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Home , Red eye (medicine)

When to Consult

Linda J. Lehman, M.D. Grand Rounds 11-16-16 “It’s an eye”

There’s a 17 year old who lost vision in her left eye last night. is 20/20 in the right eye and 20/200 in the left eye. The pressure is 15 OD and 16 OS. The eye is not injected. I think the is swollen.

Survey of Americans on Eye and Vision Health-JAMA

Online nationwide poll. Respondents describe loss of eyesight as the worst ailment that could happen to them relative to losing memory, speech, hearing or a limb. When you are uncomfortable

Things that can blind your patient Things that can kill your patient Things you can be sued over 1. Diabetes 2. eye 3. Retinal detachments 4. Trauma 5. 6. 7. 8. Things not to miss American Academy of Ophthalmology Preferred Practice Patterns

Diabetic 2016 The prevalence of diabetes in the United States and in the world is increasing: as such, the prevalence of diabetic retinopathy and vision threatening diabetic retinopathy is also expected to increase dramatically. Diabetic Retinopathy Currently only about 60% of people with diabetes have yearly screening for diabetic retinopathy. Diabetic Retinopathy People with Type 1 diabetes should have annual screenings for diabetic retinopathy beginning 5 years after the onset of their disease, whereas those with Type 2 diabetes should have a prompt examination at the time of diagnosis and at least yearly examinations thereafter. Diabetic Retinopathy Maintaining near-normal glucose levels and near-normal blood pressure lowers the risk of retinopathy developing and/or progressing, so patients should be informed of the importance of maintaining good glcosylated hemoglobin levels, serum lipids, and blood pressure. Diabetic Retinopathy Patients with diabetes may use aspirin for other medical indications without an adverse effect on their risk of diabetic retinopathy. Diabetic Retinopathy Women who develop gestational diabetes do not require an eye exam during pregnancy and do not appear to be at increased risk for developing diabetic retinopathy during pregnancy. However patients with diabetes who become pregnant should be examined early in the course of the pregnancy. Diabetic Retinopathy Referral to an ophthalmologist is required when there is any nonproliferative diabetic retinopathy, proliferative retinopathy or macular . Nonproliferative diabetic retinopathy Nonproliferative diabetic retinopathy NPDR is the earliest stage of diabetic retinopathy. Hyperglycemia damages blood vessels in the . The vessels leak extra fluid and small amounts of blood into the eye (microaneursyms). Rupture of these forms dot and blot hemorrhage. Sometimes deposits of cholesterol or other fats from blood may leak into the retina. NPDR Proliferative Diabetic Retinopathy Neovascularization is present Vascular endothelial growth factor is released

Intervention is needed Diabetes - Neovascularization

Proliferative diabetic retinopathy Laser for Neovascularization PRP Reduce severe vision loss by 50% Diabetic OCT

Anti VEG-F Vascular Endothelial growth factor influences abnormal blood vessels to grow In the retina anti VEGF agents first used for Macular Degeneration. Now other uses including Diabetic retinopathy Anti VEGF Agents Bevacizumab (Avastin) Ranibizumab (Lucentis) Pegaptanib (Macugen) Afibercept (Eylea) Lapatinib (Tykerb) Sorafenib (Nexar)

Red Eye

Treatment of red eye Viral-cool compresses. Preservative free tears

Bacterial-Antibiotic of choice

If the patient is not improving in 3-5 days (or back to normal in 5-7), consider referral Referral for Red Eye 1.Loss of vision 2.Eye surgery within the past month 3.Iritis/ history 4.Herpetic disease 5.Trauma-distorted 6.Steroids are needed Red eyes Differential diagnosis Dry eyes//Meibomitis Bacterial,allergic and viral HSV HZ Iritis/uveitis// Dry Eye Symptoms 1.Red, itchy, burning, 2.Watery eyes 3. Scratchy, gritty, foreign body sensation 4. Strings of mucus in or around eyes 5. Worse in wind or cigarette smoke 6. Contact intolerance 7. Reading,computer watching tv, riding in car may make symptoms worse. Dry eye treatments 1.Stop or change medications such as antihistamine, diuretics, antidepressants/ anti-anxiety medications 2.Lubricant eye drops 3.Drink water 4.Supplements Dry eye dietary supplements 1.Fish oil - up to 2000 mg per day 2.Vitamin E - no more than 400 mg 3.Flaxseed - up to 2000 mg per day Dry eye interventions 1.Punctal plugs 2.Thermal cautery 3.Prescription medications 4. hygiene Dry Eye Prescription Medications 1.Cyclosporin (Restasis)

2. Lifitegrast (Xiidra) Herpes Simplex Vesicular lesions of eyelid

Primary infection is a systemic disease

Refer if any vision concerns, eye red or sensitive

HSV-epithelial disease

Herpes Zoster V1 distribution-forehead, , tip of the nose (Hutchinson’s sign)

Treatment-antiviral course Refer those with red eye, light sensitivity or any eye symptoms. Refer if lesions of eyelid margin or tip of nose. HZV

Uveitis

HLA-B27 positive, ankylosing spondylitis, inflammatory bowel disease, reactive or psoriatic arthritis Post-op Post -traumatic Ankylosing spondylitis low back or stiffness SI joint space narrowing on Xray more common in men +HLA-B27 elevated ESR Anterior Uveitis Treatment Cycloplegic (red top drop) Topical steroid-prednisolone acetate Night time steroid ointment Periocular steroids Systemic steroids Immunosuppression Superior Limbic Thyroid Labs Free T4 TSH Thyroid Eye Involvement

Thyroid Associated Orbitopathy Every patient with thyroid disease should be seen for annual eye exam. Signs of Retinal Detachment 1.Flashing 2. 3.Curtain or cob web Posterior Vitreous detachment Vitreous pulls away from to optic nerve and retina Traction on retina causes light flashes Floaters

Retinal detachment treatment Office laser

Retinal detachment treatment Scleral buckle Trauma When to refer? 1.Decreased vision 2.Painful eye 3.Flashing lights 4.Eye looks abnormal 5.Significant trauma

Open Require evaluation and surgical repair Glaucoma Angle closure glaucoma

Macular Degeneration Age related Macular Degeneration Types of Macular Degeneration Dry

Wet Treatment of Dry ARMD 1.Healthy diet (colorful plate of foods) 2.AREDS2 vitamins 3.Stop smoking 4.Check amsler grid weekly 5.Annual eye exam Treatment of “Wet” ARMD Same as dry Plus Laser or Anti-VEGF

Anti VEGF injection “shot in my eye”

When to refer? 1.All ARMD patients should have an annual eye exam 2.Change in vision 3.Change on Amsler Grid Amblyopia When to consult- Amblyopia 1.Adults with useful vision in one eye only should have annual eye exams and wear protective glasses. 2.Children who fail vision screening 3.Eyes not aligned (, , ) 4.Family history Amblyopia Eyes that intermittently cross or wander can be normal up to 4 months.

Eye that are crossed continually are not normal at any age.

Amblyopia Adult has routine exam- no problems Optic nerve in amblyopic eye looks pale Failed MRI Visual field showed temporal loss in that eye only CT showed pituitary adenoma Patient is having neurosurgery this week

Think of these! Things not to miss Symptoms of brain tumors headache new seizures new double vision difficulty walking or talking changes in mental status persistent vomiting Neuroimage Call your friendly radiologist if you are not sure which scan to order Temporally horizontal hemifield vision loss Carotid ultrasound first Then cardiac echo Cranial nerve palsies Cranial nerve 6

Cranial Nerve 3

Cranial Nerve 3 A pupil involved 3rd nerve palsy is an aneurysm (posterior communicating artery) until proven otherwise.

Order CTA Cranial nerve palsy If jaw claudication, scalp tenderness, malaise, joint pain, night sweats check a C reactive protein (CRP) and Sed Rate. Giant Cell Arteritis Patients over 50 Malaise, fever, jaw claudication, scalp tenderness, night sweats Sed rate is > ½ patient’s age if male Sed rate is > ½ patients age+10 if female C reactive protein over 5 Giant Cell Arteritis Management Steroids--Usually 60 or 80 mg po /day Temporal artery biopsy preferably within a week Do NOT wait for the biopsy to start steroids THIS IS POTENTIALLY BLINDING Rheumatology consult Papilledema If severe, easy to see

If subtle, consider referral for our opinion and objective measure with OCT Papilledema Summary

When to consult ophthalmology When to consult ophthalmology? Carter K, et.al. Ophthalmology. 2001 92 different reasons why consultations were requested Top 5: 1. 2. Fungal ruled out 3. Conjunctivitis 4. Diabetic retinopathy 5. Corneal abrasion Ophthalmology Consults -Level 1 trauma center Brooklyn,NY Clinical Ophthalmology 2013 1.Trauma-orbital fracture 2.Ocular manifestations of systemic disease When to get an ophthalmology consult? forums.studentdoctor.net Google I would be happy to answer any questions. Thank you!