Transcript inflammation - Nevada Optometric Association

HE SAID, SHE SAID
Jill Autry, OD, RPh
Eye Center of Texas, Houston
[email protected]
FUCH’S DYSTROPHY
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Endothelial corneal disorder
Women > Men, 3:1 and more severely
Progresses with age
Stages
– Guttata
– Stromal and epithelial edema
– Corneal scarring
• Muro-128 5% solution/ung
• DSAEK
Who Gets Dry Eye?
• Women>Men
• Older>Younger
• Patients with autoimmune diseases
• Lupus, rheumatoid arthritis, sarcoid,
Sjogren’s, thyroid disease, rosacea, etc.
• Post-menopausal
• Medication induced
• Hormonal therapy, antidepressants, anxiolytics
Inflammation and Dry Eye
• Research clearly shows corneal, conjunctival and
lacrimal gland inflammation as a major cause of
dry eye syndrome.
• Ongoing inflammation results in the increase
production of cytokines and activated T-Cells that
mediate the inflammatory process
• Inflammation acts to shut down the components of
good tears
SJOGREN’S
• Autoimmune disease that attacks the
exocrine glands
• Associated with rheumatoid arthritis
• Specifically lacrimal and salivary glands
• Women>Men
• Increases with age
• Diagnosis often made with signs/symptoms
• Positive SSA and SSB serum autoantibodies
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Restasis
Proven To:
• Decreases inflammation in the cornea,
conjunctiva, and lacrimal gland
• Increases tear production
• Increases goblet cell density
• Decreases SPK
• Decrease dependence on artificial tears
• Excellent safety profile
– Cyclosporine undetectable in blood
Restasis® Recommendations
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BID dosing in most cases-not PRN
Severe cases use QID with a steroid initially
Continue artificial tear use initially
Burning initially or later as ocular surface heals
Use before and after contact lenses (15 minutes)
Persistence with therapy
– Results are 2-3 months away
• Discuss long-term therapy
– May attempt once daily dosing when controlled
• Mail order (90 day supply);2 boxes=1 month supply
Edward Wade, M.D.
Chris Allee, O.D.
Ting Fang-Suarez, M.D.
Jill Autry, O.D.
Mark Mayo, M.D.
Randy Reichle, O.D.
6565 West Loop South
Bellaire, TX 77401
Phone (713)797-1010
4415 Crenshaw Rd.
Pasadena, TX 77504
Phone (281)998-3333
15400 SW Frwy
Sugar Land, TX 77478
(281)277-1010
450 Medical Ctr Blvd, #305
Webster, TX 77598
(281) 332-1397
11914 Astoria Boulevard, #325
Houston, TX 77089
(281) 484-2030
21700 Kingsland Blvd.
Katy, TX 77450
(281) 578-4815
NAME
Jill Autry
AGE ______________
ADDRESS_____________________________________________________DATE
Rx
3-3-11
Restasis 1 gtt bid OU
One month supply (2 boxes=one month supply)
Three month supply (6 boxes=three month supply)

Pharmacist please note: 1 month supply=2 boxes per PPI
REFILLS--
one year
Jill Autry, O.D.
Estrogens vs. Androgens
• Androgens important in the quality/quantity of oily
secretions
• Androgen levels decrease with age resulting in
– Increased meibomian gland dysfunction
• Results in evaporative dry eye
– Lacrimal gland inflammation
• Results in aqueous deficiency
• May explain post-menopausal dry eye
• Sjogren’s patients show decreased androgen levels
ACNE ROSACEA
• Redness/telangiectasia/papules on the
cheeks, nose, and forehead
• More common in women
• More severe in men
• Fair or light skinned patients more common
and more severe
• Increased meibomian dysfunction and
blepharitis with ocular rosacea
DOXYCYCLINE
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50mg bid
No with children < 8 years old/pregnant/nursing.
qd to bid dosing
Can take with food
Can take with dairy products
Cannot take with antacids
Can cause photosensitivity
Cannot take before lying down
– Must wait 2 hours to avoid esophageal ulceration
VERNAL
KERATOCONJUNCTIVITIS
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Young Males > Young Females, 3:1
Seasonal pattern during warmer weather
Bilateral, severe itching with thick, ropy discharge
Exam
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Giant papillae under upper lid
SPK
Trantas’ dots
Shield ulcers (severe cases)
Thickened eyelids
VERNAL
KERATOCONJUNCTIVITIS
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Mast cell stabilizers
Topical and oral antihistamines
Topical and oral NSAIDS
Restasis
Topical steroids for severe exacerbations
Shield ulcer
– Antibiotics
– Cycloplegic
– Bandage CL
EPISCLERITIS
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Women > Men and more severely
Sectoral injection on bulbar conjunctiva
Mild tenderness to area
Superficial conjunctival vessels and deeper
episcleral vessels involved
• Treat with PF/Durezol q2h to start
• Taper as usual with response
MANAGEMENT
• Refer for bloodwork with multiple
recurrences/bilateral involvement
• Nodular episcleritis more typical of
systemic disease
• Refer if severe pain and/or bluish color to
conjunctiva
– Typical of scleritis
• Refer if unresponsive to topical steroid
treatment
IRITIS
• Women > Men
• Unilateral pain, circumcorneal injection,
photophobia, decreased VA
• C/F in AC, KP on corneal endothelium,
posterior synechiae, decreased/increased IOP
• Traumatic, postoperative, idiopathic,
systemic associations
• PF/Durezol q1-2h, cycloplegic, glaucoma
drops PRN
MANAGEMENT
• Most cases easily managed without referral
• Need to taper steroid over 1-2 weeks
• Refer for bloodwork/x-rays if repeat
episodes or bilateral
• Refer if unresponsive to topical therapy
– May need subconjunctival steroid injection
• Refer if posterior uveitis present
GENDER & INFLAMMATION
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Lupus (W)
Sarcoid (W)
Rheumatoid arthritis (W)
Ankylosing spondylitis (M)
Reiter’s (M)
Juvenile rheumatoid arthritis (W)
Psoriatic arthritis (W = M)
INFLAMMATORY LABS
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Lupus (ANA)
Sarcoid (ACE, Chest X-ray)
Rheumatoid arthritis (RF)
Ankylosing spondylitis (HLA-B27, sacroiliac
spinal films)
• Reiter’s (HLA-B27, joint x-rays)
• Pars planitis (HLA-B27)
• Psoriatic arthritis (ESR-Sed rate)
MACULAR HOLE
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Progress from Stage 1 to Stage 4
Women>Men
Older>Younger
Idiopathic mostly, occasionally traumatic
Best diagnosed with OCT
Full-thickness holes generally 20/200 VA
Round, dark red colored area in the center of the
macula
• Often with yellow, lipofuscin granules
MACULAR HOLE
• Distinguish from ERM pseudohole
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Macular hole perfectly round
Poor vision with macular hole
Positive Watzke-Allen with macular hole
Pseudohole with tortuous surrounding vessels
• Can follow Stage 1 and 2 holes but get
macular OCT for follow-up
• Amsler grid
MACULAR HOLE SURGERY
• Vitrectomy with membrane peel (ILM)
• Gas fluid exchange
• Face-down positioning for 2 weeks until gas
bubble absorbs
• Watch IOP closely with gas bubble
• No flying until gas bubble completely
resorbs
• Can use silicone oil but need second surgery
EXPECTED OUTCOMES
• 90% expected closure
• Expected visual outcomes dependent on
length of time macular hole present
– Best outcomes within one year
– Prognosis decreases with each year
• Average gain is 2 lines VA
CENTRAL SEROUS
RETINOPATHY
• Mostly in young (20-50yo), male patients
• Recently being reported more in women,
especially during pregnancy
• Mildly reduced VA, metamorphopsia
• Round, serous RPE detachment
• Usually resolves in 2-3 months without tx
• Controversial treatment with Diamox
MANAGEMENT
• Need baseline fluorescein to rule-out other
causes of serous detachments
– Pinpoint leakage followed by smokestack
• Can follow thereafter by monitoring VA
and macular appearance
• Watch for recurrences over time
• Rare CNV or PED in future secondary to
RPE disturbances
PIGMENTARY GLAUCOMA
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Flacid, peripheral iris bows posteriorly
Believed to rub against lens zonules
Releases iris pigment
Decreases trabecular meshwork function
One-third of pigmentary dispersion patients
will develop pigmentary glaucoma
• Bilateral
CHARACTERISTICS
• Demographics
– Young
– Myopic
Male
Caucasian
• Mid-peripheral iris transilluminating defects
(TID)
• Krukenberg spindle (K spindle)
• Heavy pigment in trabecular meshwork on
gonioscopy
• Acute IOP rise after exercising
POSSNER-SCHLOSSMAN
• More common in middle-aged males
• Open angle with high IOP (40-60)
• Patient not in pain, eye is white, cornea
without edema
• Mild C/F in AC, KP on cornea, mildly
decreased VA
• PF/Durezol q2h and glaucoma drops; avoid
prostaglandins if possible
MANAGEMENT
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Can be easily managed without referral
HOWEVER…
Watch for exacerbations
Requires close and frequent follow-up
Trabecular meshwork often weakened and
IOP is hard to control even when uveitis
subsides
• Patient often without symptoms and IOP
could be very high causing VF loss
OPTIC NEURITIS
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Decreased vision over days
Unilateral
Pain on eye movements
Decreased color vision (red cap test)
+ RAPD
Visual field defects vary
Swollen disc or retrobulbar
MRI of Brain and Orbits with Flair sequencing
OPTIC NEURITIS
TREATMENT TRIAL (ONTT)
• Recommends treatment with IV
methylprednisolone x 3 days
• Avoid prednisone orally until AFTER
treatment with IV (10-14 days)
• Hastens visual recovery but not final visual
outcome
• Prolongs time to development of MS
• Do not use oral steroids alone
MULTIPLE SCLEROSIS
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Female > Male
18-45 years old
Intermittent diplopia
Optic neuritis
Nystagmus
Tingling or numbness in extremities
Uhtoff’s sign
– Worsening vision with increased body temperature
• Lhermitte’s sign
– Shock-like sensation with neck flexion
PSEUDOTUMOR CEREBRI
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Papilledema
Negative MRI of Brain
Negative MRV of Brain
Increased opening pressure on lumbar puncture
Normal CSF composition
Obese females (Diamox and weight loss)
Pregnancy (Diamox after 20 weeks gestation)
Medication induced (remove offending agent)
PAPILLEDEMA SIGNS
• Bilateral ONH swelling caused by increased
intracranial pressure
• Peripapillary swollen NFL
• Blurring of disc margins
• Blurring of ONH vasculature
• Peripapillary flame shaped hemorrhages
• Enlarged blind spots on VF testing
• No RAPD
PAPILLEDEMA SYMPTOMS
• Transient obscurations of vision lasting
seconds (usually bilateral)
• Headaches worse upon wakening
• Diplopia secondary to 6th nerve palsy
• Little or no vision loss
*unless chronic
• Color vision intact
*unless chronic
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FLOMAX
• Alpha-1 blocker used in men for BPH
• Benign Prostatic Hypertrophy (BPH)
• Initial study; 15/16 patients exhibited floppy iris
syndrome
• Can cause miosis, prolapse, excessive movement,
PC rupture during cataract surgery
• Pre-op atropine or intraoperative alpha agonists
may help
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FLOMAX
• Notice how pupil dilates in office
• Discontinue before referral; however, may
not stop the syndrome
• Other alpha agonists are not as selective and
have not consistently shown syndrome
– prazosin-Minipress®
– terazosin-Hytrin®
– doxazosin-Cardura®
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TAMOXIFEN
• Breast cancer oral treatment/prophylaxis
• Most commonly after one year of therapy
• Macular refractile bodies and RPE changes
– Does not warrant discontinuation
• Color vision decreases or CME develops
– STOP MED
RETINAL CHANGES
• Chloroquine/Hydroxychloroquine
(Plaquenil)
– Early changes
• Retinal parafoveal granularity of RPE
– Late changes
• Bull’s eye appearance of the macula
• Choroidal filling defects on FA
• Distorted color vision
PLAQUENIL MONITORING
• Baseline (or within one year of initiation)
• Routine monitoring
– Dose and risk factor dependent
– More frequent
• Dose > 6.5 mg/kg/day for greater than 5 years
• Age > 60, kidney/liver disease, coexisting retinal disease
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Dilated fundus examination
Amsler grid
10-2 Visual field
Color vision testing
ERECTILE
DYSFUNCTION
 Viagra®
• Bluish color vision defects reported especially
with increased dosage amounts
• Concomitant nitrate use causes hypotension
• Avoid in Retinitis Pigmentosa patients
• Association with ischemic optic neuropathy
 Cialis ®
 Levitra ®
OPTIC NEUROPATHY
• Sildenafil (Viagra®)
– Used in the treatment of erectile dysfunction
– WHO classification: Possible
– Anterior Ischemic Optic Neuropathy
• Painless, immediate loss of vision
• Swollen optic nerve with APD
• Altitudinal defect
– Users are older with vasculopathic conditions
– Consider not using med with history of AION or
small optic nerve cupping
TOPAMAX
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Acute myopia; up to 6-8 diopters
Most cases within one month of initiation
Secondary angle closure
Choroidal effusion and ciliary body edema
Can lead to anterior displacement of lens and
acute angle closure with increased IOP
TOPAMAX INDUCED
ANGLE CLOSURE
• Secondary angle closure
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Shallow AC
Red eye, pain, high IOP, mydriasis
Superchoroidal effusion, not related to pupillary block
Ciliary body edema, not relieved by peripheral
iridotomy (PI)
– Need to DC med as quick as possible
– Must be tapered;cannot stop abruptly
• Hyperosmotic therapy, cycloplegic, topical
antiglaucoma agents
MIGRAINES
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Women>Men; 3:1
Generally starts before 20 years of age
Often have family history
May have nausea and vomiting, fatigue,
photophobia
• Headaches predominantly on same side;may
occasionally switch sides
• Headache triggers
-Stress
-Bright lights
-Chocolate
-Alcohol
-BC pills
-Pregnancy
MIGRAINE RELATED AURA
• Flashing lights, heat waves, jagged objects,
tunnel vision, colored spots
• Lasting 15 to 30 minutes
• May or may not be accompanied by HA
• Acephalic migraine
– History of migraine is common
CLUSTER HEADACHES
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Unilateral
Very painful
Typically affects men
Lasts minutes to hours; typically occurs at
same time each day
• May disappear as easily as they appeared
• May see ipsilateral tearing, rhinorrhea,
Horner’s
ADIE’S TONIC PUPIL
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Usually female
Poor reaction to light
Slow constriction to near
Slow redilation following near constriction
Vermiform movement
Constricts to 0.125% pilocarpine
Long standing can result in small pupil