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Basic Eye Anatomy Cross 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 scale when checking vision with the Can they near card Count Fingers? 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 4: bacterial conjunctivitis Urgent Referral to Ophthalmology Exception to the Rule: When your patient has RSVP Acute profound painless vision symptoms, urgent consult is loss (20/200 range) warranted: ◦ Typically less than 24 – 48 hours Redness ◦ Differential Dx includes: Sensitivity to light ◦ Retinal Detachment ◦ Central / Branch Retinal Vein Occlusion (inability to keep eyes open ) ◦ Central / Branch Retina Artery Occlusion Vision loss ◦ Giant Cell Arteritis Pain ◦ Vitreous Hemorrhage My preferred topical antibiotic: Polymyxin B/trimethoprim Trimethoprim: Staphylococcus aureus and Staphylococcus epidermidis, Streptococcus pyogenes, Streptococcus faecalis, Streptococcus pneumoniae, Haemophilus influenzae, ◦ Optic Neuritis 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 15 31 Acute Conjunctivitis Learning Objectives: Type of Natural History Treatment Conjunctivits Recognize some of the common “Red Eye” etiologies Adenoviral Self limited Artificial tears List common ophthalmic complications from diabetes mellitus (“pink eye”) Symptoms improve 5‐14 days Cool Compresses Differentiate between urgent and non‐urgent ophthalmic conditions 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 Key facts from WHO number of people with The number of people with diabetes worldwide: diabetes 108M (1980) approx. approx. 415M (2014). 415M (2014) The global prevalence of 145 M w/ diabetes* 4.7% (1980) Retinopathy approx. 8.5% (2014). * among adults over 18 yo http://atlas.iapb.org/wp‐content/uploads/VA‐DR‐infographic‐resized.gif 36 37 “Diabetes Epidemic” Historical Perspective: William Osler's 1892 textbook of medicine devoted only: 10 pages to diabetes, as against 65 pages to tuberculosis. Historical Trivia: Massachusetts General Hospital from 1824‐98, admitted 47,899 pts 172 (0.004%) had diabetes. https://www.diapedia.org/type‐2‐diabetes‐mellitus/3104287123/epidemiology‐of‐type‐2‐diabetes 38 http://altfutures.org/pubs/diabetes2030/IncreasingPrevalenceofDiabetesOverTime.gif 39 Syllabi/Slides for this program are a supplement to the live CME session and are not intended for other purposes. Texas has one of the highest rates for Diabetic Retinopathy 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 https://www.aao.org 40 41 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? Major risk factor associated with development of Diabetic Retinopathy Type II DM With insulin Without insulin Type I Duration of Disease Percentage with 5 years or less 40% 24% DM Retinopathy 19 years of less 84% 53% 5 years 25% 10 years 60% 15 years 80% 20 years 50% with vision threatening disease Proliferative diabetic retinopathy develops in 2% of Type II patients who have diabetes Perhaps in a young (<21 y/o) newly diagnosed diabetic, screen earlier… for less than 5 years and in 25% of patients who have diabetes for 25 years or more. 44 https://www.aao.org 45 Diabetic Macular Edema (DME) Early stage of retinopathy DME can present with any stage of Diabetic Retinopathy Non‐proliferative retinopathy (NPDR) Chronic hyperglycemia is the major risk factor of DME ‐microaneurysms The incidence of DME over a 10 year period is between 20% ‐ 40%. ‐ dot blot hemorrhages Standard Treatment: typically in‐office procedure ‐ hard exudates 1. Center involving – intravitreal injections of anti‐VEGF drug ‐ venous beading • Frequency depending on drug, response to treatment, and may require lifelong injections at periodic intervals 2. Non‐center involving – macular (focal) laser Typically, vision isn't affected unless macular edema • More than 1 treatment may be needed depending on response If no macular edema, no treatment. • Can reduce the risk of more vision loss by 50% Chances of progression within three years > 25% if 3. Combination of 1 & 2 both eyes are affected. 48 49 Syllabi/Slides for this program are a supplement to the live CME session and are not intended for other purposes. Non‐Proliferative Diabetic Retinopathy Proliferative Diabetic Retinopathy (PDR) For PDR, current standard treatment Pan‐Retinal Photocoagulation (PRP). Goal: preserve central vision Side Effects of PRP: Reduced peripheral vision TAKE HOME MESSAGE: NPDR without Diabetic Macular Edema (DME), optimize Nyctalopia (difficulty seeing in low light condition, “night blindness”) glucose and blood pressure management because no ophthalmic treatment Pain during treatment 50 53 Proliferative Diabetic Retinopathy (PDR) What Causes diabetic retinopathy? Chronically high blood sugar damages periocytes in blood vessels microaneurysms and leakage macular edema and vision loss Continued vascular damage retinal ischemia release of Vascular Endothelial Growth Factor (VEGF) new abnormal growth of blood vessels (Neovascularization) abnormal Even with PRP laser therapy, blood vessels with weak walls can lead to vitreous hemorrhage and vision loss severe vision loss is high. Abnormal blood vessels on the optic nerve and retina create tractional bands contraction of bands tractional retinal detachment and vision loss Abnormal blood vessels proliferate on the iris and angle of the eye increased intraocular pressure damage to optic nerve neovascular glaucoma and vision loss Fresh Laser Application Spots 54 55 Syllabi/Slides for this program are a supplement to the live CME session and are not intended for other purposes. If PDR is not well‐controlled, can progress into Neovascular Glaucoma Learning Objectives: aka: NVG Recognize some of the common “Red Eye” etiologies • a potentially irreversibly blinding condition. List common ophthalmic complications from diabetes mellitus Differentiate between urgent and non‐urgent ophthalmic conditions • The retina detects light and converts it to signals sent through the optic nerve to the brain. • Early stage NVG may be amenable to pharmacological management, PRP, and anti‐VEGF injection therapy. • Advanced stage NVG requires surgical intervention to create new outflow for aqueous (typically glaucoma tube shunt). 56 57 The tear film is made of three layers: •An oily layer •A watery layer •A mucus layer Blepharitis Each layer of the tear film serves a purpose. • bacteria and oily flakes at the base of eyelashes The oily layer is the outside of the tear film. It makes the tear surface smooth and • very common, especially among people who have oily skin, keeps tears from drying up too quickly. This layer is made in the eye’s meibomian dandruff or dry eyes glands, located
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