eyecare review— for primary care practitioners. primary care practitioners see variety of eye...
TRANSCRIPT
Eyecare Review—
For Primary Care Practitioners
Primary Care Practitioners
See variety of eye problems Discuss treatment options Facilitate referrals Positioned to explain
optometry's role as primary eye care providers
Outline
Anatomy Optics Turned Eyes Lazy Eye External Conditions Internal Conditions Diabetic Retinopathy
ANATOMY
Basic Anatomy
Sclera
Cornea
Pupil
Lens
Iris
Ciliary Body
Choroid
Retina
Fovea
Optic Nerve
Lashes—protection from foreign material
Glands—lubricate anterior surfaceoMeibomian glandsoGlands of ZeisoGlands of Moll
Lids
Thin, transparent, vascular layer liningoBacks of eyelidsoFornicesoAnterior sclera
Conjunctiva
Tough outer shell Composed of
collagen bundles Protects from
penetration
Sclera
Composed of regularly oriented collagen fibers
5 layers
Cornea
Space between cornea and iris
Filled with aqueous humor produced by ciliary body
Anterior Chamber
Iris gives eye color 2 muscles:
oDilator—opensoSphincter—constricts
Iris
Allows light to enter Enables view to back
of eye and eye health evaluation
Pupil
Located behind iris Focuses light on
retina Allows for
accommodation Normally transparent Where cataracts form
Lens
Primary functionsoPulls on lens for
accommodationoEpithelium secretes
aqueous fluid that fills anterior chamber
Ciliary Body
Red Reflex Light reflection off
retina Useful for assessing
media clarity Affected by any
opacity of cornea, lens, vitreous
White reflex = leukocoriaRefer immediately!
Vitreous Humor Gel-like fluid that
fills back cavity Serves as support
structure for blood vessels while eye formed—before birth
After birth, just ‘hangs out’ in there
Where floaters are located
Fundus Interior
surface of eye
IncludesoOptic nerveoRetinaoVasculature
Optic Nerve Head Collection of nerve
fibers and blood vessels from retina
Transfers info to brain’s visual cortex
Slightly yellow-pink when healthy
White ‘full moon’ appearance can mean trouble!
Optic Nerve Head Cup is natural
depression in center of nerve
Cup size varies between people
Very large cup, or change in appearance over time, can indicate glaucoma
Physiologic Cup
Optic Disc
Optic Nerve
Macula Dense collection
of cone photoreceptors Fine detail and
color vision Macular degeneration
affects this area
Retinal Vessels Include arteries and veins Only place in body
where you can directly visualize blood vessels
Excellent indicators of systemic diseases o HTNo Diabeteso High cholesterolo Carotid disease
Peripheral Retina Can only be evaluated
with dilated pupil Important to evaluate
periodically to fully assess eye health
OPTICS
Optics Review Myopia Hyperopia Astigmatism Presbyopia
Myopia Nearsightedness See well up close
but blurry in distance Eye is too long Light focuses in
front of retina
Hyperopia Farsightedness See well in distance Eye is too short Focus point is
behind retina
Hyperopia Blurry image on retina Lens focuses to
compensate Hyperopes often
asymptomatic much their of lives
Can cause headaches or eyestrain with extended reading
These problems can get worse after age 40
Astigmatism Surface of cornea is
irregular or misshapen Light focuses at
various points causing distorted vision
Often combined with nearsightedness and farsightedness
Presbyopia Normal, age-related
change Near vision becomes
difficult Mid-40s lens
becomes less elastic and losesability to change focus
Time for bifocals…
MISALIGNED EYES
Turned Eyes - Strabismus Eye misalignment
o One or both turn in, out, up or down
Caused by muscle imbalance
3 Kinds of Strabismuso Esotropiao Exotropiao Hypertropia
1. Esotropia
Eye turns in towards nose
3 Types of Esotropia Infantile (congenital)
o Develops in first 3 months of lifeo Surgery usually recommended—
along with vision therapy and glasses
Accommodativeo Usually noted around age 2o Child typically farsightedo Focusing to make images clear can
cause eyes to turn inwardo Treated with glasses but
vision therapy may also be needed
3 Types of Esotropia Partially
Accommodativeo Combination of
accommodative dysfunction and
muscle imbalance
o Glasses and vision therapy won’t completely correct eye turn
o Surgery may be required for best binocularity
If you see Esotropia Refer to pediatric
optometrist or ophthalmologist
Sooner the better for best chance of good vision
2. Exotropia Eye turns outward Congenital—present
at birth Surgery usually needed
to re-align Many exotropias are
intermittento May occur when patient is tired or not paying
attentiono Concentration can force eyes to re-aligno Vision therapy and/or glasses can help
2. Exotropia When intermittent
oBrain sometimes receives info from both eyes (binocular)
oLess chance of amblyopia
oHowever, important to be seen by eyecare provider when deviation noted
3. Hypertropia One eye vertically
misaligned Usually from paresis
of an extra-ocular muscle
Typically much more subtle for patient to describe and provider to diagnose
2 Types Congenital
oMost common typeoPatients can
compensate for years by tilting head
oCan be discovered by looking at childhood photos
2 Types Acquired
o Trauma—Extra-ocular muscle ‘trapped’ by orbital fracture
o Vascular infarct—Systemic diseases that affect blood supply to nerves can cause temporary nerve palsy
Diabetes and HTN most common
Palsies tend to resolve over weeks or months
o Neurological—In rare cases a tumor or aneurysm can cause symptoms
LAZY EYE
Lazy Eye - Amblyopia Decreased vision
uncorrectable by glasses or contacts—not due to eye disease
For some reason, brain doesn’t fully acknowledge images seen
Lazy Eye - Amblyopia 3 Types of
AmblyopiaoStrabismicoAnisometropicoStimulus
deprivation
1. Strabismic Amblyopia One eye deviates from other
and sends conflicting info to brain
Brain doesn’t like to see double—so “turns off” info from deviated eye
Results in under developed visual cortex for that eye
Can usually be reversed or decreased if treated during first 9 years
Need to visit eyecare provider ASAP to determine cause
Treatment If caught early,
treatment can teach brain how to see bettero Vision therapy/patchingo Glasseso Surgical re-alignment
Early vision screenings are critical!
2. Anisometropic Amblyopia Anisometropia—
significant difference in Rx between eyes
Commonly one eye more farsighted
Farsighted eye works hard to see clearly—and sometimes gives up
Brain relies on info from other eye
2. Anisometropic Amblyopia If not caught, one
eye won’t learn to see as well as other
Vision therapy and glasses are both beneficial
Sooner the better
3. Deprivational Amblyopia Any opacity in visual
pathway can be devastating to developing visual systemoCongenital cataractsoCorneal opacitiesoPtosis (droopy eyelid)oOther media opacities
EXTERNALCONDITIONS
Common External Ocular Conditions
Blepharitis Hordeolum—stye Preseptal
cellulitis Orbital cellulitis Pterygium Corneal ulcer
Conjunctivitiso Viral “pink eye”o Adenoviruso Bacterialo Allergico Hyperacuteo Chlamydial
Blepharitis Inflammation of
eyelids (anterior or posterior)
Symptomso Itchingo Burningo Crustingo Dry eye
sensationo Foreign body
sensation
Blepharitis Signs
o Crusts on lid margins
o Thickened, reddened eyelids
o Plugged or inspisated meibomian glands along eyelid
Treatmento Warm
compresses, 10 minutes 1-2 x/day
o Lid scrubs with diluted baby shampoo
o Artificial tearso Erythromycin
ointment at night
Hordeolum (stye) Abscessed
meibomian gland
Raised, tender nodule
Often gets larger over days to a week
Hordeolum Signs
o Raised nodule protruding out from or under lid
o Red, swollen lido Capped glands
at site of infection
Treatmento Warm
compresses, BID-TID for 10 mins
o Topical meds don’t penetrate abscess
o Oral antibiotics if no response to traditional treatment
Preseptal Cellulitis Bacterial infection
of eyelid anterior to orbital septum
Can arise fromo concurrent sinus
infectiono penetrating lid
traumao dental infectiono hordeolumo insect bite
Preseptal Cellulitis Signs
o Painful, swollen lid extending past orbital rim
o May be unable to open eye
o No decreased vision, restricted ocular motility or proptosis
o White conjunctiva
Treatmento Amoxicillin
(augmentin) 500 mg PO TID
o Treat infection quickly to minimize risk of orbital cellulitis
Orbital Cellulitis Serious infection of
soft tissues behind orbital septum
Can be life-threatening
Causeso Sinus infectiono Extension of preseptal
cellulitiso Dental infectiono Penetrating lid injuryo After ocular surgery
Orbital Cellulitis Signs
o Tender, warm periorbital lid edema
o Proptosiso Painful
ophthalmoplegiao Decreased visiono Severe malaise,
fever and pain
Treatmento Medical
emergencyo Hospitalization
with IV antibioticso Consider
orbit/head CT to look for abscess
o Consult pediatrician or infectious disease specialist
Preseptal vs. Orbital Cellulitis Preseptal
o Painful, swollen lid extending beyond orbital rim
o Normal visiono Full EOMso White
conjunctivao No proptosiso No fever
Orbitalo Painful, swollen
lid that stops at orbital rim
o Decreased visiono Restricted
ocular motilitieso Proptosis o Fever/malaise
Pterygium Triangular-shaped
growth of conjunctival tissue onto cornea
Causeso UV exposureo Drynesso Irritants
Smoke Dust
Pterygium Signs
o Dry eyeo Irritationo Rednesso Blurred vision
Management and Treatmento UV tint on glasseso Avoid irritating
environmentso Artificial tearso Topical
vasoconstrictor or mild steroid
o Surgery
Corneal Ulcer Infection of
corneao Bacterialo Fungalo Acanthamoeba
Causeso SCL wearero Traumao Compromised
cornea from pre-existing condition
Corneal Ulcer Signs
o Paino Photophobiao Blurred visiono Dischargeo Hypopyon
Treatment:o Start
immediately Fortified
antibiotics Fluoroquinolones
o Culture may not be necessary if ulcer is small
o Must be monitored daily!
Conjunctivitis (red eye) Various Causes
1.Viral/Adenovirus
2.Bacterial3.Allergic4.Chlamydial5.Herpetic6.Toxic
Conjunctivitis Signs
o Irritationo Burning/
stingingo Wateringo Photophobiao Pain or foreign
body sensationo Itching
Dischargeo Wateryo Mucoido Mucopurulento Purulent
1. Viral Conjunctivitis (pink eye) Most viral infections are
fairly mild and self-limiting Signs & Symptoms
oWateringoRednessoPhotophobiaoDiscomfort/foreign body
sensationoPalpable preauricular node
1. Viral Conjunctivitis Patients often have recent history
of URI Treat symptoms
o Cool compresseso Artificial tearso Topical vasoconstrictors or mild
anti-inflammatory Frequent handwashing Usually runs course in
1-3 weeks
2. Adenoviral Conjunctivitis Highly contagious Most common types
o Pharyngoconjunctival fever (PCF)— can be caused by adenovirus types 3, 4 & 7
o Epidemic keratoconjunctivitis (EKC)—caused most commonly by adenovirus types 8 & 19
2. Adenoviral Conjunctivitis Signs
o Wateringo Conjunctival
follicleso Subconjunctival
hemorrhageso Chemosiso Pseudomembrane
so Lymphadenopathyo Keratitis
3. Bacterial Conjunctivitis Common, especially
in children Usually self-limiting Signs/symptoms
o Acute rednesso Burning/grittinesso Mucopurulent
discharge o Lids stuck shut in
morning
3. Bacterial Conjunctivitis Common organisms: S. aureus, S.
epidermidis, S. pneumonia, H. influenza (esp. peds)
Usually self-limiting But important to use broad-spectrum
antibiotic until discharge cleared (5-7 days)
Antibioticso Tobramycino Polytrim—polymyxin + trimethoprimo Fluoroquinolones like
Ocuflox or Ciloxan
5. Hyperacute Conjunctivitis Cause
o Sexually transmitted
o Neisseria gonorrhoeae
Signso Swollen, tender lidso Copious purulent
dischargeo Significant
conjunctival redness and swelling
o Lymphadenopathy
5. Hyperacute Conjunctivitis Treatment
oLavage oTake scrapings for culture and
sensitivity testingoPatients usually hospitalized and
started on IM CeftriaxoneoTopical antibiotics not effective
6. Chlamydial Conjunctivitis Cause
oSexually transmitted ocular infection Signs
oPatients typically have mild but persistent follicular conjunctivitis non respondent to topical antibiotics
oAny conjunctivitis lasting longer than 3 weeks despite therapy should be suspect
6. Chlamydial Conjunctivitis Patients can have concomitant
genital infection (could be asymptomatic)oRefer for work-up if necessary
TreatmentoOral—Azithromycin 1g, doxycycline
100mg bid x 7 days, erythromycin 500mg qid x 7 days. Also need to tx partners!
oTopical—erythromycin, tetracycline, or sulfacetamide ung bid-tid x 2-3 weeks
4. Allergic Conjunctivitis Can be seasonal
or acute Signs/symptoms
o Itching is hallmarko Conjunctival rednesso Chemosiso Lid edemao Thin, watery
dischargeo No palpable
preauricular nodes
4. Allergic Conjunctivitis Treatment
o Eliminate offending agento If mild
Cool compresses Artificial tears/vasoconstrictors
o If moderate or severe Topical antihistamine/mast-cell stabilizer (ie.
Patanol) Topical NSAID Topical steroid Oral antihistamine
INTERNALCONDITIONS
Internal Ocular Conditions Glaucoma Cataracts Macular
Degeneration Retinal
detachment
Glaucoma Progressive loss of
Nerve fiber layer at ONH (increased cupping)
Can lead to peripheral visual field loss
Sometimes caused by elevated intraocular pressure
Glaucoma Pathophysiology of progression not
well understood Increased IOP
o Damages nerves as they leave eye, causing cell death
o Reduces blood supply to ONH, indirectly destroying cells by starving them of oxygen and nutrients
Abnormal levels of neurotransmitter (glutamate) cause cells to die off
Glaucoma Monitoring
o IOPo ONH appearanceo Visual field testingo Newer methods
include HRT (Heidelberg
Retinal Tomograph II) GDx Nerve Fiber
Analyzer Genetic testing
Glaucoma IOP reduction is mainstay
of treatment Decrease aqueous production
o B-blockerso Alpha-agonistso Carbonic anhydrase inhibitors
Increase uveoscleral outflow o prostaglandin analogs
Cataract Clouding of natural
lens Patients experience
oBlurred/dim visionoGlare, especially
at nightoHalos around lightsoDoubling or ghost
images of objects
Etiology Everyone develops them
if they live long enough!
Types of cataractsoAge-related—senileoTrauma—blunt or
perforating injuryoSystemic conditions—
diabetesoMedications—steroids
Main Types Age-related
oNuclear sclerotic
oCortical spokes
oPosterior sub-capsular
oMature cataract
Treatment Surgery When loss of vision
interferes with daily activitiesoDrivingoReadingoHobbies
Outpatient Surgery 5-10 minutes with
skilled surgeono Incision through
cornea or sclera under upper lid
o Circular tear in anterior capsule
o Lens broken up with ultra sound instrument
o Fragments suctioned out
o Lens implant inserted
Secondary Cataract Cloudiness forms on
posterior capsule after cataract surgery
30-50% of patients YAG laser used to
create opening Vision quickly
restored
Macular Degeneration
#1 cause of blindness in Americans over age 65
Pathophysiology Causes not well understood Theorized link to
o UV light exposureo subsequent release of free
radicalso oxidation within retinal
tissues Another theory—areas of
decreased vascular perfusion in retina, lead to cell death
Two Types Dry (atrophic)
o90% of those diagnosed
Wet (exudative)o10% of those
diagnosedoBut accounts for
90% of blindness caused by disease
Symptoms None Blurred vision Metamorphopsia
—straight lines appear wavy or distorted
Scotomas—missing areas in vision
Dry Form Slow, progressive loss
of central vision Breakdown of
underlying retinal tissues, resulting in mottling or clumping of normal pigment
Drusen begin to accumulate
Geographic atrophy can also occur
Wet Form Can quickly
degrade central vision
Break in underlying tissues allows new blood vessels or fluid to come through
New blood vessels are weak so frequently break and bleed
Treatment for Dry Form Regular eye exams Careful discussion
regarding family history
Education UV protection Antioxidants
o AREDSo PreserVision
Stop smoking
Treatment for Wet Form Refer to retinal
specialist Photocoagulation Photo-dynamic therapy
(PDT) Submacular surgery Macular translocation Anti-angiogenic drug
therapy
Retinal Detachment Several types
oRhegmatogenous—caused by break in retina
oExudative—caused by fluid accumulation beneath retina
oTractional—proliferative fibrovascular vitreal strands
Signs & Symptoms Flashing lights in peripheral
vision New floaters—black spots or
‘cobwebs’ Peripheral scotoma—dark
shadow or “curtain” blocking vision
Emergency Patients with these
symptoms must see eyecare provider immediately
Additional risk factorsoHighly nearsightedoDiabeticoRecent trauma/injury
Treatment Laser
photocoagulation or cryotherapy
Pneumatic retinopexy—gas bubble to tamponade retina back into place
Scleral buckle Silicone oil
DIABETICRETINOPATHY
Diabetic Retinopathy Diabetes
affects retinal micro-vasculature
One of leading causes of blindness among ages 20-64
Progression Over time, elevated and fluctuating
blood sugar damages vessel walls Vessels leak fluid, lipids or blood into
retina New vessels grow to bring more
oxygen to retina
Symptoms Fluctuating vision Blurred vision Distortion Sudden loss of vision
Treatment Control blood sugar Refer to retinal
specialist when vision threatened
PRP (pan-retinal photocoagulation)
Focal laser Vitrectomy Retinal detachment repair
Working Together Together we can
catch vision threatening conditions earlier
Glad to answer questions
Always happy to take your calls
Questions?