len oshinskie, o.d. chief, optometry section newington va medical center

Len Oshinskie, O.D.Chief, Optometry Section

Newington VA Medical Center

TopicsLaser-assisted Cataract surgeryAge-related macular degenerationDiabetic Macular EdemaGlaucoma and MedicationsRed eyeDry eyePractical advice

Common Causes of Blindness and Visual Impairment

Age-related macular degeneration

Diabetic retinopathyGlaucomaCataract

Femtosecond laserApproved by FDA for several steps in

cataract surgery in 2009-2010Uses 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 surgeryIncisions more reproducible than bladed

incisionsLess risk for capsular ruptureMore precise opening so IOL can be more

accurately placedLess energy from phaco probe for at risk pts,

less inflammationPerhaps less risk of infection

Disadvantages of laser assisted cataract surgeryTakes longerRequires expensive equipmentCapsulorhexis not always completeNot paid for by MedicarePts have higher expectations

Age-related macular degenerationLeading cause of blindness over age

65Drusen and pigment atrophy and

clumpingexudative changes(heme, lipid, small

central retinal detachments)sudden distortion of vision, new

unilateral blur, scotoma, difficulty reading

Macular Degeneration TypesAtrophic (dry) AMD 80-90%Neovascular(wet) AMD 10-20%

Drusen

AREDS 1500 mg vit C400 IU vit E15 mg betacarotene80 mg zinc2 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):2005-2015Placebo 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 2Large dose of vit E(prostate and heart

failure)Coumadin users

Genetics and AMDOne study to suggest genetic testing maybe

important before prescribing AREDS supplement

Exudative (Wet) AMD

Early exudative AMD

OCTocular coherence tomography

Br J Ophthal 1997; 81:154-162A 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 medicationsMacugen(Pegaptanib) 2004Avastin(bevacizumab) 2005 but not FDA

approvedLucentis(ranibizumab) 2006Eylea(aflibercept) 2011

Intravitreal injection

Studies on Treatment of Wet AMD(ETDRS visual acuity chart)

Visual Acuity with Eylea

Ocular side effectsCataractInflammationRetinal detachmentendophthalmitis

Jetrea(ocriplamin)Intravitreal injectionApproved for treatment of vitreo-retinal

adhesionsSide effects-transient vision decrease and

inflammation

Aspirin use in pts with wet AMD

Conflicting reportsRecent studies suggest an increased risk, but

not randomizedIf risks for CV complications, suggest continuing ASA

Trends in Treating Diabetic Retinopathy

Mechanism of Diabetic Macular EdemaHyperglycemiathickened endothelial

cellsIschemia increased VEGF, loss of pericytes

Macular edema : increased permeability increased hydrostatic pressure dilating blood vessels, pericytes disruptedInflammatory component

Treatment of Diabetic Macular EdemaAnti-VEGF treatmentCorticosteroidsLaser

Anti-VEGF treatment of DMELucentis more effective than sham or laser in

decreasing thickness and improving visionLucentis 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 injectionsDoes not hurt as much as you thinkVery safe (2.1% have ocular complications)Multiple injections neededVery effective in preventing vision lossIt usually take several weeks for vision to

improve/stabilizePost op: expect mild soreness, irritation,

floaters, subconj hemeReport any sudden vision changes or pain statThere may be small risk for CVA

Marijuana and glaucomaAAO June 2014 recommendations:Only lowers IOP 3-4 hoursNot as effective as available medicationsPotential for abusePotential for lung damageLowers BP (less perfusion)Topical THC drops tried but not effective(not

water soluble enough)effects of Marinol on glaucoma are not impressiveNo standardization of dose with various forms of

marijuana plantsNot legal in federal system

Plaquenil Monitoring

Visual fieldOCT and FAFFocal ERG

TopiramateAngle closure glaucomaVisual field defects

Tear film compositionLipid, aqueous, mucin

Tear film componentsLipid-Meibomian glandsaqueous-lacrimal glandMucin-goblet cellsIdeal tear filmhas uniform thickness maintains corneal coverage between blinkslimited debris

Dry eyeMultifactorial disease of tears and ocular

surfaceDiscomfort, vision changes and tear film

instabilityDecreased tear production, increased

osmolarity and inflammation of ocular surface

Dry Eye CascadeClin Ophthalmol. 2009; 3: 405–412.

Guidelines from the 2007 International Dry EyeWorkshopBY MICHAEL A. LEMP, M. D. AND GARY N. FOULKS, M. D.

.

Dry Eye DiseaseStevenson et al in Arch Ophthalmology 2012;130:90-100

Dry Eye SymptomsDrynessIrritation/burning(“hurt”)Foreign body sensation(“sand in my eyes”)WateringIntermittent blurred visionItching

Differential Diagnosis Pt with Symptoms of Dry EyeBlepharitisRosaceaExposure keratitis (TAO, CN 7

palsy,ectropion )

Risk factors for Dry EyeStevenson et al. Arch Ophthalmology 2012;130:90-100

Increased ageFemale >malesHormonal inbalanceAutoimmune diseaseVitamin deficiencyMedicationsEnvironmental stressContact lens useOphthalmic surgery(LASIK)

Contributors to Dry EyeAir flow(AC, fans etc)HumiditySmokeAlcoholAntihistaminesDiureticsBlink rate(reading and computer)

Evaluation of the Dry Eye PatientHistoryTear Breakup time-qualitySchirmer-quantityCorneal staining(fluorescein or lissamine

green)Tear wedge-quantityOsmolarity

Break up Time

Corneal staining

Tear Wedge

Lid PositionProptosisLagophthalmusEctropionParkinson’sCN VII palsyPartial blinkerSleep apnea

TreatmentArtificial tears-preserved and non-preservedRestasis(topical cyclosporin A)Topical corticosteroidsOmega 3/Fish OilQhs ointmentTetracyclinesPunctal plugstarsorrhaphy

Using Artificial tearsAvoid OTC “gets the red out” dropsUse drops that say lubricant or artificial tearsMust use 4 times a dayDon’t touch tip of bottle to eye or lids

Systane BalanceRefresh Optive AdvancedFreshKote(by Rx only)

Give ointment at night ?

Punctal plugs

My patient has glaucoma, is it safe to prescribe them_____?antihistaminestricyclic antidepressantsParkinson's diseaseanti-cholinergics such as atropineanti-spasmolyticsanti-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 55-70HyperopiafemalesAsians

Signs/Symptoms of Acute Angle Closure Glaucoma

Painhazy/blurred visionhaloes around lightsfrontal HAnausea/vomitingFixed pupilSteamy corneaRed eye

Glaucoma MedicationsProstaglandin 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 EyeInfectious(bacterial, viral, fungal)Inflammatory(uveitis,

episcleritis,scleritis)Increased IOPAllergicMechanical(lid, FB, contact lens)Dry eyeToxic

Differential Diagnosis of the Red EyeSystemic disorders/dermatologic diseasethryroid diseaseChlamydiarosaceaatopic dermatitissubconjunctival hemorrhage

When to refer the red eyeHistory important for deciding when to referRefer if associated with :Blur Pain Hx of narrow angles Pupil unresponsive to light Hx of Herpes keratitis or zoster, light

sensitivityContact lens wearerChemical injury involving alkaline

Clinical examStain the cornea with fluoresceinexamine lids(entropion, bleparitis)pupil(ACG, uveitis)cul-de-sacs for FB

Older Ophthalmic antibioticsErythromycinSulfacetamidegentamicinneomycin/polymyxin

B/gramicidin/dexamethasone(Maxitrol)

Current trendsFluoroquinolones(Vigamox/Moxema,

Zymaxid, Quixin/Iquix, Besivance)Tobradex(beware steroids)Polytrim(trimethoprim/polymyxin B)Polysporin ointment

When to refer the red eyeVision changesPainRedness getting worseHistory of narrow anglesLight sensitivityFixed pupil or steamy corneaPrevious 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 SteroidsIncreases IOP in 10-15%allow proliferation of destructive organisms(HSK, Pseudomonas)

cataractsduty to warnlimit refillsTry Lotemax