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Basic Eye Anatomy Cross ‐ Section View of the Anterior

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Basic Eye Anatomy Cross ‐ Section View of the Anterior Sound like an expert, learn the lingo… First: basic eye anatomy •Anatomical Landmarks • Cornea External/ .Lids/Lashes • Iris Ocular .Lacrimal system • Adnexa Lens .Conjunctiva and Sclera • Disc– meaning optic nerve • Fundus– meaning retina .Cornea Anterior . •Common Abbreviations for Common Conditions: Segment Anterior Chamber • POAG‐ primary open angle glaucoma .Iris • PDR‐ proliferative diabetic retinopathy .Lens • AMD (ARMD) – age‐related macular degeneration • DME‐ diabetic macular edema .Vitreous Posterior • phaco‐ phacoemulsification (aka: cataract surgery) and typically this would include an IOL Segment .Optic nerve • IOL‐ intraocular lens .Retina • IOP‐ intraocular pressure • DES‐ dry eye syndrome • TED‐ thyroid eye disease https://www.aao.org/young‐ophthalmologists/yo‐info/article/learning‐lingo‐ophthalmic‐abbreviations 7 8 Cross ‐ Section view of the anterior segment Basic anatomy Space between cornea and iris Anterior (translucent covering) Segment Posterior Segment 9 10 Syllabi/Slides for this program are a supplement to the live CME session and are not intended for other purposes. Your patient has an eye complaint, now what? But wait, don’t I need these? History: ◦ Laterality‐ is it one eye or both eyes? ◦ Any recent eye surgery or trauma? ◦ Ask about RSVP symptoms ‐ Redness, Sensitivity to light, Vision loss, Pain Vision: ◦ Check one eye at a time with near card with patient’s glasses on Motility: ◦ Have the patient move their eyes up and down, then side to side ◦ Do both eyes move together in the same direction? Penlight Exam: ◦ Conjunctiva and sclera ◦ Cornea and anterior chamber ◦ Pupil size, shape, reaction, and color 11 12 Basic Tool Kit Allow the patient to hold the card at a comfortable reading distance. If not able to see #s If you are talking to an ophthalmologist, sound like an expert and use the Jaeger Can they scale when checking vision with the near Count Fingers? card See Hand Motion? Detect Light? $10.64 13 14 Syllabi/Slides for this program are a supplement to the live CME session and are not intended for other purposes. Use your Card Case 1: Urgent Referral to Ophthalmology Exception to the Rule: 66 y/o woman I woke up this morning with a red When your patient has RSVP Acute profound painless vision left eye. There is mild irritation, symptoms, urgent consult is loss (20/200 range) but no pain. My vision is the same. warranted: ◦ Typically less than 24 – 48 hours I don’t recall hitting my eye or getting anything in my eye. Redness ◦ Differential Dx includes: Sensitivity to light ◦ Retinal Detachment R yes ◦ Central / Branch Retinal Vein Occlusion (inability to keep eyes open ) ◦ Central / Branch Retina Artery Occlusion S no Vision loss ◦ Giant Cell Arteritis V no Pain ◦ Vitreous Hemorrhage P no ◦ Optic Neuritis 15 16 Case 1: Bonus Question Case 1: 66 y/o woman I woke up this morning with a red left eye. There is mild irritation, but no pain. My vision is the same. I don’t recall hitting my eye or getting anything in my eye. R yes S no V no P no What is this anatomical landmark called? 17 18 Syllabi/Slides for this program are a supplement to the live CME session and are not intended for other purposes. Case 1: subconjunctival hemorrhage Case 2: 60 y/o man I woke up this morning with a red left eye. There is mild irritation and mild pain, no real itching. My vision is about the same, but it’s very teary. My young grandchildren were visiting over the weekend and gave me an upper respiratory infection. • Mostly idiopathic, but more common in hypertensive patients R yes • More common with advancing age as fibrous connections under the conjunctiva, including elastic and connective tissues, become more fragile S yes, but mild • May occur after sudden severe venous congestion to the head, such as in a Valsalva maneuver, severe cough, vomiting, sneezing, weight lifting V no • Observe, usually resolves in a few weeks, can use artificial tears as needed • Only recurrent or persistent SCH mandates further systemic evaluation P not really 19 20 Case 2: Adenoviral Conjunctivitis Case 2: 21 22 Syllabi/Slides for this program are a supplement to the live CME session and are not intended for other purposes. Case 2: Adenoviral Conjunctivitis Case 2: Adenoviral Conjunctivitis • Highly infectious (7‐14 days after symptoms start) • Desiccated adenovirus can live up to 28 days on hard surfaces • Must educate on preventing spread • strict hand‐washing • no sharing of towels, bed sheets, pillows, make‐up • Be sure to clean your office • Clean all contaminated hard surfaces with 1:10 bleach dilution • First‐Line Treatment: Artificial Tears, cool compresses as needed. • Inform patient to contact their eye care provider: if symptoms not improved after 1 week, they may need to come into the office. • * 13.9% developed corneal infiltrates and may require treatment with topical steroids 23 24 Case 2: Adenoviral Conjunctivitis Case 3: 35 y/o woman Over the last 3 days, my eyes are red, itchy, and teary. I feel like they are swollen, no change in vision. Whenever I’m outside, is seems to be worse, but not sensitive to light. R yes S no V no P no ++ Itchy 25 26 Syllabi/Slides for this program are a supplement to the live CME session and are not intended for other purposes. Case 3: Seasonal Allergic Conjunctivitis Case 3: Seasonal Allergic Conjunctivitis Itching mostly in the inner OTC Systemic OTC Eye Drops RX Only Eye Drops corners (medial canthus) Medication •Ketotifen (Zaditor®) • Cetirizine and •Bepotastine • Loratadine (Claritin®) pseudoephedrine (Bepreve®) • Cetirizine (Zyrtec®) (Zyrtec‐D®) • Olopatadine • Diphenhydramine (Pazeo®) (Benadryl®) • Azelastine (Optivar®) • Loratadine (Claritin®) • Fexofenadine (Allegra®) 27 29 Case 4: Case 4: bacterial conjunctivitis 25 y/o elementary school teacher woke up yesterday with eyelashes mattered together. By the end of the day, she noted that she had some discharge again in the right eye. R yes S no V no P mild 30 31 Syllabi/Slides for this program are a supplement to the live CME session and are not intended for other purposes. Case 4: bacterial conjunctivitis Case 5: bacterial (gonococcal) conjunctivitis 25 y/o elementary school teacher woke up this morning with eye pain, eyelashes mattered together. She has used an entire box of tissues this morning and it’s only 10 am. R yes S some V unchanged My preferred topical antibiotic: Polymyxin B/trimethoprim P yes Trimethoprim: Staphylococcus aureus and Staphylococcus epidermidis, Streptococcus pyogenes, Streptococcus faecalis, Streptococcus pneumoniae, Haemophilus influenzae, Haemophilus aegyptius, Escherichia coli, Klebsiella pneumoniae, Proteus mirabilis (indole‐negative), Proteus vulgaris (indole‐positive), Enterobacter aerogenes and Serratia marcescens. Polymyxin B: Pseudomonas aeruginosa, Escherichia coli, Klebsiella pneumoniae, Enterobacter aerogenes and Haemophilus influenzae 32 33 Case 5: bacterial (gonococcal) conjunctivitis Acute Conjunctivitis Type of Natural History Treatment Conjunctivits Adenoviral Self limited Artificial tears (“pink eye”) Symptoms improve 5‐14 days Cool Compresses Seasonal Allergic Seasonal Systemic antihistamine Recurrent OTC/Rx allergy eye drops Bacterial Typically self limited Artificial tears (non‐gonococcal) Symptoms improve in 1 week Consider topical antibiotic Bacterial Rapid development Erythromycin ointment (gonococcal) Severe hyperpurulent Systemic antibiotic Progress to corneal infection Urgent referral to Ophthalmology 34 35 Syllabi/Slides for this program are a supplement to the live CME session and are not intended for other purposes. Diabetes by the numbers Learning Objectives: Key facts from WHO Recognize some of the common “Red Eye” etiologies The number of people with List common ophthalmic complications from diabetes mellitus diabetes 108M (1980) Differentiate between urgent and non‐urgent ophthalmic conditions approx. 415M (2014). The global prevalence of diabetes* 4.7% (1980) approx. 8.5% (2014). * among adults over 18 yo 36 http://atlas.iapb.org/wp‐content/uploads/VA‐DR‐infographic‐resized.gif 37 “Diabetes Epidemic” number of people with Historical Perspective: William Osler's 1892 textbook of medicine devoted only: 10 pages to diabetes, as diabetes worldwide: against 65 pages to tuberculosis. approx. 415M (2014) 145 M w/ Retinopathy Historical Trivia: Massachusetts General Hospital from 1824‐98, admitted 47,899 pts 172 (0.004%) had diabetes. 38 https://www.diapedia.org/type‐2‐diabetes‐mellitus/3104287123/epidemiology‐of‐type‐2‐diabetes 39 Syllabi/Slides for this program are a supplement to the live CME session and are not intended for other purposes. Diabetic Retinopathy ...IS the leading cause of new cases of legal blindness in working‐age Americans Prevalence for any diabetic retinopathy in the US 4.2 M By 2020, estimated to grow 6 M Estimated vision‐threatening in the US 0.7 M By 2020, this number estimated to grow 1.34M http://altfutures.org/pubs/diabetes2030/IncreasingPrevalenceofDiabetesOverTime.gif 40 https://www.aao.org 41 Texas has one of the highest rates for Diabetic Retinopathy 42 43 Syllabi/Slides for this program are a supplement to the live CME session and are not intended for other purposes. New screening recommendation? Perhaps in a young (<21 y/o) newly diagnosed diabetic, screen earlier… 44 45 Major risk factor associated with development of Diabetic Retinopathy Case 6: Type II DM With insulin Without insulin 44 y/o man with DM Type II for last 20 Type I Duration of Disease Percentage with 5 years or less 40% 24% years. He complains that his vision has DM Retinopathy gotten more blurry over the last 2‐3 19 years of less 84% 53% months, and having difficult seeing 5 years 25% road signs while driving. OD 10 years 60% 15 years 80% R no OS 20 years 50% with vision threatening disease S no V yes P no Proliferative diabetic retinopathy develops in 2% of Type II patients who have diabetes for less than 5 years and in 25% of patients who have diabetes for 25 years or more.
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