Eye Care for Health Care Providers
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Transcript Eye Care for Health Care Providers
Len Oshinskie, O.D.
Chief, Optometry Section
Newington VA Medical Center
Topics
Laser-assisted Cataract surgery
Age-related macular degeneration
Diabetic Macular Edema
Glaucoma and Medications
Red eye
Dry eye
Practical advice
Common Causes of Blindness
and Visual Impairment
Age-related macular
degeneration
Diabetic retinopathy
Glaucoma
Cataract
Femtosecond laser
Approved by FDA for several steps in cataract surgery
in 2009-2010
Uses laser energy at 1053 nm that is precise to 3
microns( lens capsule is 2-28 microns thick)
Ultra short pulse does not damage surrounding tissue
(10-15 of a sec)
Femtosecond
laser assisted
cataract surgery
Advantages to laser assisted
cataract surgery
Incisions more reproducible than bladed incisions
Less risk for capsular rupture
More precise opening so IOL can be more accurately
placed
Less energy from phaco probe for at risk pts, less
inflammation
Perhaps less risk of infection
Disadvantages of laser assisted
cataract surgery
Takes longer
Requires expensive equipment
Capsulorhexis not always complete
Not paid for by Medicare
Pts have higher expectations
Age-related macular degeneration
Leading cause of blindness over age 65
Drusen and pigment atrophy and clumping
exudative changes(heme, lipid, small central
retinal detachments)
sudden distortion of vision, new unilateral
blur, scotoma, difficulty reading
Macular Degeneration Types
Atrophic (dry) AMD 80-90%
Neovascular(wet) AMD 10-20%
Drusen
AREDS 1
500 mg vit C
400 IU vit E
15 mg betacarotene
80 mg zinc
2 mg copper
Over 5 yr followup reduced risk of progression to
advanced AMD by 25 % if pt had certain macula
findings(larger drusen)
AREDS 2 results May 2013
JAMA 2013: 309(19):2005-2015
Placebo controlled clinical trial(AREDS 1 was placebo)
Multiple arms: lutein 10 mg/zeathanthin 2 mg,
DHA(350 mg) and EPA(650 mg), both, AREDS 1
AREDS 1 formula with lutein/zeaxanthin(removing
betacarotene) slightly reduced risk of developing
advanced AMD
Adding DHA and EPA did not reduce risk
Risks with AREDS 2
Large dose of vit E(prostate and heart failure)
Coumadin users
Genetics and AMD
One study to suggest genetic testing maybe important
before prescribing AREDS supplement
Exudative (Wet) AMD
Early exudative AMD
OCT
ocular coherence tomography
Br J Ophthal 1997; 81:154-162
A significantly increased expression of VEGF
(p=0.00001) and TGF-β (p=0.019) was found in the
retinal pigment epithelium (RPE) of maculae with
AMD compared with control maculae.
Anti-VEGF medications
Macugen(Pegaptanib) 2004
Avastin(bevacizumab) 2005 but not FDA approved
Lucentis(ranibizumab) 2006
Eylea(aflibercept) 2011
Intravitreal injection
Studies on Treatment of Wet AMD
(ETDRS visual acuity chart)
Visual Acuity with Eylea
Ocular side effects
Cataract
Inflammation
Retinal detachment
endophthalmitis
Jetrea(ocriplamin)
Intravitreal injection
Approved for treatment of vitreo-retinal adhesions
Side effects-transient vision decrease and
inflammation
Aspirin use in pts with wet
AMD
Conflicting reports
Recent studies suggest an increased risk, but not
randomized
If risks for CV complications,
suggest continuing ASA
Trends in Treating Diabetic
Retinopathy
Mechanism of Diabetic Macular
Edema
Hyperglycemiathickened endothelial
cellsIschemia increased VEGF, loss of pericytes
Macular edema :
increased permeability
increased hydrostatic pressure
dilating blood vessels, pericytes disrupted
Inflammatory component
Treatment of Diabetic Macular
Edema
Anti-VEGF treatment
Corticosteroids
Laser
Anti-VEGF treatment of DME
Lucentis more effective than sham or laser in
decreasing thickness and improving vision
Lucentis as adjunct to laser more effective than laser
alone in decreasing thickness and improving vision
Eylea showed improved vision compared to laser
Lucentis approved by FDA for Tx of DME
What to tell your patients about
intravitreal injections
Does not hurt as much as you think
Very safe (2.1% have ocular complications)
Multiple injections needed
Very effective in preventing vision loss
It usually take several weeks for vision to
improve/stabilize
Post op: expect mild soreness, irritation, floaters,
subconj heme
Report any sudden vision changes or pain stat
There may be small risk for CVA
Marijuana and glaucoma
AAO June 2014 recommendations:
Only lowers IOP 3-4 hours
Not as effective as available medications
Potential for abuse
Potential for lung damage
Lowers BP (less perfusion)
Topical THC drops tried but not effective(not water soluble
enough)
effects of Marinol on glaucoma are not impressive
No standardization of dose with various forms of
marijuana plants
Not legal in federal system
Plaquenil Monitoring
Visual field
OCT and FAF
Focal ERG
Topiramate
Angle closure glaucoma
Visual field defects
Tear film composition
Lipid, aqueous, mucin
Tear film components
Lipid-Meibomian glands
aqueous-lacrimal gland
Mucin-goblet cells
Ideal tear film
has uniform thickness
maintains corneal coverage between blinks
limited debris
Dry eye
Multifactorial disease of tears and ocular surface
Discomfort, vision changes and tear film instability
Decreased tear production, increased osmolarity and
inflammation of ocular surface
Dry Eye Cascade
.
Clin Ophthalmol. 2009; 3: 405–412
Guidelines from the 2007 International Dry Eye
Workshop
BY MICHAEL A. LEMP, M. D. AND GARY N. FOULKS, M. D.
.
Dry Eye Disease
Stevenson et al in
Arch Ophthalmology
2012;130:90-100
Dry Eye Symptoms
Dryness
Irritation/burning(“hurt”)
Foreign body sensation(“sand in my eyes”)
Watering
Intermittent blurred vision
Itching
Differential Diagnosis Pt with
Symptoms of Dry Eye
Blepharitis
Rosacea
Exposure keratitis (TAO, CN 7 palsy,ectropion )
Risk factors for Dry Eye
Stevenson et al. Arch Ophthalmology 2012;130:90-100
Increased age
Female >males
Hormonal inbalance
Autoimmune disease
Vitamin deficiency
Medications
Environmental stress
Contact lens use
Ophthalmic surgery(LASIK)
Contributors to Dry Eye
Air flow(AC, fans etc)
Humidity
Smoke
Alcohol
Antihistamines
Diuretics
Blink rate(reading and computer)
Evaluation of the Dry Eye Patient
History
Tear Breakup time-quality
Schirmer-quantity
Corneal staining(fluorescein or lissamine green)
Tear wedge-quantity
Osmolarity
Break up Time
Corneal staining
Tear Wedge
Lid Position
Proptosis
Lagophthalmus
Ectropion
Parkinson’s
CN VII palsy
Partial blinker
Sleep apnea
Treatment
Artificial tears-preserved and non-preserved
Restasis(topical cyclosporin A)
Topical corticosteroids
Omega 3/Fish Oil
Qhs ointment
Tetracyclines
Punctal plugs
tarsorrhaphy
Using Artificial tears
Avoid OTC “gets the red out” drops
Use drops that say lubricant or artificial tears
Must use 4 times a day
Don’t touch tip of bottle to eye or lids
Systane Balance
Refresh Optive Advanced
FreshKote(by Rx only)
Give ointment at night ?
Punctal plugs
My patient has glaucoma, is it
safe to prescribe them_____?
antihistamines
tricyclic antidepressants
Parkinson's disease
anti-cholinergics such as atropine
anti-spasmolytics
anti-psychotic medications
Glaucoma Classification
• Primary, chronic or idiopathic
•
•
•
•
type(open angle)
secondary forms: pseudoexfoliation,
pigmentary, uveitic, steroid induced,
traumatic, post-op, others)
low-tension or normal-tension type
developmental type
angle-closure type
Narrow angle and dilated pupil
Meds to avoid if pt has
narrow angles
Antihistamines and decongestants: Pseudoephedrine,
diphenhydramine , hydroxyzine, and clemastine
fumarate
Asthma medicines: Albuterol, metaproterenol sulfate,
isoetharine, and theophylline
Motion sickness medicines: Scopolamine and
dimenhydrinate
Tricyclic antidepressants, such as amitriptyline,
nortriptyline , doxepin, clomipramine amoxapine,
chlordiazepoxide and amitriptyline ), trimipramine
and imipramine.
Risk factors for acute angle-closure
glaucoma
Age 55-70
Hyperopia
females
Asians
Signs/Symptoms of Acute Angle
Closure Glaucoma
Pain
hazy/blurred vision
haloes around lights
frontal HA
nausea/vomiting
Fixed pupil
Steamy cornea
Red eye
Glaucoma Medications
Prostaglandin analogs(Xalatan, Lumigan,
Travatan Z, Zioptan, latanoprost)
beta-blockers( Ocupress, Betagan, Betoptic S,
Betimol, Istalol, timolol)
alpha agonist(Alphagan P, brimonidine)
CAI(Trusopt, Azopt, dorzolamide)
Combo meds(Cosopt, Combigan, Simbrinza)
miotics(pilocarpine)
Oral carbonic anhydrase inhibitors(Diamox)
Differential Diagnosis of the Red
Eye
Infectious(bacterial, viral, fungal)
Inflammatory(uveitis, episcleritis,scleritis)
Increased IOP
Allergic
Mechanical(lid, FB, contact lens)
Dry eye
Toxic
Differential Diagnosis of the Red
Eye
Systemic disorders/dermatologic disease
thryroid disease
Chlamydia
rosacea
atopic dermatitis
subconjunctival hemorrhage
When to refer the red eye
History important for deciding when to refer
Refer if associated with :
Blur
Pain
Hx of narrow angles
Pupil unresponsive to light
Hx of Herpes keratitis or zoster, light sensitivity
Contact lens wearer
Chemical injury involving alkaline
Clinical exam
Stain the cornea with fluorescein
examine lids(entropion, bleparitis)
pupil(ACG, uveitis)
cul-de-sacs for FB
Older Ophthalmic antibiotics
Erythromycin
Sulfacetamide
gentamicin
neomycin/polymyxin
B/gramicidin/dexamethasone(Maxitrol)
Current trends
Fluoroquinolones(Vigamox/Moxema, Zymaxid,
Quixin/Iquix, Besivance)
Tobradex(beware steroids)
Polytrim(trimethoprim/polymyxin B)
Polysporin ointment
When to refer the red eye
Vision changes
Pain
Redness getting worse
History of narrow angles
Light sensitivity
Fixed pupil or steamy cornea
Previous bouts of uveitis or Herpes simplex keratitis
Urgent Eye/Visual Symptoms
• eye pain(keratitis, uveitis, ACG)
• photophobia(keratitis, uveitis)
• numerous floaters(retinitis, RD, VH)
• sudden onset distortion or blur(AMD)
• sudden unilateral vision loss(CRAO/CRVO,
RD, AION)
• red eye with blur(ACG, keratitis, posterior
uveitis)
• Fixed pupil with pain or diplopia
Topical Steroids
Increases IOP in 10-15%
allow proliferation of destructive
organisms(HSK, Pseudomonas)
cataracts
duty to warn
limit refills
Try Lotemax