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