Chronic eye diseases Title of section divider What s new, and how GPs can help Eg. Case Study 1. Dr Jesse Gale, ophthalmologist 1
Title of section divider Cataract Eg. Case Study 1. 2
Cataract - what s old? Cataract surgery remains the most cost effective intervention to improve quality of life Cataract surgery is quick day-case surgery under topical anaesthetic, with improved vision immediately. The only systemic contraindication to cataract surgery under local anaesthetic is the inability to lie still and flat. 3
Cataract - what s new? Improved biometric devices and smaller wounds result in ever greater precision in refractive outcomes, amongst a greater range of eyes. Multifocal lenses attempt to provide near and distance vision, but the trade off is haloes, glare. Often we try blended or monovision with one eye focused near, the other distant. 4
Cataract how can GPs help? Prioritisation in the DHB is always the central issue. Currently the threshold is around 6/18 for first eye and 6/60 for second eye. These referral acuities need to be based on corrected vision, with glasses or pinhole. If you refer directly, please include pinhole acuity, visual fields, and red reflex. Post op: patients can resume normal activity immediately, should take drops for around 4 weeks, can drive as soon as acuity is normal. 5
Glaucoma Title of section divider Eg. Case Study 1. 6
Glaucoma what s old? Glaucoma is accelerated wear and tear of the optic nerve. It is asymptomatic, subtle, and cannot be detected in general practice. No suitable screening tests exist for community screening. Opportunistic screening at optometry will miss a proportion. Half remain undiagnosed. Glaucoma can occur at any pressure: IOP is a risk factor. The only treatment is to lower the IOP, slowing deterioration. Presentation and name 1/06/2017 7
Glaucoma what s new? New treatments to lower IOP without lowering quality of life are coming online. New drops that are more effective and reduce fluctuations in IOP New drug delivery devices to improve compliance, reduce side effects 8
Glaucoma what s new? New treatments to lower IOP without lowering quality of life are coming online. New drops that are more effective and reduce fluctuations in IOP New drug delivery devices to improve compliance, reduce side effects New SLT laser is safe and repeatable, now available at DHB too 9
Glaucoma what s new? New treatments to lower IOP without lowering quality of life are coming online. New drops that are more effective and reduce fluctuations in IOP New drug delivery devices to improve compliance, reduce side effects New SLT laser is safe and repeatable, now available at DHB too Increased use of cataract surgery to lower IOP, sometimes combined with new minimally invasive glaucoma surgery Presentation and name 1/06/2017 10
Glaucoma what s new? New treatments to lower IOP without lowering quality of life are coming online. New drops that are more effective and reduce fluctuations in IOP New drug delivery devices to improve compliance, reduce side effects New SLT laser is safe and repeatable, now available at DHB too Increased use of cataract surgery to lower IOP, sometimes combined with new minimally invasive glaucoma surgery New treatments independent of IOP such as gene therapy or stem cells. 11
Glaucoma how can GPs help? Diagnosis recommend glaucoma checks by optometrists for patients with family history or steroid use. Management please continue any glaucoma drops the patient wants please be forthcoming with concerns about side effects: 12
Glaucoma how can GPs help? Diagnosis recommend glaucoma checks by optometrists for patients with family history or steroid use. Management please continue any glaucoma drops the patient wants please be forthcoming with concerns about side effects: Prostaglandins (latanoprost = Hysite, travoprost = Travatan, bimatoprost = Lumigan) all cause red eyes, irritation, blepharitis, and prostaglandin associated periorbitiopathy. Presentation and name 1/06/2017 13
Glaucoma how can GPs help? Diagnosis recommend glaucoma checks by optometrists for patients with family history or steroid use. Management please continue any glaucoma drops the patient wants please be forthcoming with concerns about side effects: Beta-blockers (timolol, betaxolol) cause typical side effects: hypotension, bronchospasm, depression, cognitive difficulty, loss of libido, hypo-joie de vivre. 14
Glaucoma how can GPs help? Diagnosis recommend glaucoma checks by optometrists for patients with family history or steroid use. Management please continue any glaucoma drops the patient wants please be forthcoming with concerns about side effects: Others brimonidine, brinzolamide (Azopt), dorzolamide (Dortim, Trusopt) cause surface reactions 15
Glaucoma how can GPs help? Diagnosis recommend glaucoma checks by optometrists for patients with family history or steroid use. Management please continue any glaucoma drops the patient wants Follow up please be forthcoming with concerns about side effects: stop the medication and inform the ophthalmologist patients should hassle the clinics when appointments overdue optometrists can help check IOP or visual fields 16
Macular degeneration Title of section divider Eg. Case Study 1. 17
Macular degeneration what s old? Dry AMD supplements are prescribed when intermediate risk, usually on ophthalmic advice. Neovascular ( wet ) AMD usually responds well to intravitreal anti-vegf medications, which has created a revolution in treatment but also a huge burden of ongoing care in the eye clinic for increasing numbers of elderly Major cause of blindness in New Zealand. 18
Macular degeneration what s new? More intravitreal treatments are emerging, with more potency and longer duration, but still too expensive. A disruptive cost saving drug may be available soon after legal battles! Nurse injectors are about to begin in Wellington, have started procedures in Masterton. Presentation and name 1/06/2017 19
Macular degeneration what s new? Micropulse laser for reducing drusen is of limited benefit. Available in Hamilton on referral from an ophthalmologist. Intraocular magnifiers have optical downsides. Available in Tauranga on referral from an ophthalmologist. 20
Macular degeneration what s new? Genetic testing may allow younger family members to understand who benefit from supplements. The recommended vitamins A, C, E and Zinc have been rationalised and retested. Vitamin A was removed due to lung cancer risk, zinc dose was reduced for copper depletion, and two antioxidants zeaxanthin and lutein were added. Blackmores Macu-Vision and Lutein Defense is $1.40/day, cheaper versions may be available online. 21
Macular degeneration how GPs help? Recognise distortion as a key symptom for wet AMD, an Amsler grid can be helpful. This requires an acute referral. Rather than advising about supplements, suggest the Macular Degeneration NZ toll free number and brochure on diet and supplements. Low vision services are now available in the community, offering magnifiers and lights. Optometrists can refer to Blind foundation (6/24). Presentation and name 1/06/2017 22
Diabetic retinopathy Title of section divider Eg. Case Study 1. 23
Diabetic retinopathy what s old? The concept of diabetic retinopathy as a microvascular disease, causing accumulating ischaemia and VEGF, followed by unhealthy responses. This has stood the test of time. When complications arise, laser is used to ablate the retina cautiously, resulting in many clinic visits and long term observation. Low-oxygen help signals (VEGF) 24
Diabetic retinopathy what s old? The concept of diabetic retinopathy as a microvascular disease, causing accumulating ischaemia and VEGF, followed by unhealthy responses. This has stood the test of time. When complications arise, laser is used to ablate the retina cautiously, resulting in many clinic visits and long term observation. 25
Diabetic retinopathy what s new? The optical coherence tomograph (OCT) shows incredible detail and now optometrists are using them in the community to reduce referrals (some ethical issues about costs). Fenofibrate and ACE inhibitors show specific benefits in reducing maculopathy independent of cholesterol or BP. Avastin has reduced the need for laser, improved outcomes, but demand is soaring. In worst eyes the newer Eylea may be best treatment, but not funded. 26
Diabetic retinopathy how GPs help? Enrol patients for community screening, especially pregnant women. Manage sugars, blood pressure and cholesterol (consider ACE-I, fenofibrate, as appropriate). Recognise blur with floaters or distortion as symptoms of advanced or complicated diabetic retinopathy, require urgent referral to clinic. 27
Summary Title of section divider Eg. Case Study 1. 1/06/201 Presentation and name 28 7
Summary Cataract DHB threshold is 6/18 first eye with glasses or pinhole. Glaucoma please don t be shy to report side effects, refer to optometrist for IOP and field check ups if appointments are overdue. Macular degeneration MDNZ provides useful advice on diet and supplements for dry AMD, optometrists can provide low vision services and register with Blind foundation Diabetic retinopathy Make use of community screening, but recognise blur with floaters or distortion as symptoms of advanced disease. Presentation and name 1/06/2017 29
More information Title of section divider Dr Jesse Gale Eg. Case Study 1. Capital Eye Specialists, Level 2, 148 Cuba St, Wellington 6011 jg@ces.net.nz 1/06/201 Presentation and name 30 7