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
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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
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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
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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
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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?
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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
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Case 2: Adenoviral Conjunctivitis Case 2:
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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
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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
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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®)
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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
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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
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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
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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
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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…
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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.
https://www.aao.org 46 47
Syllabi/Slides for this program are a supplement to the live CME session and are not intended for other purposes. Case 6: Diabetic Macular Edema Diabetic Macular Edema (DME) DME can present with any stage of Diabetic Retinopathy Chronic hyperglycemia is the major risk factor of DME The incidence of DME over a 10 year period is between 20% ‐ 40%. Standard Treatment: typically in‐office procedure 1. Center involving – intravitreal injections of anti‐VEGF drug • Frequency depending on drug, response to treatment, and may require lifelong injections at periodic intervals 2. Non‐center involving – macular (focal) laser • If the patient has not seen an ophthalmologist in the last 12 months, should More than 1 treatment may be needed depending on response see one in the next few weeks. • Can reduce the risk of more vision loss by 50% 3. Combination of 1 & 2
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Non‐Proliferative Diabetic Retinopathy Early stage of retinopathy Non‐proliferative retinopathy (NPDR) ‐microaneurysms ‐ dot blot hemorrhages ‐ hard exudates ‐ venous beading
Typically, vision isn't affected unless macular edema If no macular edema, no treatment. Chances of progression within three years > 25% if TAKE HOME MESSAGE: NPDR without Diabetic Macular Edema (DME), optimize both eyes are affected. glucose and blood pressure management because no ophthalmic treatment
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Syllabi/Slides for this program are a supplement to the live CME session and are not intended for other purposes. Case 7: Case 7: PDR with tractional retinal bands
32 y/o woman with DM Type II for last 8 years. She has been trying to get pregnant and has brought her HgA1c from 13.8% to 8.7% in the last 6 months. She has no complaints but has not seen an ophthalmologist in over 5 or 6 years, maybe only when she was first diagnosed. R no S no OU V no Some evidence indicate that decrease in HbA1c value during any 6-month period should be limited to less than 2% in order to prevent the progression of P no retinopathy. It is also evident that too rapid a decrease at the initiation of glycemic control could cause severe or transient exacerbation of the progression of retinopathy.
52 Jpn J. Ophthalmol 1992;36(3):356-67.53
Proliferative Diabetic Retinopathy (PDR) Proliferative Diabetic Retinopathy (PDR)
Even with PRP laser therapy, For PDR, current standard treatment Pan‐Retinal Photocoagulation (PRP). severe vision loss is high. Goal: preserve central vision Side Effects of PRP: Reduced peripheral vision Fresh Laser Nyctalopia (difficulty seeing in low light condition, “night blindness”) Application Pain during treatment Spots
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Syllabi/Slides for this program are a supplement to the live CME session and are not intended for other purposes. What Causes diabetic retinopathy? If PDR is not well‐controlled, can progress into Neovascular Glaucoma aka: NVG Chronically high blood sugar damages periocytes in blood vessels microaneurysms and • a potentially irreversibly blinding condition. leakage macular edema and vision loss Continued vascular damage retinal ischemia release of Vascular Endothelial Growth • The retina detects light and converts it to signals sent Factor (VEGF) new abnormal growth of blood vessels (Neovascularization) abnormal through the optic nerve to the brain. blood vessels with weak walls can lead to vitreous hemorrhage and vision loss Abnormal blood vessels on the optic nerve and retina create tractional bands • Early stage NVG may be amenable to pharmacological contraction of bands tractional retinal detachment and vision loss management, PRP, and anti‐VEGF injection therapy. Abnormal blood vessels proliferate on the iris and angle of the eye increased intraocular pressure damage to optic nerve neovascular glaucoma and vision loss • Advanced stage NVG requires surgical intervention to create new outflow for aqueous (typically glaucoma tube shunt).
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Case 8: Case 8:
52 y/o woman For months, my eyes seem red and irritated, especially in the afternoons or after I have been reading for a while. My vision also gets blurry after reading for about an hour. R yes S no V mild P irritated, burning, stinging
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Syllabi/Slides for this program are a supplement to the live CME session and are not intended for other purposes. The tear film is made of three layers: •An oily layer •A watery layer Case 8: Chronic Dry Eye •A mucus layer
Each layer of the tear film serves a purpose. The oily layer is the outside of the tear film. It makes the tear surface smooth and keeps tears from drying up too quickly. This layer is made in the eye’s meibomian glands, located in the eyelids.
The watery layer is the middle of the tear film. It makes up most of what we see as tears. This layer cleans the eye, washing away particles that do not belong in the eye. This layer comes from the lacrimal glands, located in the upper temporal region of the orbit.
The mucus layer is the inner layer of the tear film. This helps spread the watery layer over the eye’s surface, keeping it moist. Without mucus, tears would not stick to the eye. Mucus is made in the conjunctiva. This is the clear tissue covering the white of your eye and inside your eyelids.
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Case 8: Chronic Dry Eye Case 8: Chronic Dry Eye
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Syllabi/Slides for this program are a supplement to the live CME session and are not intended for other purposes. Case 8 plus : Severe untreated dry eye Case 9:
Urgent Referral to 28 y/o man contact lens wearer started having Ophthalmology foreign body sensation in his right eye about 2 days ago, and now presents with redness, pain, When patient has: sensitivity to light, and decreased vision. Redness R yes Sensitivity to light Vision loss S yes Pain V yes P yes
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Case 9: microbial keratitis Case 9: microbial keratitis with Hypopyon
If the cornea is not clear, ophthalmology needs to be near. If the anterior chamber is not clear, ophthalmology needs to be near.
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Syllabi/Slides for this program are a supplement to the live CME session and are not intended for other purposes. Something is in the anterior chamber… Hyphema Case 10:
35 y/o man started having redness and swelling of the right eye about 4 days ago, and now presents with redness, tenderness on the eyelid, no change in vision. R yes S no V no P tender on the eyelid If the anterior chamber is not clear, ophthalmology needs to be near.
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Case 10: Chalazia Blepharitis
• bacteria and oily flakes at the base of eyelashes • very common, especially among people who have oily skin, dandruff or dry eyes • symptoms include: foreign body or burning sensation, excessive tearing, itching, sensitivity to light (photophobia), red and swollen eyelids, redness of the eye, blurred vision, frothy tears, dry eye, or crusting of the eyelashes on awakening
No cure for blepharitis, only treatments to help control symptoms: Eyelid hygiene: Chalazia – sterile inflammation of meibomian gland, can • Warm Compresses become secondarily infected (aka: internal hordeolum) • Eyelid scrub Medication: External hordeolum (aka: stye)‐ acute staphylococcal • Topical antibiotic infection of lash follicle • Topical steroid • Combination of both
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Syllabi/Slides for this program are a supplement to the live CME session and are not intended for other purposes. Case 10: Chalazia & Hordeolum Case 11: Medical Treatment: • Warm compresses 4 times daily × 2 weeks (10 min each) 55 yo woman complains of progressive vision • dexamethasone/neomycin/polymyxin b (Maxitrol ®) ointment apply 4 times daily after warm loss, burning, stinging pain in both eyes. She has compress. noted that these growths have been enlarging for • Alternative: Bacitracin or erythromycin ointment years. Refer to Ophthalmology if not resolved in 7‐14 days for second line treatment including incisional drainage, intra‐lesional steroid injection R yes If recurrent chalazia in same location, refer to ophthalmology. S no May be sebaceous cell carcinoma V yes but chronic P burning, stinging
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Case 11: Pterygium Case 11: Pterygium
• Use of sunglasses, avoiding UV light exposure • Artificial tears to lubricate surface • Surgical excision if visually significant • Risk of recurrence higher with younger patients
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Syllabi/Slides for this program are a supplement to the live CME session and are not intended for other purposes. Common differential diagnosis for the Red Eye
o Conjunctivitis (Viral, Allergic Seasonal, Bacterial) Urgent Referral to Ophthalmology oSubconjunctival hemorrhage For more information on any of the When patient has: oDry Eye these entities: Redness http://eyewiki.aao.org/Main_Page oBlepharitis (Chalazia, Hordeolum) Sensitivity to light oPterygium (inability to keep eyes open ) oCorneal ulcer Vision loss oCorneal foreign body and abrasion Pain oChemical burn (Flash burn) oIritis (Uveitis) oAcute angle closure glaucoma
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Q&A:
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Syllabi/Slides for this program are a supplement to the live CME session and are not intended for other purposes.