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 scale when checking vision with the Can they near card Count Fingers? 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 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
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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
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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 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
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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? 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.
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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
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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
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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).
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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 in the eyelids. • symptoms include: foreign body or burning sensation, excessive tearing, itching, sensitivity to light (photophobia), red and The watery layer is the middle of the tear film. It makes up most of what we see as swollen eyelids, redness of the eye, blurred vision, frothy tears, tears. This layer cleans the eye, washing away particles that do not belong in the dry eye, or crusting of the eyelashes on awakening eye. This layer comes from the lacrimal glands, located in the upper temporal region of the orbit. No cure for blepharitis, only treatments to help control symptoms: Eyelid hygiene: The mucus layer is the inner layer of the tear film. This helps spread the watery • Warm Compresses layer over the eye’s surface, keeping it moist. Without mucus, tears would not stick • Eyelid scrub to the eye. Mucus is made in the conjunctiva. This is the clear tissue covering the Medication: white of your eye and inside your eyelids. • Topical antibiotic • 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. Common differential diagnosis for the Red Eye Learning Objectives:
o Conjunctivitis (Viral, Allergic Seasonal, Bacterial) Recognize common “Red Eye” etiologies oSubconjunctival hemorrhage For more information on any of the List common ophthalmic complications from diabetes mellitus oDry Eye these entities: Differentiate between urgent and non‐urgent ophthalmic conditions http://eyewiki.aao.org/Main_Page oBlepharitis (Chalazia, Hordeolum) oPterygium oCorneal ulcer oCorneal foreign body and abrasion oChemical burn (Flash burn) oIritis (Uveitis) oAcute angle closure glaucoma
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Urgent Referral to Ophthalmology When patient has: Redness Sensitivity to light (inability to keep eyes open ) Vision loss Pain
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Syllabi/Slides for this program are a supplement to the live CME session and are not intended for other purposes.