Sclera, Choroid, Retina, Oh My! AMIEE HO, OD, FAAO PACIFIC UNIVERSITY

Statement of Disclosures No financial disclosures

https://en.wikipedia.org/wiki/The_Wizard_of_Oz_(1939_film)#/media/File:Judy_Garland_in_The_Wizard_of_Oz_trailer_2.jpg Sclera, Choroid, Retina, oh my! AMIEE HO, OD, FAAO PACIFIC UNIVERSITY

Cases The Red Eye The Black Spot Good Vision Super Healthy Guy The Red Eye A little bump in the road

64 year old African American male Ocular History

CC: Eye pain and redness OD x 3 days Ocular Hx: ◦ >> Pain with bright light ◦ Age‐related cataracts OU ◦ Pain is dull(?) ◦ Dry eye OU vs. mild mucus fishing syndrome ◦ Gradually more painful ◦ Mild blurred vision ◦ Slightly more scleral show OS>OD ◦ Exophthalmometry nearly symmetric ◦ A little watery https://pixabay.com/photos/cat‐wink‐funny‐fur‐animal‐red‐1333926/ ◦ First time, no previous Hx of similar pain ◦ Refractive error OU and presbyopia ◦ (‐)trauma; (‐)FB; (‐)itchiness; (‐)mucus; (‐) CL wearer LEE: ~1 month ago Medical History Medications and Vitals

Medical Hx: Medications Vitals o HEMOGLOBIN: 13.5 g/dL ◦Anemia o DILTIAZEM o HEMATOCRIT: 40.0 % o ALBUTEROL ◦Asthma o PLATELETS: 295 k/uL o BUDESONIDE/FORMOTEROL o INR: 1.3 RATIO ◦COPD o TIOTROPIUM o HEMOGLOBIN A1C: 5.9 % H o CARBOXYMETH 0.5% (REFRESH TEARS) ◦GERD o GLUCOSE: 101 mg/dL o OMEPRAZOLE ◦Hypertension o MICROALBUMIN: 1.6 mg/dL o ESTIMATED GLOMERULAR FILTRATION o Allergies: NKDA ◦Hyperlipidemia RATE: 70 mL/min/m2* o CHOLESTEROL: 183 mg/dL ◦Primary Hyperparathyroidism https://pixabay.com/illustrations/doctor‐african‐oncology‐orthopaedic‐3187935/ o HDL: 30 mg/dL L ◦Prostate Cancer o LDL: 129 mg/dL

◦Substance Abuse o LAST BLOOD PRESSURE: 134/87

Exam Findings Yikes!

ENTERING VAcc: OD: 20/20 OS: 20/20

EOMs: SAFE OU https://pixabay.com/photos/cat‐wink‐funny‐fur‐animal‐red‐1333926/ CVFs: FTFC OD, OS PUPILS: ERRL, (‐) APD OD, OS

https://www.atlasophthalmology.net/photo.jsf?node=506&locale=en

SL Exam Findings 3+ MG stasis, LIDS, LASHES, 3+ MG stasis, Posterior Exam Findings (‐) lids tender to touch; (‐) lid swelling LACRIMAL (‐) lids tender to touch; (‐) lid swelling Clear Media Clear Pinguecula; melanosis; chemosis 3‐9:00; CONJUNCTIVA Pinguecula; melanosis hyperemia temporal>inferior>nasal>superior Distinct Margins Distinct Pink and healthy Rim Pink and healthy Arcus 360; trace endo pigment OD>OS; CORNEA Arcus 360; trace endo pigment OD>OS; (‐) NaFl staining (‐) NaFl staining 0.30x0.30 C/D ratio (VxH) 0.30x0.30 4x4 ANGLES 4x4 AV 2/3; ALR ¼ Blood vessels AV 2/3; ALR ¼ (+)1+ cell; (+) 1+ flare ANTERIOR Deep and quiet CHAMBER Homogenous Background Homogenous Flat IRIS Flat Flat, even pigment Macula Flat, even pigment 1+ NSC LENS 1+ NSC No holes, tears or breaks 360; Periphery No holes, tears or breaks 360 Clear VITREOUS Clear RPE dropout along vessel vs 16 IOP 08 vessel sheathing superior Reliable, full field FDT Reliable, full field (elevated vessel?) SL Exam Findings 3+ MG stasis, LIDS, LASHES, 3+ MG stasis, (‐) lids tender to touch; (‐) lid swelling LACRIMAL (‐) lids tender to touch; (‐) lid swelling

Pinguecula; melanosis; chemosis 3‐9:00; hyperemia CONJUNCTIVA pinguecula; melanosis temporal>inferior>nasal>superior (‐) conj blanching after phenyl Arcus 360; trace endo pigment OD>OS; CORNEA Arcus 360; trace endo pigment OD>OS; (‐) NaFl staining (‐) NaFl staining 4x4 ANGLES 4x4 Interesting observation (+)1+ cell; (+) 1+ flare ANTERIOR Deep and quiet CHAMBER AFTER DILATION…… Flat IRIS Flat 1+ NSC LENS 1+ NSC Clear VITREOUS Clear 16 IOP 08 Reliable, full field FDT Reliable, full field

Assessement/Plan ~5 day f/u

Assessment/Plan: 1. Anterior uveitis vs. scleritis OD ◦ Start 1% cyclopentalate BID + PRED FORTE q1h OD only

2. Vessel sheathing vs RPE dropout along vessel OD

◦ RTC in 1 day for DFE, IOP check, A/C check ◦ RTC immediately if symptoms worsen 5 day F/U

Assessment/Plan: 1) Scleritis OD ◦Rx’d indomethacin 25 mg PO TID + ranitidine 150 mg PO BID ◦D/C cyclopentolate ◦Continue topical Pred Forte TID for now Recommend full physical examination by internist Ordered CBC, ESR, uric acid, RPR, FTA‐ABS, rheumatoid factor, ANA, C3, C4,ACE, serum ANCA, CF 50

17 day F/U Labs Ordered CBC, ESR, uric acid, RPR, FTA‐ABS, rheumatoid factor, ANA, C3, C4,ACE, serum ANCA, CF 50 Assessment/Plan: Test Results Norms Scleritis OD Immunoglobulin E 3438.0 <114 ◦ Taper Pred Forte down BID x 1 week, Qday x 1 week and then stop ◦ Stop NSAIDs/ranitidine ESR 64 0‐20 ◦ AFTs PRN Red cell distribution width 15.8 12‐15 ◦ Return precautions Monocytes 11.3 2‐10 Eosinophils 8.8 1‐6 Complement function activity <10 31‐60 ~1 month F/U

Assessment/Plan: Improving scleritis OD ◦ Now with subconjunctival hemorrhage OD ◦ Cont Pred Forte daily OD for 1‐2 weeks then stop ◦ Return precautions Scleritis

RTC general 2 months for follow up ◦ No showed

Posterior Scleritis

Classification Scleritis

Anterior (98%) Posterior (2%)

Non‐necrotizing Necrotizing Diffuse Nodular

Diffuse Nodular Necrotizing Necrotizing without with inflammation inflammation (Scleromalacia Perforans) https://www.retinarocks.org/ Indian Journal of Ophthalmology https://www.atlasophthalmology.net/photo.jsf?node=506&locale=en Kumawat D, Chawla R, Hasan N. Retinochoroidal fold https://www.atlasophthalmology.net/photo.jsf?node=514&locale=en with severe discedema in a case of posterior scleritis. Indian J Ophthalmol [serial online] 2020 [cited 2020 Dec 31];68:647-9. Available

https://www.atlasophthalmology.net/photo.jsf?node=3255&locale=en from: https://www.ijo.in/text.asp?2020/68/4/647/280786 https://www.atlasophthalmology.net/photo.jsf?node=4072&locale=en

https://www.ncbi.nlm.nih.gov/books/NBK499944/#:~:text=The%20main%20differential%20diagnosis%20of,foreign%20body%20sensation%2C%20and%20tearing.

Signs and Symptoms Etiology

Anterior Posterior 50% have associated systemic disease o Chorioretinal folds o Pain o Retinal detachment o Rheumatoid arthritis (10‐30%) oSyphilis o Injection o Vitritis o Most common oSurgically induced necrotising scleritis (SINS) o Scleral edema o Optic disc edema o Cotton wool spots o Connective tissue disease (30%) oGout o Scleral nodule(s) o Decreased VA (wide range) o Granulomatosis with polyangiitis oTB o Globe tenderness to palpation o May be with or without o Replapsing polychondritis oLyme disease o Normal or decreased VA o Ocular pain o Ocular redness o Lupus oSarcoidosis o Photophobia o Discomfort with EOMs or have EOM o Reiter’s restriction oHypertension o Corneal infiltrate/thinning o B‐scan o Polyarteritis nodosa oForeign body o Scleral thinning (30%) o Thickening of sclera and choroid o AS “T” sign oViruses, bacteria, fungi, parasite (4‐10%) A/C cells/flare (30%) o o o Enhanced depth imaging OCT o Behcet o Thickening of choroid

https://www.ncbi.nlm.nih.gov/books/NBK499944/#:~:text=The%20main%20differential%20diagnosis%20of,foreign%20body%20sensation%2C%20and%20tearing. https://www.ijo.in/article.asp?issn=0301‐4738;year=2020;volume=68;issue=9;spage=1818;epage=1828;aulast=Murthy https://www.reviewofoptometry.com/article/how‐to‐play‐the‐shell‐game Epidemiology Differentials

Episcleritis Pingueculitis Middle age Conjunctivitis Phlyctenule Females>Males Trauma Retrobulbar mass African Americans Ocular rosacea Myositis

https://www.atlasophthalmology.net/photo.jsf?node=506&locale=en Herpes zoster Scleral ectasia Anterior uveitis Staphyloma

https://www.atlasophthalmology.net/photo.jsf?node=514&locale=en

Evaluation Treatment

History ◦ Oral NSAID o Immunosuppressive agents Examine sclera in all directions of gaze by gross inspection in adequate room light ◦ Oral Steroids o Biologics Slit‐lamp examination ◦ Add H2 blocker or PPI o Infectious etiologies: o Topical and systemic antibiotics DFE Complete physical exam o*Recommend glasses or eye shield Lab work‐up and imaging (for significant thinning/perforation risk) ◦ CBC, ESR, C‐reactive protein, uric acid, RPR, FTA‐ABS, RF, ANA, ACE, ANCAs, HLA‐B27, Lyme serology ◦ B‐scan, OCT, UBM, MRI or CT, Chest x‐ray,

https://www.ncbi.nlm.nih.gov/books/NBK499944/#:~:text=The%20main%20differential%20diagnosis%20of,foreign%20body%20sensation%2C%20and%20tearing.

Prognosis

Mild or moderate scleritis – relatively good Necrotizing and posterior scleritis – higher risk of VA loss Recurrences are common The Black Spot 42 year old African American Male 42 year old African American Male New patient Ocular history: Medications: ◦ Unremarkable ◦ Hydrocortisone 1% ointment CC: black spot in vision OD x 1 week Medical history: Allergies: ◦ Constant, stable ◦ Eczema ◦ NKDA ◦ Blurred vision FOHx: ◦ Darker color vision ◦ Unremarkable BP: 138/96 ◦ Denies headaches, pain, flashes, curtain over vision, floaters FMHx: ◦ Unremarkable

42 year old African American Male 42 year old African American male

VAsc Anterior segment: unremarkable OD/OS ◦ OD: 20/25 ◦ OS: 20/20+2 IOP: 20 OD/ 20 OS GAT Pupils: PERRL (‐)APD OD/OS EOMs: SAFE CVF: FTFC OD/OS Posterior segment: ◦ OD: 1.0DD central circular edema CT: Ortho (distance); 2XP (near) ◦ OS: unremarkable Red cap: equal between eyes ◦ OU: mild arterial attenuation Amsler grid: yellow shadow‐central circle, no metamorphopsia OD

42 year old African American Male

Assessment: ◦ Central serous chorioretinopathy OD ◦ Pt reports elevated stress for the last few months ◦ Pt reports using hydrocortisone for eczema on eyes and regularly gets it into eyes ◦ Elevated BP Plan: ◦ Pt edu on findings and relation to stress and cortisol use ◦ Recommended avoiding use of hydrocortisone, especially getting into eyes ◦ Exam summary letter written to PCP to encourage f/u for elevated BP ◦ RTC in 1 month for f/u Why CSCR?? The Choroid Central serous is a pachychoroid disease! Choroid is very important!

What does pachychoroid mean? ◦ Pachy (Greek) –thick

Thickened choroid

Changes in choroid can indicate disease

https://commons.wikimedia.org/wiki/File:Blausen_0388_EyeAnatomy_01.png

ENHANCED DEPTH IMAGING OCT The Choroid

Layers of the choroid ◦ Bruch’s Membrane ◦ Choriocapillaris ◦ Sattler’s layer https://www.opticianonline.net/cet‐archive/153 ◦ Haller’s layer ◦ Choroid/sclera transition zone (suprachoroid)

Park, Byeong & Chung, Hye & Kim, Hyung Chan. (201).3 Effects of Diabetic Retinopathy and Intravitreal Bevacizumab Injection on Choroidal Thickness in Diabetic Patients. Journal of the Korean Ophthalmological Society. 54. 1520. 10.3341/jkos.2013.54.10.1520.

The Choroid The Choroid

Choroidal thickness Choroidal thickness ◦ Subfoveal thickness range: 260‐350µm ◦ >300µm can be pathologic ◦ Varies based on: ◦ Age ◦ Refractive error/axial length Thickest ◦ Diurnal variation ◦ Blood pressure ◦ Ethnicity

https://europepmc.org/abstract/med/23141578 https://iovs.arvojournals.org/article.aspx?articleid=2186229 https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5782455/#ref14 https://www.reviewofoptometry.com/article/imaging‐the‐choroid‐theres‐an‐app‐for‐that https://eventpilot.us/web/page.php?page=Session&project=AAOPT19&id=2704790&filterUrn=urn%3Aeventpilot%3Aall%3Aagenda%3Afilter%3Acategoryid%3DLectures Pachychoroid Diseases Pachychoroid diseases Central serous chorioretinopathy Features: Pachychoroid pigment epitheliopathy ◦ Attenuated small and medium choroidal vessels ◦ Dilated large choroidal vessels (increased vascular permeability) Pachychoroid neovasculopathy Polypoidal choroidal vasculopathy Consequences: ◦ Can cause RPE compromise ◦ Can cause vision loss ◦ Can cause neovascularization

Pachychoroid diseases Central serous chorioretinopathy Central serous chorioretinopathy Pachychoroid pigment epitheliopathy Pachychoroid neovasculopathy M>F Polypoidal choroidal vasculopathy 30‐60 y.o. Type A, stress, glucocorticoids EDI OCT: ◦ Dilated outer choroidal vessels https://commons.wikimedia.org/wiki/File:Central_serous_chorioretinopathy_with_increased_choroidal_thickness.png ◦ Attenuated small/medium vessels

Pachychoroid diseases Pachychoroid Pigment Epitheliopathy Central serous chorioretinopathy Pachychoroid pigment epitheliopathy Clinical features: Pachychoroid neovasculopathy • EDI OCT – Pachychoroid • Normal VA (asymptomatic) Polypoidal choroidal vasculopathy • Orange‐redish fundus • Fundus tessellation absent • Non‐specific RPE changes • Sub‐RPE drusen‐like deposits • Small PEDs

This image was originally published in the Retina Image Bank. John S. King MD. Pam Hall. Title. Retina Image Bank. 2018; 28556. © the American Society of Retina Specialists

Yu, Shawn X., and Raman Bhakhri . “Overlooked and Misdiagnosed: Understanding the Pachychoroid Spectrum .” American Academy of Optometry Conference . American Academy of Optometry Conference , 1 July 2020, Orlando, Florida . Pachychoroid diseases Pachychoroid Neovasculopathy Central serous chorioretinopathy Pachychoroid pigment epitheliopathy Type I CNV EDI OCT – Pachychoroid Pachychoroid neovasculopathy Polypoidal choroidal vasculopathy

https://www.flickr.com/photos/nationaleyeinstitute/7543920284

Pachychoroid Neovasculopathy

Type I CNV EDI OCT – Pachychoroid Type I: https://commons.wikimedia.org/wiki/File:Retina‐OCT800.png ◦ Underneath RPE Absence of drusen ◦ Vessels originate from the choroid ◦ Corresponds to hidden CNV Often misdiagnosed as AMD Type II: ◦ Break through RPE but remains sub‐retinal ◦ Vessels also originate from the choroid Symptoms: ◦ Corresponds to classic CNV Decreased VAs

Type III: Central scotoma https://www.flickr.com/photos/nationaleyeinstitute/7543920284 ◦ Vessels originate from the retinal arteries Metamorphopsia ◦ Aka: retinal angiomatous proliferation (RAP)

Pachychoroid diseases Polypoidal Choroidal Vasculopathy Central serous chorioretinopathy Pachychoroid pigment epitheliopathy First described in 1990s Pachychoroid neovasculopathy No universal definition Polypoidal choroidal vasculopathy Pachychoroid Choroidal vascular abnormalities Polyps – aneurysmal dilation Type 1 CNV

https://www.atlasophthalmology.net/photo.jsf?node=9171&locale=en

https://www.aaojournal.org/article/S0161‐6420(17)32863‐4/fulltext#secsectitle0040 Yu, Shawn X., and Raman Bhakhri . “Overlooked and Misdiagnosed: Understanding the Pachychoroid Spectrum .” American Academy of Optometry Conference . American Academy of Optometry Conference , 1 July 2020, Orlando, Florida . Polypoidal Choroidal Vasculopathy Polypoidal Choroidal Vasculopathy

Clinical features: Orange‐red nodules

Serous subretinal detachment OCT https://www.ijo.in/article.asp?issn=0301‐4738;year=2018;volume=66;issue=7;spage=896;epage=908;aulast=Anantharaman Submacular hemorrhage PEDs Serous or hemorrhagic PEDs Polyps Double layer sign Exudative Hemorrhagic Mixed https://www.ijo.in/article.asp?issn=0301‐4738;year=2018;volume=66;issue=7;spage=896;epage=908;aulast=Anantharaman Pachychoroid

https://www.ncbi.nlm.nih.gov/pmc/articles/PMC6256905/ https://www.aaojournal.org/article/S0161‐6420(17)32863‐4/fulltext#articleInformation https://www.aaojournal.org/article/S0161‐6420(17)32863‐4/fulltext#articleInformation Yu, Shawn X., and Raman Bhakhri . “Overlooked and Misdiagnosed: Understanding the Pachychoroid Spectrum .” American Academy of Optometry Conference . American Academy of Optometry Conference , 1 July 2020, Orlando, Florida . Yu, Shawn X., and Raman Bhakhri . “Overlooked and Misdiagnosed: Understanding the Pachychoroid Spectrum .” American Academy of Optometry Conference . American Academy of Optometry Conference , 1 July 2020, Orlando, Florida .

Polypoidal Choroidal Vasculopathy Polypoidal Choroidal Vasculopathy

Best diagnosed by indocyanine green (ICG) angiography Characteristics: Subtype of AMD? >Asian & African American M>F (Asian); M=F (Caucasian) Age: 50‐65

https://www.atlasophthalmology.net/photo.jsf?node=9171&locale=en

https://www.ijo.in/viewimage.asp?img=IndianJOphthalmol_2018_66_7_896_234954_f6.jpg https://vimeo.com/303317232 Yu, Shawn X., and Raman Bhakhri . “Overlooked and Misdiagnosed: Understanding the Pachychoroid Spectrum .” American Academy of Optometry Conference . American Academy of Optometry Conference , 1 July 2020, Orlando, Florida .

Polypoidal Choroidal Vasculopathy Polypoidal Choroidal Vasculopathy

Diagnosis AMD vs PCV, why does it matter?? Fundus exam

Spectral domain OCT https://www.ncbi.nlm.nih.gov/pmc/articles/PMC6256905/ PCV responds better to combo therapies

ICG angiography

https://www.ijo.in/viewimage.asp?img=IndianJOphthalmol_2018_66_7_896_234954_f6.jpg

https://vimeo.com/303317232 Pachychoroid Disease

CSCR Pachychoroid Pachychoroid Polypoidal choroidal pigment neovasculopathy vasculopathy epitheliopathy Enhanced depth imaging Pachychoroid  attenuated choriocapillaris & Sattler’s layer; dilated Haller’s layer OCT “Good Vision” Other features Subretinal CSCR w/o subretinal Type I CNV Type I CNV detachment fluid Absence of drusen Polyps PED Non‐specific RPE >Asian & African American changes Treatment Monitor Monitor Anti‐VEGF Combo Tx: Anti‐VEGF, PDT, steroids

9 year old Caucasian female 9 year old Caucasian female CC: “Good vision in both eyes” says Grandma VAsc: Refraction: Last eye exam: last year, has glasses but rarely wears them ◦ OD: 20/25 ◦ OD: +5.25 ‐1.00 x 090 20/20‐ ◦ OS: 20/25+2 ◦ OS: +5.00 ‐0.75 x 086 20/25+ ◦ OU: 20/20‐1 Ocular Hx: unremarkable Pupils: PERRL (‐) APD Anterior segment: Unremarkable OU Medical Hx: unremarkable EOMs: SAFE OU FOHx: unremarkable CVF: FTFW IOP: FMHx: unremarkable ◦ OD: 15 CTsc: ◦ OS: 16 ◦ Distance: 6 esophoria Meds: None ◦ Near: 6 esophoria Allergies: NKDA Assessment/Plan Neuroretinitis OS ◦ Denies systemic conditions ◦ Denies neurological symptoms ◦ No medications ◦ (+) cats at home

OMD Testing Neuroretinitis MRI: minimal prominence of left optic cup, which may be seen with mild Pathophysiology: papilledema. Otherwise normal brain and orbits MRI ◦ Inflammation of optic disc vasculature causing exudation of fluid into peripapillary retina Bartonella: (+) presence of IgM antibodies suggests recent infection. Differentials: ◦ Any condition which can cause optic disc edema Lyme: negative

https://journals.lww.com/jneuro‐ophthalmology/fulltext/2011/03000/neuroretinitis__review_of_the_literature_and_new.16.aspx

Proposed Classification of Neuroretinitis Cat Scratch Neuroretinitis

Etiologies Cases of neuroretinitis between 1950‐2010 Cat scratch disease is the most common cause of neuroretinitis ◦ Bartonella henselae is most likely cause of cat‐scratch disease Based on etiology: Incidence: 9.3 per 100,000 Idiopathic Self‐limiting, benign ◦ Single episode ◦ Recurrent Children Infectious ◦ Most common: cat scratch disease

https://journals.lww.com/jneuro‐ophthalmology/fulltext/2011/03000/neuroretinitis__review_of_the_literature_and_new.16.aspx https://journals.lww.com/internat‐ophthalmology/Fulltext/2001/01000/Neuroretinitis.9.aspx?casa_token=w1DlI0jvnwkAAAAA:s7SVp3xxEroxlPItvfUvJHHnCG4Ra3Ew1vWPYlno7oKQXOl2y9RNsC‐OZ92BeozONSGyi8hq_Msr7wo51hsqrTI Cat Scratch Neuroretinitis Neuroretinitis

Review of 65 case reports: Characteristics: Laterality: unilateral VA: ◦ Stellate maculopathy ◦ Disc edema Age: 4‐64 years ◦20/40 (14.5%) ◦20/50‐20/200 (33.3%) ◦ Vitreous inflammation Gender: 1.8 (female) : 1 (male) ◦>20/200 (52.2%) ◦ CWS Symptoms: ◦Final VA 20/40 or better (93%) ◦ NLF hemes VF: Central defect (88%) ◦Systemic symptoms (73%) ◦ Multifocal deep yellow‐white retinal lesions ◦Eye pain (7.7%) Pupils: RAPD (67.5%) Color vision: (+) defect ◦ Resolution: spontaneous https://www.ijo.in/viewimage.asp?img=IndianJOphthalmol_2014_62_10_982_145986_u2.jpg

https://journals.lww.com/jneuro‐ophthalmology/fulltext/2011/03000/neuroretinitis__review_of_the_literature_and_new.16.aspx

Testing and Tx for Neuroretinitis

OCT Labs: Treatment: ◦ Cat scratch titers (Bartonella species) oAntibiotic shortened course of systemic FA ◦ Fluorescent treponemal antibody disease absorption test (FTA‐ABS) oMeds most effective: FAF ◦ Tuberculosis skin test (PPD) o Rifampin (87% of cases) ◦ Lyme disease “Super healthy guy” MRI o Ciprofloxacin (84%) ◦ Angiotensin‐converting enzyme o Trimethoprim‐sulfamethoxazole (58%) ◦ Chest x‐ray

https://journals.lww.com/jneuro‐ophthalmology/fulltext/2011/03000/neuroretinitis__review_of_the_literature_and_new.16.aspx

41 year old Caucasian male 41 year old Caucasian male CC: Reading at near is getting a little difficult VAsc: Refraction: ◦ OD: +0.25 ‐0.50 x 180 20/20 ◦ Have to pull reading material further away ◦ OD: 20/20‐ ◦ OS: 20/20‐ ◦ OS: pl ‐0.50 x 180 20/20 ◦ Makes text on computer and phone a little bigger ◦ Add +1.00 20/20 CT (distance): ortho Medical Hx: unremarkable CT (near): ortho Anterior seg: unremarkable OU ◦ Last PCP visit: within the last year Ocular Hx: unremarkable Pupils: PERRLA (‐) APD IOP: ◦ Last eye exam: can’t remember EOMs: SAFE OU ◦ OD: 13 CVF: FTFC OD/OS ◦ OS: 14 FMHx: unremarkable FOHx: unremarkable BP: 186/121 OLD vs NEW HTN Guidelines What’s the next step? Systolic BP Diastolic BP Old category Old New New Old category Old New New systolic Systolic category diastolic diastolic category Normal <120 <120 Normal Normal <80 <80 Normal Pre‐ 120‐139 120‐129 Elevated Pre‐ 80‐89 <80 Elevated hypertension hypertension Stage 1 HTN 140‐159 130‐139 Stage 1 HTN Stage 1 HTN 90‐99 80‐89 Stage 1 HTN

Stage 2 HTN >160 >140 Stage 2 HTN Stage 2 HTN >100 >90 Stage 2 HTN

Hypertensive >180 >180 Hypertensive Hypertensive >110 >120 Hypertensive

Crisis crisis Crisis crisis https://pixabay.com/photos/background‐beach‐beautiful‐beauty‐2413081/

41 year old Caucasian male How to Properly Measure Blood Pressure The patient should be seated and relaxed for 5 to 10 minutes prior to taking measurement The proper sized cuff should be chosen for the patient’s arm ◦ If cuff is too large, you can overestimate BP, if cuff is too small, you can underestimate BP The patient should have unrestricted bearing of the upper arm The patient should be seated with legs uncrossed and with back against a chair or wall First reading BP: 176/113 The patient should have a slightly bent arm with palm up so the midpoint of the upper arm is resting at right atrium level BP: 186/121 ◦ If the arm is above heart level, the reading will be underestimated BP: 178/111 ◦ If the arm is held below heart level, the reading will be overestimated (due to gravitational forces) The patient’s arm is rested on a table or an armrest, or it can be fully supported by the clinician if needed. No

https://pixabay.com/photos/doctor‐investigation‐blood‐pressure‐4303020/ exertion should be present in order to prevent muscle contractions, which could artificially increase the reading. The clinician should palpate for the radial pulse, then pump the cuff quickly to the point where this pulse first disappears. The clinician should then continue to pump for an additional 30 mm Hg before slowly deflating the cuff at a rate of 2 to 3 mm Hg/second and listening for the first sound.

https://www.optometrytimes.com/view/know‐latest‐classifying‐and‐referring‐hypertension

New BP guidelines HTN Management

Category Systolic Diastolic Category Systolic Diastolic Recommended follow-up Normal < 120 < 80 Normal < 120 < 80 Recheck yearly Elevated 120 – 129 <80 Elevated 120 – 129 <80 Letter to PCP; Should recheck in 3-6 months, discuss lifestyle modification Stage 1 130 – 139 80 – 89 Stage 1 130 – 139 80 – 89 Letter to PCP; Refer within 2 months Discuss lifestyle modification Stage 2 ≥140 ≥90 BP: 177/112 Stage 2 ≥140 ≥90 Refer to PCP within 1 month Hypertensive crisis >180 >120 Discuss lifestyle modification Hypertensive crisis >180 >120 Refer immediately

https://healthmetrics.heart.org/wp-content/uploads/2017/11/Detailed-Summary.pdf http://www.acc.org/latest-in-cardiology/ten-points-to-remember/2017/11/09/11/41/2017-guideline-for-high-blood-pressure-in-adults HTN Follow‐Up Ocular manifestations of HTN Progression of diabetic retinopathy Hypertensive crisis Hypertensive retinopathy BP: >180 / >120 Anterior ischemic optic neuropathy Glaucoma Central or branch retinal artery occlusion Idiopathic polypoidal choroidal vasculopathy (CRAO or BRAO) Macroaneurysms Central or branch retinal vein occlusion (CRVO Ocular ischemic syndrome Hypertensive Urgency Hypertensive Emergency or BRVO) Subconjunctival hemorrhage Choroidal infarction Transient visual obscurations Cranial nerve palsies No end organ damage End organ damage Refer within 24‐48 hours Refer Immediately

https://healthmetrics.heart.org/wp-content/uploads/2017/11/Detailed-Summary.pdf https://www.reviewofoptometry.com/article/hypertension‐more‐than‐meets‐the‐eye http://www.acc.org/latest-in-cardiology/ten-points-to-remember/2017/11/09/11/41/2017-guideline-for-high-blood-pressure-in-adults

41 year old Caucasian male 41 year old Caucasian male Confirmed he has high blood pressure…. Patient declined dilation What’s the next step? Only wants spectacle Rx

Can we still dilate the patient?

2.5% phenylephrine?

10% phenylephrine?

https://jamanetwork.com/journals/jamaophthalmology/article‐abstract/2204793?casa_token=0QgWstzprBgAAAAA:lhJyURn0_C1PS1KsaV6N7lrt15xvIwSpn6W6wGarmsI_yI4zR49IdURLS3b‐GmAEtNYrwoC8KQ

41 year old Caucasian male Patient declined dilation Only wants spectacle Rx

https://commons.pacificu.edu/work/ns/8b1a81ed‐9527‐4872‐976c‐3bce1be2f94b Clinical guidelines for children

What about kids?

https://pediatrics.aappublications.org/content/140/3/e20171904/tab‐figures‐data

30 year old Hispanic female CC: routine annual exam, no complaints with vision ‐ currently 2 months pregnant

Medical Hx: (+) Type 2 diabetes x 2 years, (‐) HTN “A little bump in the road” Ocular Hx: unremarkable, (‐) Hx of DR FMHx: (+) Diabetes: father FOHx: (+) Cataracts: father

Dilate or not? Dilate or not?

Diabetes Diabetes

Pre‐existing DM Gestational DM Pre‐existing DM Gestational DM Gestational Diabetes Dilate or not? oNot a risk factor for DR Diabetes

Pre‐existing DM Gestational DM

https://pixabay.com/photos/belly‐pregnant‐woman‐close‐up‐1434852/

Pre‐existing Diabetes Recommendations DR Risk factors: • Type I vs. Type II American Optometric Association recommendations: • Duration ~2 years • Blood glucose control “good” • Hypertension (‐) HTN “Women with diabetes who become pregnant should have a comprehensive eye • Maternal age 30 y.o. and vision examination during every trimester of pregnancy, with follow‐up at 6 to 12 months postpartum.” • Stage of DR (‐) History of DR

https://pixabay.com/vectors/baby‐black‐icon‐pregnancy‐pregnant‐1295835/

https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4165189/ https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3862469/ https://www.aao.org/eyenet/article/ocular‐changes‐during‐pregnancy

30 year old Hispanic female Are dilation drops safe? CC: routine annual exam, no complaints with vision ‐ currently 2 months pregnant Proparacaine Phenylepherine For Dilation Medical Hx: (+) Type 2 diabetes x 2 years, (‐) HTN Pregnancy Category C Tropicamide Ocular Hx: unremarkable, (‐) Hx of DR Proparacaine or Benoxinate FMHx: (+) Diabetes: father For GAT Sodium Fluorescein FOHx: (+) Cataracts: father

https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5082244/ https://www‐uptodate‐com.proxy.lib.pacificu.edu:2443/contents/phenylephrine‐ophthalmic‐drug‐information?search=topical%20ophthlamic%20phenylephrine%20pregnancy&source=search_result&selectedTitle=7~150&usage_type=default&display_rank=7 https://www.sciencedirect.com/science/article/pii/S0039625712001816?casa_token=QcE6BqTxk0kAAAAA:NSbMv_P15WxGsGg71wn7CRe5HaX9fY7BRzOBslewBOItAqzUQd5lwZCdkMoOBA2WrJKtTYtMlw Pregnancy Categories New Pregnancy Labeling Established in 1979 by the FDA NEW Pregnancy drug labeling: narrative sections and subsections FDA Pregnancy Categories Category A Strong studies failed to demonstrate risk to fetus

Category BAnimal studies failed to demonstrate risk to fetus; no adequate studies in humans Category CAnimal studies show adverse effect on fetus; no adequate studies on humans; warrant use if benefits outweigh the risks Category D Positive evidence of risk on human fetus; warrant use if benefits outweigh the risks

Category X Studies demonstrated fetal abnormalities and fetal risk; risks https://www.fda.gov/drugs/labeling‐information‐drug‐products/pregnancy‐and‐lactation‐labeling‐drugs‐final‐rule outweigh potential benefits

https://www.fda.gov/Drugs/DevelopmentApprovalProcess/DevelopmentResources/Labeling/ucm093307.htm https://chemm.nlm.nih.gov/pregnancycategories.htm https://www.drugs.com/pregnancy‐categories.html

Pregnancy Labeling Pregnancy Labeling Example

Learn more! Federal Register FDA

https://www.drugs.com/pro/descovy.html https://www.federalregister.gov/documents/2014/12/04/2014‐28241/content‐and‐format‐of‐labeling‐for‐human‐prescription‐drug‐and‐biological‐products‐requirements‐for

Don’t forget!

Topical medication recommendation: ◦ Use minimal concentration ◦ Use minimal dose ◦ Punctual occlusion Thank you ◦ Wipe off extra drug

Amiee Ho, OD, FAAO [email protected] Pacific University College of Optometry

https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3862469/