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Home , Blepharitis, Orbital cellulitis, Stye

1/15/2016

EYECARE REVIEW : PART II LECTURE # 9 FOR PRIMARY CARE EYECARE REVIEW: PART II PHYSICIANS FOR THE PRIMARY CARE PHYSICIAN Steve Butzon, O.D. Member Director – IDOC STEVE BUTZON, O.D. President of W.S.O.S. [email protected]

EYECARE REVIEW: PART II LERNING OBJECTIVES

 Recognize of Common External and Internal Ocular Conditions

 Identify eye conditions that are within the Practitioner’s purview of treatment  Refer undiagnosed eye conditions for a consult to either an Optometrist or Ophthalmologist

BLEPHARITIS COMMON EXTERNAL OCULAR CONDITIONS  of   (anterior or posterior)   Viral  Symptoms  Hordeolum—  Bacterial  Itching

 Preseptal  Allergic  Burning

  Crusting

 Dry eye sensation   Foreign body sensation  Corneal ulcers

1 1/15/2016

DEMODEX BLEPHARITIS

 Signs  Treatment

 Crusts on lid margins  Warm compresses, 10 minutes 1-2 x/day  Thickened, reddened eyelids  Antimicrobial Lid wipes

 Plugged or inspisated  100 mg bid 2 wks meibomian glands  ointment at along night

DEMODEX  Demodex blepharitis is a common but  overlooked external . The Abscessed pathogenesis of Demodex blepharitis can cause ocular surface inflammatiion .  Raised, tender nodule  Signs: Collerettes and Inflammed glands  Often gets larger over days to a week  Symptoms: itchy eyelid and morning crusting of lashes and burning/tearing eyes evening. Treatment : Tea tree oil (Cliradex Pads) is used to treat Demodex blepharitis by reducing Demodex counts with additional antibacterial, antifungal, and anti-inflammatory actions . Oral Invermectin can also be prescribed.

CHALAZION PRESEPTAL CELLULITIS

 Signs  Treatment  Bacterial infection of  Raised nodule  Warm compresses, BID- eyelid anterior to orbital protruding out from TID for 10 mins septum or under lid  Topical meds don’t  Can arise from  Red, swollen lid penetrate  Concurrent sinus infection  Capped glands at  Oral if no  Penetrating lid trauma site of infection response to traditional treatment or in acute  Dental infection tender nodule lesions  Hordeolum (stye)  Excise lesion  Insect bite

2 1/15/2016

PRESEPTAL CELLULITIS ORBITAL CELLULITIS

 Serious infection of soft  Signs  Treatment tissues behind  Can be life-threatening  Painful, swollen lid  (augmentin) 500 extending past orbital mg PO TID x 10 days  Causes

rim  Sinus infection  ZPAK  May be unable to open  Extension of preseptal cellulitis  Treat infection quickly to eye minimize the risk of orbital  Dental infection  No decreased vision, Cellulitis  Penetrating lid injury restricted ocular  After ocular motility or proptosis

 White

PRESEPTAL VS. ORBITAL ORBITAL CELLULITIS CELLULITIS  Signs  Treatment  Tender, warm  Preseptal  Orbital  Medical emergency periorbital lid  Painful, swollen lid  Painful, swollen lid  Hospitalization with IV  Proptosis antibiotics  Normal vision  Decreased vision  Painful  Full EOMs  Restricted ocular motilities ophthalmoplegia  Consider /head CT to look for abscess  No proptosis  Proptosis  Decreased vision  No fever  Fever/malaise  Consult pediatrician or  Severe malaise, fever infectious disease   and Child Mean age 21 mos. Child Mean age 12 specialist Cause Bacteremia or Cause Trauma

PTERYGIUM PTERYGIUM  Management and Treatment  Signs  UV tint on glasses

 Triangular-shaped growth of conjunctival  Dry eye  Avoid irritating environments

tissue onto  Artificial  Irritation  Causes  Topical vasoconstrictor or mild  Redness steroid

 UV exposure   Surgery  Dryness

 Irritants

 Smoke

 Dust

3 1/15/2016

CORNEAL ULCER

 Infection of cornea  Signs  Treatment:  Bacterial  Pain  Start immediately  Fungal   Fortified antibiotics

 Acanthamoeba  Blurred vision  Fluoroquinolones

 Causes  Discharge  Amniotic membrane graft  SCL wearer   Culture may not be  Trauma necessary if ulcer is small

 Must be monitored daily!  Compromised cornea from pre-existing condition

CONJUNCTIVITIS () CONJUNCTIVITIS

 Various Causes  Signs  Discharge

Viral/Adenovirus  Irritation  Watery Bacterial  Burning/stinging  Mucoid  Watering  Mucopurulent Allergic  Photophobia  Purulent Chlamydial  Pain or foreign Herpetic body sensation

Toxic  Itching

VIRAL CONJUNCTIVITIS (PINK EYE) VIRAL CONJUNCTIVITIS

 Most viral infections are fairly mild and self-limiting  Patients often have recent history of URI  Signs & Symptoms  Treat symptoms  Watering  Cool compresses  Redness   Photophobia Artificial tears

 Discomfort/foreign body sensation  Topical vasoconstrictors or mild anti- inflammatory  Palpable preauricular node  Frequent hand washing  Usually runs course in 1-3 weeks

4 1/15/2016

ADENOVIRAL CONJUNCTIVITIS ADENOVIRAL CONJUNCTIVITIS

 Signs  Highly contagious  Watering  Most common types  Conjunctival follicles  Pharyngoconjunctival fever (PCF)— can be caused by adenovirus  Subconjunctival hemorrhages types 3, 4 & 7   Epidemic (EKC)— caused most commonly by adenovirus  Pseudomembranes types 8 & 19  Lymphadenopathy



BACTERIAL CONJUNCTIVITIS BACTERIAL CONJUNCTIVITIS

 Common organisms: S. aureus, S. epidermidis, S.  Common, especially in pneumonia, H. influenza (esp. peds) children  Usually self-limiting  Usually self-limiting  But important to use broad-spectrum until discharge cleared (5-7 days)  Signs/symptoms  Antibiotics  Acute redness  Tobramycin  Burning/grittiness  Polytrim—polymyxin + trimethoprim  Mucopurulent discharge  Fluoroquinolones like  Lids stuck shut in morning Ocuflox or Ciloxan

HYPERACUTECONJUNCTIVITIS HYPERACUTECONJUNCTIVITIS

 Cause  Treatment  Sexually transmitted  Lavage  Neisseria gonorrhoeae

 Signs  Take scrapings for culture and sensitivity testing  Swollen, tender lids  Patients usually hospitalized and started on  Copious purulent discharge IM Ceftriaxone  Significant conjunctival redness and swelling  Topical antibiotics not effective

 Lymphadenopathy

5 1/15/2016

CHLAMYDIALCONJUNCTIVITIS CHLAMYDIALCONJUNCTIVITIS

 Signs  Patients can have concomitant genital infection (could be asymptomatic)  Cause  Refer for work-up if necessary  Sexually transmitted ocular infection  Treatment

 Follicular conjunctivitis  Oral—Azithromycin 1g, doxycycline 100mg bid x 7 days, erythromycin 500mg qid x 7 days. Also need  Non- respondent to topical to tx partners! antibiotics  Topical—erythromycin, tetracycline, or  Usually unilateral ung bid-tid x 2-3 weeks  Foreign body sensation

ALLERGIC CONJUNCTIVITIS

 Treatment  Can be seasonal or acute  Eliminate offending agent  Signs/symptoms  If mild  Itching is hallmark  Cool compresses  Conjunctival redness  Artificial tears/vasoconstrictors  Chemosis  If moderate or severe  Lid edema  Topical antihistamine/mast-cell stabilizer  Thin, watery discharge  Topical NSAID  No palpable preauricular  Topical steroid nodes  Oral antihistamine

INTERNAL OCULAR CONDITIONS

   

6 1/15/2016

GLAUCOMA

 Progressive loss of Nerve fiber layer at ONH (increased cupping)  Can lead to peripheral visual field loss  Sometimes caused by elevated intraocular pressure  Two main types

GLAUCOMA GLAUCOMA

 Pathophysiology of progression not well understood  Monitoring  IOP  Increased IOP  ONH appearance  Damages nerves as they leave eye, causing cell death  Visual field testing  Reduces blood supply to ONH, indirectly destroying cells by starving them of oxygen and nutrients  Newer methods include

 Abnormal levels of neurotransmitter (glutamate)  HRT (Heidelberg Retinal cause cells to die off Tomograph II)  GDx Nerve Fiber Analyzer

 Genetic testing

GLAUCOMA

 Clouding of natural  IOP reduction is mainstay of treatment  Patients experience

 Decrease aqueous production  Blurred/dim vision

 B-blockers  Glare, especially  Alpha-agonists at night  Carbonic anhydrase inhibitors  Halos around lights  Increase uveoscleral outflow  Doubling or ghost images of objects  prostaglandin analogs

7 1/15/2016

ETIOLOGY MAIN TYPES

 Everyone develops them if they live  long enough! Age-related

 Types of cataracts  Nuclear sclerotic

 Age-related—senile  Cortical spokes

 Trauma—blunt or perforating  Posterior injury sub-capsular  Systemic conditions—diabetes  Mature cataract  Medications—steroids

TREATMENT OUTPATIENT SURGERY

 Surgery  5-10 minutes with skilled surgeon  When loss of vision interferes  Incision through cornea with daily activities or under upper lid

 Driving  Circular tear in anterior capsule  Reading  Lens broken up with ultra sound instrument  Hobbies  Fragments suctioned out

 Lens implant inserted

OPHTHALMIC SIDE EFFECTS OF SECONDARY CATARACT SYSTEMIC MEDICATIONS

 Cloudiness forms on posterior capsule after cataract surgery  30-50% of patients

 YAG laser used to create opening  Vision quickly restored

8 1/15/2016

NEW PLAQUENIL GUIDELINES MACULAR DEGENERATION Primary Risk factors   Duration: > 5 yrs #1 cause of

 Cumulative :Damage: >1,000g blindness in

 Age: Elderly Americans

 Systemic disease: High BMI, over Liver and Kidney Dysfunction age 65  Ocular disease: Retinal or Macular disorders Dilated eye exam and 10-2 visual field prior to starting medication as well as a fundus photo .

PATHOPHYSIOLOGY TWO TYPES

 Causes not well understood  Dry (atrophic)  Theorized link to  90% of those diagnosed  UV light exposure  Wet (exudative)  subsequent release of free radicals  10% of those diagnosed  oxidation within retinal tissues   Another theory—areas of decreased But accounts for 90% of blindness caused vascular perfusion in , lead to cell by disease death

SYMPTOMS DRY FORM

 Slow , progressive loss of  None central vision  Blurred vision  Breakdown of underlying retinal tissues, resulting in  Metamorphopsia— mottling or clumping of straight lines appear normal pigment wavy or distorted  Drusen begin to accumulate, little white  —missing flecks (Tombstones) of old areas in vision dead RPE Cells  can also occur

9 1/15/2016

WET FORM TREATMENT FOR DRY FORM

 Can quickly degrade  Regular eye exams central vision  Careful discussion regarding  Break in underlying family history tissues allows new blood vessels or fluid to come  Education through  UV protection  New blood vessels are  Antioxidants weak so frequently break  AREDS II supplements and bleed  Stop smoking

TREATMENT FOR WET FORM RETINAL DETACHMENT

 Several types

 Rhegmatogenous  Refer to retinal specialist —caused by break in retina  Photocoagulation  Exudative—  Photo-dynamic therapy (PDT) caused by fluid accumulation  Sub macular surgery beneath retina  Tractional—  Macular translocation proliferative fibrovascular  Anti-VEGF drug therapy vitreal strands

SIGNS & SYMPTOMS EMERGENCY

 Patients with these symptoms must see  Flashing lights in peripheral vision eyecare provider immediately New —black spots or  Additional risk factors ‘cobwebs’  Highly nearsighted Peripheral —dark shadow  Diabetic or “curtain” blocking vision  Recent trauma/injury

10 1/15/2016

TREATMENT

 Laser photocoagulation or cryotherapy  Pneumatic retinopexy— gas bubble to tamponade retina back into place  Scleral buckle  Silicone oil

DIABETIC PROGRESSION  Over time, elevated and fluctuating blood sugar damages vessel walls  Diabetes affects retinal  Vessels leak fluid, lipids or blood into retina micro-vasculature  New vessels grow to bring more oxygen to retina  One of leading causes of blindness among ages 20-64

SYMPTOMS TREATMENT  Control blood sugar  Fluctuating vision  Refer to retinal specialist  Blurred vision when vision threatened

 Distortion  PRP (pan-retinal photocoagulation)  Sudden loss of vision  Focal laser

 Vitrectomy

 Anti-VEGF treatment for diabetic

11 1/15/2016

HYPERTENSIVE RETINOPATHY

Damage to the retina and to the retinal circulation due to high blood pressure (i.e. hypertension).

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