Common Eye Conditions Every Primary Care Clinician Should Know
Cynthia S. Chiu, MD, FACS Associate Professor UCSF Department of Ophthalmology
UCSF Family Medicine Board Review March 9, 2016 http://www.timandjeni.com/images/cookiemonster.jpg Disclosure
I have no financial interest in any of the products mentioned in this presentation The Eye Exam
Eye Vital Sign Near Vision Card Held at 14 inches Glasses as needed
http://www.drbanker.com/images/Nearvision.gif Pupils
Look for afferent pupillary defect Swinging flashlight test +APD indicates optic nerve or large retinal lesion
http://img.tfd.com/ElMill/thumb/F0P-24-S2958.jpg Motility
Six extraocular muscles Test cardinal fields of gaze
http://www.opsweb.org/OpPhoto/Extern/Motility/muscle.jpg http://www.opsweb.org/OpPhoto/Extern/Motility/9gazedwg.jpg Confrontational Visual Fields
Cover eyes on same side Hold fingers midway between Normal per eye: 60-60-60-90
http://www.ncbi.nlm.nih.gov/bookshelf/br.fcgi?book=cm&part=A3460&rendertype=figure&id=A3464 Penlight Exam
Lids Lashes Conjunctiva/Sclera
Cornea
Iris/Pupil Puncta Lens
http://cache.heraldinteractive.com/blogs/sports/rap_sheet/wp-content/uploads/2009/11/bionic-eye.jpg Anterior Chamber Depth
Deep chamber: illumination of nasal iris Shallow chamber: shadow on nasal iris Dilation: Phenylephrine 2.5%, Tropicamide 1%
http://iei.ico.edu/images/anatomy.jpg http://www.ophthobook.com/wp-content/uploads/2007/12/video-glaucoma-shallowpenlight.jpg Fundoscopy
PanOptic or Direct Ophthalmoscope Evaluate optic nerve, retinal vessels, macula
http://www.welchallyn.com/images/corporate/0509_wa_bmurf/011810xx1PanOpticRedHe.jpg http://webvision.med.utah.edu/imageswv/retina.jpeg Primary Care Ophthalmology
http://www.factzoo.com/sites/all/img/reptiles/chameleon-eyes.jpg The Red Eye
http://i.zdnet.com/blogs/lord-of-the-rings-ii-eye-of-sauron-4900244.jpg Viral Conjunctivitis
URI Clear or mucous discharge Lymphadenopathy Contagious! Treat for comfort Bacterial Conjunctivitis
Purulent discharge Culture Staph, Strep, Hflu – Polymixin/Trimethoprim – Fluoroquinolones – NOT Tobra or Gent GC, chlamydia – Systemic Rx Allergic Conjunctivitis
History of atopy Conjunctival edema Itchy!
Topical antihistamines – Elestat – Zaditor – Patanol Visine tachyphylaxis Blepharitis
Redness, itching, “grit”, dry eyes Rosacea, Staph, Demadex Warm compresses, baby shampoo, artificial tears Doxycycline, Azithromycin
http://www.stop-rosacea.com/ Herpes Simplex
When to refer: V1, V2 red eye eye pain change in vision
Acyclovir Herpes Zoster
Hutchinson’s sign: nasociliary nerve Treat Post-Herpetic Neuralgia: Lyrica, Neurontin, TCA’s
Uveitis
Inflammation of vascular tissue Auto-immune Infectious Toxic Masquerade
May require immunosuppression Angle Closure Glaucoma
Headache Loss of vision Firm eye
IV Diamox, Mannitol Glaucoma gtt’s Surgical treatment
Subconjunctival Hemorrhage
Valsalva, HTN, anticoagulants, eye rubbing, spontaneous In the setting of trauma: refer Corneal Abrasion
Pain! Loss of epithelium Not infected
Erythromycin ung Artificial Tears Patching Corneal Foreign Body
Iron is toxic Surgical treatment Hyphema
Severe eye trauma Risk of rebleed Risk of glaucoma Ruptured Globe
Peaked pupil Brown tissue outside the eye CT scan NOT MRI Fox shield, NPO Common Diseases of Aging
http://www.jaredyellin.com/wp-content/uploads/2009/12/old-man-winking1.jpg Cataract
Painless progressive loss of vision with age Also caused by DM, XRT, trauma, medications Difficulty reading, driving, glare Outpatient surgery Glaucoma
Chronic progressive optic neuropathy Loss of visual field Risk factors: age, tobacco, race, family hx Medications may have systemic interactions http://img.medscape.com/fullsize/migrated/569/545/569545.fig2.gif http://cdn.shopmedvet.com/images/uploads/2640_7780_thumb.jpg Macular Degeneration
Risk factors: age, UV, tobacco, Family Hx Loss of central vision Dry form: AREDS vitamins, stop smoking Wet form: anti-VEGF injections Disorders of the Eyelid and Orbit
http://greatpiercingshop.com/blog/wp-content/uploads/2009/12/eyelid-piercing-method-and-aftercare_49.jpg Chalazion
Blocked oil gland Inflammation
Warm compresses Incision/curettage Cellulitis
Preseptal vs Orbital
Preseptal: full EOM, no proptosis, quiet eye Treat PO Abx
Orbital: proptosis, strabismus, inflamed eye Treat IV ABx Thyroid Orbitopathy
Proptosis Strabismus/Diplopia Corneal exposure Optic nerve compression
131-I may aggravate Surgical treatment Disorders of the Retina
http://webphysics.davidson.edu/faculty/dmb/EdibleOpticalMaterials/index_files/cyclops.jpg Retinal Detachment
Flashes/Floaters Loss of vision/field Sudden, painless
Surgical treatment
http://www.rameshshahmd.com/pictures/retinal%20detach.%201.jpg?nxg_versionuid=published Diabetic Retinopathy
Microvascular disease Bleeding Macular edema Neovascularization
Glucose/BP control Laser ablation Anti-VEGF
Hypertensive Retinopathy
Mild: arteriolar narrowing Mod: cotton wool spots, hemorrhages Severe: disc edema, vessel leakage, infarcts HIV/CMV Retinopathy
Microvascular disease Annual exam if CD4>200 CMV retinitis
http://depts.washington.edu/hivaids/images/oit/oit_c7_d06.jpg Retinal Artery Occlusion
Embolic: cardiac echo, carotid doppler Vasculitic (GCA) Retinal Vein Occlusion
Hypertension Glaucoma Young patients: hypercoagulable Neuro-Ophthalmology
http://www.capitalgainsmedia.com/images/Development%20News%20Photos/Dev-Ino-Issues%2002/Dev-Ino%20Issue%200244/DSC01869.jpg Stroke
Homonymous field defect Location of lesion is contralateral + upside-down Pituitary Adenoma
Compression of nasal fibers at optic chiasm Bitemporal hemianopia
http://www.lfhk.cuni.cz/patfyz/intranet/Figures/58/18.13.jpg Temporal Arteritis
Acute vision loss
Headache, jaw claudication, scalp tenderness, proximal myalgias, constitutional symptoms
ESR and CRP Prednisone 100mg QD Temporal artery biopsy Optic Neuritis
Loss of vision Pain with EOM +/- disc edema
Multiple Sclerosis Steroids
http://www.djo.harvard.edu/files/2982_355.jpg Pseudotumor Cerebri
Headache, tinnitus Papilledema Vision loss
Female, overweight Medication-induced
LP: opening pressure
http://www.caleyes.com/images/papilledema-image.jpg Horner Syndrome
Anisocoria in the dark Mild ptosis Acute and painful: R/O carotid dissection
http://www.mrcophth.com/oculoplasticgallery/traumatichorner/horner.jpg Third Nerve Palsy
Aniscoria in the light Severe Ptosis EOM paresis Microvascular PCA/PCom aneurysm
http://www.nature.com/eye/journal/v18/n3/images/6700625f1.jpg http://www.revophth.com/Images//2008/10/083_RPJ8_F6.gif Thank You!
http://blog.omy.sg/dingan/files/2009/05/bob.jpg References
http://www.drgreene.com/21_1254.html http://www.bobzyeruncle.com/archives/images/conjunctivitis-GC.html http://www.ueseyecare.com/images/photos/allergic_conjunctivitis_l.jpg http://www.ueseyecare.com/images/photos/viral_conjunctivitis_l.jpg http://www.vigamox.com/images/packaging.jpg http://dro.hs.columbia.edu/ced3/conjhemb.jpg http://www.aafp.org/afp/20030401/1481_f3.jpg http://eyemicrobiology.upmc.com/Images/Sub/PhotoEyeDendrite.jpg http://www.hkmj.org.hk/skin/images/108-1.jpg http://www.medicalskincare.be/images/content/herpes03.jpg http://www.tusalud.com.mx/images/herpes_zoster.jpg http://eyelearn.med.utoronto.ca/Lectures04-05/RedEye/images/11Kera2.jpg http://www.nova.edu/~albert/ScleritisWeb.jpg http://www.mrcophth.com/externaleyediseases/sp.JPG http://e-learning.studmed.unibe.ch/augenheilkunde/systematik/aderhaut/images/iritis2.jpg http://www.emedicine.com/oph/images/456cmv7.jpg http://www.revoptom.com/handbook/images/62a.jpg http://images.google.com/imgres?imgurl=http://www.asoprs.org/Graphics/gravesct.jpg&imgrefurl=http://www.asoprs.org/Pages/thyroid.html&h=250&w= 429&sz=9&tbnid=ul6zL-4JdFYJ:&tbnh=71&tbnw=122&start=1&prev=/images%3Fq%3Dthyroid%2Beye%2Bmuscles%26hl%3Den%26lr%3D http://www.medscape.com/content/2002/00/44/63/446304/art-mop446304.coat.fig3.jpg http://www.jeremydiamond.co.uk/graphics/cataract_eye.jpg http://technology.kingston.ac.uk/dirc/medical/images/catara2.jpg http://www.drloden.com/Pages/Pics/cataract.gif http://www.eri.harvard.edu/faculty/peli/Opthalm_Mngt_0803_files/xNat.beauty.jpg http://www.avclinic.com/images/tonometry.jpg http://www.avclinic.com/Glaucoma.htm http://www.lasikinstitute.org/Glaucoma_whatis.html http://www.neec.com/images/photos/mitrev5.jpg http://www.rvscny.com/images/Diabetic%20retinopathy.jpg http://www.tedmontgomery.com/the_eye/eyephotos/pics/DiabeticRetinopathyProliferative.jpg http://www.neec.com/images/photos/diabetic%20retinopathy%20figure%203.jpg
References
http://www.gaileyeyeclinic.com/images/dr3.gif http://www.foxeyecare.com/canon/large/diabetic_retinopathy.jpg http://hubnet.buffalo.edu/ophthalmology/site/Home/Eye_Disorders/Hypertensive_retinopathy.jpg http://www.mrcophth.com/retinacases/CMV.gif http://www.opt.indiana.edu/ce/antseg/graphics/cwsaids.jpg http://www.ohiovalleyeye.com/images/macdegen_K45_dry.jpg http://www.opt.pacificu.edu/ce/catalog/10701-PS/4hemorr.jpg http://www.ttuhsc.edu/eye/Faculty%20Presentations/Visual%20Field%20Testing%20Tech%20Seminar_files/slide0036_image002.jpg http://webeye.ophth.uiowa.edu/dept/GCA/images/GCAfig1b_.jpg http://www.ophthalmic.hyperguides.com/tutorials/oculoplastics/temporal_arteritis/slides/Slide1.jpg http://www.mrcophth.com/pathology/gca2.jpg http://content.lib.utah.edu/EHSL-WFH/image/icon124.jpg http://www.atlasophthalmology.com/atlasimg/1396_6_low_thumb.jpg http://www.tedmontgomery.com/the_eye/eyephotos/pics/CentralRetinalArteryOcclusion.jpg http://www.omnieyespecialists.com/images/eye_brao.jpg http://dro.hs.columbia.edu/vr3/crvob.jpg http://www.scielo.br/img/revistas/abo/v66n6/18991f1.jpg http://www.drugdigest.org/images/pillimages/A0315100.JPG http://ec1.images-amazon.com/images/I/31ITYXvQYpL._AA200_.jpg http://www.aafa.org/images/eye.jpg http://www.aclens.com/accessoryphotos/visine-advanced-relief-eye-drops-15-6683-v3b.jpg http://content.answers.com/main/content/wp/en-commons/thumb/6/69/420px-Gray784.png http://eyelearn.med.utoronto.ca/Lectures02-03/RedEye/images/RedEye_033.jpg http://www.varga.org/corneal_foreign_body_2.jpg http://www.permanente.net/homepage/kaiser/pictures/7945.gif http://www.medscape.com/pi/editorial/conferences/2001/747/art-aad-02.fig1.jpg http://www.opt.pacificu.edu/ce/catalog/10310-SD/Trauma%20Pictures/Hyphema.jpg http://www.revoptom.com/handbook/images/25aa.jpg http://www.tedmontgomery.com/the_eye/eyephotos/pics/Chalazion.jpg http://medicine.ucsd.edu/clinicalimg/eye-periorbital-cellulitis1.jpg http://eyelearn.med.utoronto.ca/Lectures05-06/RedEye/images/RedEye_010.jpg