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LECTURE # 9 for PRIMARY CARE EYECARE REVIEW: PART II PHYSICIANS for the PRIMARY CARE PHYSICIAN Steve Butzon, O.D

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LECTURE # 9 for PRIMARY CARE EYECARE REVIEW: PART II PHYSICIANS for the PRIMARY CARE PHYSICIAN Steve Butzon, O.D 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 Signs and Symptoms 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 Inflammation of Blepharitis Conjunctivitis eyelids (anterior or posterior) Demodex Viral Symptoms Hordeolum—stye Bacterial Itching Preseptal cellulitis Allergic Burning Orbital cellulitis Crusting Dry eye sensation Pterygium Foreign body sensation Corneal ulcers 1 1/15/2016 DEMODEX MITE 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 Doxycycline bid 2 wks meibomian glands Erythromycin ointment at along eyelid night DEMODEX CHALAZION Demodex blepharitis is a common but overlooked external eye disease. The Abscessed pathogenesis of Demodex blepharitis can cause meibomian gland ocular surface inflammatiion . Raised, tender nodule Signs: Collerettes and Inflammed eyelash 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 abscess Concurrent sinus infection Capped glands at Oral antibiotics 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 orbital septum Can be life-threatening Painful, swollen lid Amoxicillin (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 surgery motility or proptosis White conjunctiva PRESEPTAL VS. ORBITAL ORBITAL CELLULITIS CELLULITIS Signs Treatment Tender, warm Preseptal Orbital Medical emergency periorbital lid edema Painful, swollen lid Painful, swollen lid Hospitalization with IV Proptosis antibiotics Normal vision Decreased vision Painful Full EOMs Restricted ocular motilities ophthalmoplegia Consider orbit/head CT to look for abscess No proptosis Proptosis Decreased vision No fever Fever/malaise Consult pediatrician or Severe malaise, fever infectious disease and pain Child Mean age 21 mos. Child Mean age 12 specialist Cause Bacteremia or Cause Sinusitis Trauma PTERYGIUM PTERYGIUM Management and Treatment Signs UV tint on glasses Triangular-shaped growth of conjunctival Dry eye Avoid irritating environments tissue onto cornea Artificial tears Irritation Causes Topical vasoconstrictor or mild Redness steroid UV exposure Blurred vision Surgery Dryness Irritants Smoke Dust 3 1/15/2016 CORNEAL ULCER CORNEAL ULCER Infection of cornea Signs Treatment: Bacterial Pain Start immediately Fungal Photophobia Fortified antibiotics Acanthamoeba Blurred vision Fluoroquinolones Causes Discharge Amniotic membrane graft SCL wearer Hypopyon Culture may not be Trauma necessary if ulcer is small Must be monitored daily! Compromised cornea from pre-existing condition CONJUNCTIVITIS (RED EYE) 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 Chemosis Epidemic keratoconjunctivitis (EKC)— caused most commonly by adenovirus Pseudomembranes types 8 & 19 Lymphadenopathy Keratitis 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 antibiotic 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 HYPERACUTE CONJUNCTIVITIS HYPERACUTE CONJUNCTIVITIS 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 CHLAMYDIAL CONJUNCTIVITIS CHLAMYDIAL CONJUNCTIVITIS 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 sulfacetamide ung bid-tid x 2-3 weeks Foreign body sensation ALLERGIC CONJUNCTIVITIS 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 Glaucoma Cataracts Macular Degeneration Retinal detachment 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 CATARACT Clouding of natural lens 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 sclera 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)
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