ophthalmologist! Marmor MF et al, Ophthalmology 2011; 118: 415-22 Hydroxychloroquine/Chloroquine Screening recommendations Baseline: Dilated Eye Exam and Visual Field Testing Look for pre-existing disease that could contraindicate use or complicate interpretation of screening tests Consider baseline referral to optometry or ophthalmology Routinely check for toxic daily dosing: > 6.5 mg/kg ideal body weight No additional ophthalmic testing for the first 5 years for routine patients in absence of visual symptoms, renal or hepatic disease Browning DJ, Am J Ophthalmol 2013: 155: 418-28 Marmor MF, Am J Ophthalmol 2013; 155: 413-14 Hydroxychloroquine/Chloroquine Screening recommendations Follow up: Consider annual undilated visual fields and where available, SDOCT photos: sensitive and widely available Take any visual field changes seriously and evaluate with objective tests Refer to ophthalmology with any subjective or visual field changes for more advanced objective testing Require at least 2 methods (1 objective) to confirm toxicity before recommending drug discontinuation Browning DJ, Am J Ophthalmol 2013: 155: 418-28 Marmor MF, Am J Ophthalmol 2013; 155: 413-14 8
Common Questions (and Answers): 1. What does my patient need before undergoing cataract surgery? Excellent medical care by you and communication with ophthalmology! 2. Are vitamins really helpful in preventing vision loss? YES: AREDS for AMD 3. What do I need to do for patients on Plaquenil? Baseline and regular evaluations with visual fields and eye exams by opthalmology or optometry References Keay L, Lindsley K, Tielsch J, Katz J, Schein O. Routine preoperative medical testing for cataract surgery. Cochrane Database of Systematic Reviews 2012, Issue 3. Art. No.: CD007392. DOI: 10.1002/14651858.CD007293.pub3 Schein OD, Katz J, Bass EB, Tielsch JM, Lubomski LH, Feldman MA, Petty BG, Steinberg EP. The value of routine preoperative medical testing before cataract surgery. N Engl J Med 2000;342:168-75. Greenberg PB, Tseng VL, Jiang L, Wu W-C. Cataract surgery in the very ill. J Cataract Refract Surg 2011;37:970-971 American Academy of Ophthalmology Cataract in the Adult Eye. Preferred Practice Patterns. San Francisco, CA(2006). Available at www.aao.ppp Chen CK, Tseng VL, Wu W-C, Greenberg PB. Survey of the management of antithrombotic therapy in cataract surgery patients. J Cataract Refract Surg 2010; 36:1239-40. Ong-Tone L, Paluck EC, Hart-Mitchell RD. Perioperative use of warfarin and aspirin in cataract surgery by Canadian Society of Cataract and Refractive Surgery members: Survey. J Cataract Refract Surg 2005;31:991-6. Milam AH, John SK. The Human Retina in Heath and Disease CD-ROM. Phiadelphia, PA, Scheie Eye Institute, 2001. Eye Diseases Prevalence Research Group, Arch Ophthalmol 2004;122:564-72. AREDS Research Group. A randomized, placebo-controlled, clinical trial of high-dose supplementation with vitamins C and E, beta carotene, and zinc for age-related macular degeneration and vision loss: AREDS report no. 8. Arch Ophthalmol 2001;119:1417-36. AREDS Study 2 Research Group. Lutein + zeaxanthin and omega-3 fatty acids for age-related macular degeneration: the Age-Related Eye Disease Study 2 (AREDS2) randomized clinical trial. JAMA 2013:309:2005-15. Marmor MF et al, Ophthalmology 2002;109: 1377-82. Marmor MF et al, Ophthalmology 2011; 118: 415-22. Lyons and Severns, Am J Ophthalmol 143:801-9, 2007. Browning DJ, Am J Ophthalmol 2013: 155: 418-28 9