sign in sign up
<<
Home , Allergic conjunctivitis, Herpes simplex keratitis, Optic neuropathy

6/7/2017

Disclosures Ocular Manifestations Walter O. Whitley, OD, MBA, FAAO has received consulting fees, of Systemic Disease honorarium or research funding from: • Alcon • Science Based Health COPE#45545-SD • Allergan • Shire • Bausch and Lomb • Sun Pharmaceuticals Walter O. Whitley, OD, MBA, FAAO • Biotissue • TearLab Corporation Director of Optometric Services • Beaver-Visitec • Tearscience Virginia Consultants • Ocusoft Residency Program Supervisor PCO at Salus University • Publications • Advanced Ocular Care – Co-Chief Medical Editor • Review of – Contributing Editor • Optometry Times – Editorial Advisory Board

Virginia Eye Consultants Ocular ER: Big 5 Do Not Miss Tertiary Referral Eye Care Since 1963 • John D. Sheppard, MD, MMSc • Walter Whitley, OD, MBA, FAAO • • Stephen V. Scoper, MD • Mark Enochs, OD • • David Salib, MD • Chris Kuc, OD, FAAO Intraocular foreign bodies • Elizabeth Yeu, MD • Cecelia Koetting, OD, FAAO • Orbital blow-out fracture • Thomas J. Joly, MD, PhD • Leanna Olennikov, OD • • Dayna M. Lago, MD • Chris Kruthoff, OD • Temporal arteritis • Constance Okeke, MD, MSCE • Jillian Janes, OD • Esther Chang, MD • Jay Starling, MD • Samantha Dewundara, MD • Rohit, Adyanthaya, MD • Albert Cheung, MD

1 6/7/2017

The Herpes Virus Family What are the Triggers?

• Herpes Simplex • HSV-1: Orofacial and ocular infections • HSV-2: Genital infections

• Herpes Zoster

• Epstein Barr

•

Herpes Simplex Virus HSV Ocular Signs and Symptoms

• Primary vs. recurrent infections • Symptoms • Signs • Recurrent • • Unilateral • More common as a recurrent HSV • • vesicles • Blurred VA • Epithelial dendrites • Tearing • Decreased K sensitivity • K • Remain dormant in the sensory ganglia • Redness • KPs • FB sensation • stroma / sphincter • High IOP • Vitritis • More than 90% carry the latent virus • • Papillitis

• Active phase can lead to destructive inflammatory phase

2 6/7/2017

Primary Ocular HSV Infection Recurrent Ocular Infection

• Unilateral blepharoconjunctivitis • Reactivation of virus in latently infected sensory • Follicular ganglion • Palpable preauricular lymphadenopathy • Can occur in almost any ocular tissue • Skin or eyelid vesicles • Blepharoconjunctivitis • Epithelial keratitis – lowest risk • Epithelial keratitis • Stromal keratitis – highest risk • Iridocyclitis

• Stromal keratitis / are rare

Case Example Initial Presentation

• 71YOWF • BCVA • OD: 20/20 • OS: 20/40 • OS has a film over it, red, blurry • OS Findings: • 2+ Injection • Started 3 days ago • Peripheral scars but doesn’t recall • Onset was sudden with constant irritation previous episodes • May have gotten eye cream in the eye • IOP: • OD 14 • OS Not taken • Used Pred Forte and Acuvail last night

• Was out in the garden working on her bushes

3 6/7/2017

Considerations Treatment for HSV Epithelial Keratitis

• Dendrites vs. Pseudodendrites • Dendritic keratitis usually resolves within 3 weeks

• Can present as marginal keratitis • Goal to minimize stromal damage and scarring

• Decreased corneal sensitivity • Consider epithelial debridement

• Neurotrophic keratopathy • Topical / Oral antivirals

• Topical steroids??

Diagnosis Mechanism of Action

• HSV Dendritic Keratitis OS • Penetrates cell infected with the virus

• Phosphorylated within the cell to ganciclovir monophosphate by a • Treatment: viral thymidine-kinase • Zirgan 5X daily • Activation continues due to several cell kinases leading to • Zirgan 0.15% ganciclovir ophthalmic gel formulation of ganciclovir triphosphate • Inhibits viral DNA polymerase • Approved for treatment of acute herpetic keratitis • Incorporates into viral DNA • Dosage – One drop 5 times a day until healed, then one drop 3 times a day for 7 days • Prevents replication by chain termination • Supplied in 5 gm tube

4 6/7/2017

HSV Stromal Keratitis Treatment for HSV Stromal Keratitis • Interstitial – Non-necrotizing • Type III • Unifocal or multifocal stromal haze • Topical • With or without neovascularization • Prednisolone acetate1% q2h with taper over 1-2 weeks • Disciform • Difluprednate qid • Endotheliitis • Stromal and epithelial edema • Iritis w/ keratic precipitates • Topical / oral antiviral • Necrotizing • QID • Dense area of stromal inflammation with epithelial defect OR • Difficult to distinguish from bacterial and fungal infections • Acyclovir 400 mg BID • Consider cultures and stains OR • Valacyclovir 500 mg QD • Use concurrently until patient off steroids

Herpes and Bell’s Palsy Complications of Herpetic

• HSV or HZV has been shown to cause Bell’s Facial • Epitheliopathy Nerve Palsy • Neurotrophic keratopathy

• Main concern is dry eye secondary to poor lid • Severe / chronic recurrent disease function • Bullous keratopathy • Corneal scarring / vascularization • Irregular

• Penetrating keratoplasty

5 6/7/2017

Oral Antivirals Herpetic Eye Disease Study I

• Inhibit viral DNA polymerase without inhibiting • Herpes Stromal Keratitis, Not on Steroid Trial normal cellular activity • Pred Phosphate faster resolution and fewer treatment failures • Works best if treatment initiated within 72 hours • Delaying treatment did not affect outcome • Herpes Stromal Keratitis, on Steroid Treatment • Pregnancy category B • No apparent benefit in the addition of oral acyclovir to the • Caution in patients with renal disease treatment of topical and topical antiviral • HSV Iridocyclitis, Receiving Topical Steroids HSV HZO • Trend in the results suggests benefit in adding oral acyclovir

Acyclovir 400 mg 5x/day for 1 week 800 mg 5x/day for 1 week

Valacyclovir 500 mg TID for 1 week 1000 mg TID for 1 week

Famciclovir 250 mg TID for 1 week 500 mg TID for 1 week

Herpetic Eye Disease Study II Orals for Simplex???

• HSV Epithelial Keratitis Trial • No benefit from oral ACV with topical trifluridine in preventing the development of stromal keratitis / iritis • Acyclovir Prevention Trial • Reduced by 41% the probability of recurrence • 50% reduction in the rate of return of the more severe form • Ocular HSV Recurrence Factor Study • No results available

6 6/7/2017

Case Example - BL Examination • 63YOWM Referred by PCP for sudden decrease VA OD and swelling of OD>OS for 1 week • Non-healing scab on R forehead • Pressure from forehead to cheek • Worse in evenings • : 2+ injection OD • Mild seasonal • K: 2+SPK, 2+ MCE, 1+ KPs, No dendrites OD • Some tearing and redness OD • AC: 2+ Cells OD • : 2+ NS OD / 1+NS OS • IOP: 31/13

Diagnosis??? Herpes Varicella-Zoster Virus • Considerations: • Primary infections: Chicken pox • PCP told him he had an infection not • Remains latent in dorsal root or other sensory ganglia after • Episode started 3 weeks prior primary infection • May lie dormant for years to decades • Treatment • Valacyclovir 1000mg TID po • • Difluprednate QID OD Later infections: Shingles • Timolol 0.5% QAM OD • Virus specific cell-mediated immune responses decline • F/u 1 week • Localized cutaneous rash erupting in a single dermatome • HZO accounts for 10-25% of all cases of shingles

7 6/7/2017

Herpes Zoster Ophthalmicus Herpes Zoster Ophthalmicus • 90% of U.S. population infected with VZV by adolescence • Conjunctivitis • 100% of U.S. population by 60 years of age • • Pseudodendrites • 1.5-3.4 cases per 1,000 individuals • Keratic precipitates • Iritis • Synechiae • • Elevated IOP • Potential vascular occlusion • Nerve palsies • (longer-term) http://emedicine.medscape.com/article/783223-overview#aw2aab6b4

HZO: Signs and Symptoms HZO: Treatment • Local wound care • Post-herpetic • Prodromal phase: fatigue, malaise, low-grade fever • Analgesia neuralgia • Tricyclic • Unilateral rash over the forehead, upper eyelid, and • Antivirals antidepressants nose • Valtrex 1g TID • 60% of patient have dermatomal pain prior to rash • Topical capsaicin ung • Erythematous macules to papules to vesicles to pustules to • Antibiotics?? • Gabapentin crusts • Other symptoms: eye pain, conjunctivitis, tearing, decrease • Oral corticosteroids VA, eyelid rash • Hutchinson’s sign

• Post-herpetic neuralgia: >12 months for 50%

8 6/7/2017

Vaccines for HZO - Zostavax “The Common Eyeritis”

• Zostavax is live attenuated herpes zoster (HZ) virus • >50% reduction in the incidence of HZ • >60% reduction in symptom severity in patients who • 32YOWM, Red, Painful Eye OD, Photophobic, No developed HZ • 66.5% reduction in postherpetic neuralgia. discharge • • Must have chicken pox as a child No previous episodes • Ocular/Medical Hx: unremarkable • May help patients who've had HZO already • No other associated symptoms • SLE: 2+ injection / 2+ cells

1. Oxman MN, Levin MJ, Johnson GR, et al. A vaccine to prevent herpes zoster and postherpetic neuralgia in older adults. N Engl J Med. 2005 Jun 2;352(22):2271-84.

Case Example - AM Uveitis • Classic Symptoms • 44yo Asian American c/o blurred VA, redness, • Acute onset • Decreased vision tearing, periorbital edema starting 2-3 days prior • Redness • Photophobia • Pain • Med Hx: Uncontrolled DM (Dx in 1998) • Excessive tearing

• Vasc: OD 20/60 PH 20/30 OS 20/80 PH 20/40

• IOP: 21 / 18

Retrieved from http://eyecaremanual.com/eye-conditions/photophobia/photophobia.html on 3/22/11

9 6/7/2017

Clinical Signs What is Your Treatment? • Prednisolone acetate 1% vs. difluprednate 0.05% vs. • VA etabonate .5% • Conjunctiva • • Homatropine 5% vs. Scopolamine 0.25% vs. Atropine • Anterior chamber 1% • Iris • • Would you prescribe an oral medication? • IOP • Lens • Would you consider lab testing? • Vitreous • Disc edema • Photo accessed• Periphlebitis from http://www.medicinenet.com/image-collection/uveitis_picture/picture.htm

Case Example Pulse Therapy • Acute, non-granulomatous, anterior uveitis OS • Cause??? • QID to Q 1 Hour for 7 to 10 Days • Treatment • Zero Tolerance for AC Cells • Ordered labs – CBC w/diff, ESR, SMA-12, HLA-B27, Urinalysis, FTA-ABS, HgA1c, FBS, • Avoids Surface Toxicity RPR, Lyme Western Blot • Difluprednate q2h OS • Quick & Dirty • Homatropine 0.5% TID OS • Hit It Hard and Fast: Aggressive • Doxycyline 100 mg BID po

10 6/7/2017

Lab Testing Considerations

• Minimum lab testing • Joint pain??? • CBC with differential • Erythrocyte sedimentation rate (ESR) • Breathing problems??? • Angiotensin converting enzyme (ACE) • Venereal disease research laboratory (VDRL) • Fluorescent treponemal antibody absorption (FTA-ABS) • Retrobulbar eye pain??? • Lyme titers in endemic areas*** • HLA-B27 • Skin lesions??? • Antinuclear antibody (ANA) • Urinalysis • Retinal scars??? • Chest X-ray • PPD***

Condition Clinical Features Test Indicated

Ankylosing spondylitis Young male, low back pain, chest pain HLA-B27, sacroiliac X-ray

Reiter’s syndrome Young male, arthritis, urethritis, conjunctivitis HLA-B27, ESR, CRP

Juvenile idiopathic arthritis Slight male predilection, sacroiliitis common ANA, RF, knee radiograph

Inflammatory bowel disease Ulcerative colitis, diarrhea, abdominal cramps HLA-B27, GI referral for endoscopy

Sarcoidosis African Americans, females, vasculitis, vitritis ACE, chest X-ray or CT scan

Tuberculosis Prolonged cough, fever, chills, night sweats, PPD, chest X-ray weight loss

Syphilis Hx of sexual contact with infected person, FTA-ABS, VDRL, RPR rash, fever, malaise, headache, joint pain

Toxoplasmosis Immunocompromised status, exposure to Toxoplasma IgG or IgM for acute cats, hx of eating raw meat, punched-out acquired cases retinal lesions

Lyme disease Recent tick bite Lyme Western Blot

11 6/7/2017

Uveitis: Common Systemic Associations Lyme Titer

• Most common cause • Ordered based on suspicion • Idiopathic : 38-70% • Erythema migrans is the only manifestation of Lyme disease in the United • Other systemic causes States for which clinical diagnosis should be made in the absence of • HLA-B27 related disease laboratory confirmation • Ankylosing spondylitis • • A patient with a significantly characteristic symptom with the appropriate • Psoriatic arthritis history of possible exposure should be started on antibiotics after appropriate laboratory studies have been drawn • Inflammatory bowel disease • • Systemic Erythematosus • • Behcets Disease

Photo accessed from http://www.aao.org/theeyeshaveit/red-eye/images/anterior-uveitis.jpg

Case Example - You’ve Got to be Kidding Tx for Lyme Disease Me!

• Early infection or nonspecific symptoms with positive Lyme titers in the adult • 27yowm presents with red, painful, blurry VA OS. Started 10 days may be treated with oral doxycycline (100 mg twice daily for 4 to 6 weeks) or ago after returning from a trip to Italy. Taking 500mg Naprosyn for tetracycline (500 mg four times a day for 4 to 6 weeks). HA. • Health – Unremarkable • Severe infection in adults with definitive ocular, neuroophthalmic, neurological, or cardiac involvement may be treated with penicillin G (24 • to PCN million units, intravenous, daily in four divided doses for 21 days) or • Vasx: OD 20/20-3 OS 20/25-3 with NI intravenous ceftriaxone (2 g/day in two divided doses for 21days. • IOP: 9 / 10 • SLE: • OD Mild limbal flush / 1+ Cells • OS 2+ Inj / 2+ Cells

12 6/7/2017

What is Your Treatment? Case Example

• Prednisolone acetate 1% vs. difluprednate 0.05% • Acute, bilateral non-granulomatous, anterior uveitis OU vs. loteprednol etabonate .5% • Cause??? • Treatment • Difluprednate qid OD, q2h OS • Homatropine 5% vs. Scopolamine 0.25% vs. • Cyclopentolate 2% TID OU Atropine 1% • Labs???

• Would you consider lab testing?

• Would you prescribe an oral medication?

Fluorescent Treponemal Antibody Absorption Screening Tests for Syphilis (FTA-ABS)

• Venereal Disease Research Lab (VDRL) • Detects specific antibodies against T pallidum • VDRL may become non-reactive in latent syphilis or after successful • Confirms diagnosis of syphilis treatment • More specific than VDRL • False positives may occur in: • More sensitive in primary syphilis • Pregnancy • Test may remain positive for life • • Systemic lupus erythematosis • Reactive: • Rapid Plasma Reagin (RPR) • Primary syphilis 95% • Secondary 100% • Alternative to VDRL • Late latent 100% • Tertiary 96% • False positives may occur in pregnancy and SLE

13 6/7/2017

Syphilis So He Has an Allergy to PCN?

• STD caused by T pallidum / great imitator / any tissue and • Augenbraun M, Workowski K. Ceftriaxone therapy for syphilis: report organ from the emerging infections network. Clin Infect Dis. 1999 Nov. 29(5):1337-8 • Sexually active / multiple partners • Tetracycline, erythromycin, and ceftriaxone have shown antitreponemal • Systemic Sx – Depends on stage – primary painless ulcer / activity in clinical trial secondary skin rash palms, soles, trunk / tertiary neurosyphilis • Slow taper of steroid • All types of ocular inflammation • • Labs Lost to follow up • VDRL / RPR • FTA – ABS • ESR elevated • Tx – penicillin therapy • Good prognosis if treated early

Uveitis - Take Home Pearls Case Example - SD

• Be a detective and find the cause • 38 year old, African American, Female presents with red, painful, and photophobic OS • Be aggressive with treatment • Started 3 weeks ago / similar episode 10 years ago • Don’t taper too soon • Tried dexamethasone 0.1% but no relief • Treat and follow • BCVA OD 20/25 OS 20/20

• IOP: 17 mmHg

14 6/7/2017

Differentials When Should Lab Tests Be Ordered?

• Conjunctivitis • Bilateral cases • Hyperacute cases

• Atypical age group • Worsens with tapering • • Recurrent uveitis • VA worsens • Scleritis • Scleritis • Immunosuppressed

• Uveitis • Recalcitrant cases

Treatment for Scleritis Rheumatoid Arthritis

• NSAIDS • Middle aged women • Arthritis affecting both sides equally • Systemic steroids • Morning stiffness • Immunosuppressive therapy • Inflammation of joints and tissue • Diagnostic Testing • Topical steroids??? • Positive rheumatoid factor • Anti-CCP present • Elevated CBC • Joint X-ray

Photo accessed from http://img.webmd.com/dtmcms/live/webmd/consumer_assets/site_images/articles/health_tools/ rheumatoid_arthritis_overview_slideshow/PRinc_rm_x-ray_of_rheumatoid_arthritis.jpg

15 6/7/2017

Rheumatoid Arthritis Rheumatoid Factor (RF)

• 25% RA patients have ocular manifestations • Differentiates RA from other chronic arthritides • sicca - 15-25% patients • Positive values (titers > 1:80) occur in approximately 70% of patients with • Sjogrens frequently accompanies RA rheumatoid arthritis • Episcleritis • Positive in only 5% of patients with JRA • Most common systemic condition associated with scleritis • Can be positive in the following • Uveitis • Sjogren’s • SLE • Syphilis • Chronic infections • Sarcoidosis • Liver disease

Rheumatoid Arthritis Treatment Plaquenil (hydroxychloroquine sulfate)

• NSAIDs • Indicated for the treatment of discoid and systemic • Steroids lupus erythematosus, rheumatoid arthritis, and • Disease Modifying Anti-rheumatic Drugs malaria • Methotrexate • Sulfasalazine • Dosage: 200mg to 400mg per day • Hydroxychloroquine • Primary risk factors • Duration > 5 years • Cumulative dose >1000g • Age • Systemic – High BMI, liver, kidney dysfunction • Ocular – or macular changes

16 6/7/2017

Plaquenil Examinations

• Complete dilated examination

• Color vision / Amsler??

• Central visual field testing 10-2

• Fundus photography for co-existing retinal disease

• Spectral domain OCT, FAF, mfERG (if available)

65 Accessed from http://www.kellogg.umich.edu/theeyeshaveit/side-effects/chloroquine.html

Sjögren’s Is More than Dry Eye1 Recent Clinical Findings for Sjögren's Diagnostics1-4

Current Screening New SS Panel • Combined serology sensitivity & • Combined serology sensitivity & specificity is around 40-60% specificity is 87% and 82.5% respectively • Cumulative specificity of 92.2% for CA6, SP-1, and PSP • None of the serology test diagnose • Approximately 50% of the early & SS early new cases are identified (Ro and La Negative) • Misses approximately 25-35 % • Picks up additional cases cases • All serology tests identifies are • Comprises of both organ/non- non-organ specific auto-antibodies organ specific auto-antibodies and could occur in other autoimmune diseases 1. Tincani A, et al. Novel aspects of Sjögren’s Syndrome in 2012. BMC Med Apr 4 2013;11:93. doi: 10.1186/1741-7015-11-93. 2. Shen L, et al. Novel in Sjogren’s Syndrome. Clin Immunol 2012;145:251-255. 3. Huang Y, et al. The immune factors involved in the pathogenesis, diagnosis, and treatment of Sjogren’s Syndrome. Clin Dev Immunol 2013; Article ID 160491. doi:10.1155/2013/160491. 1. http://www.sjogrens.org/home/about-sjogrens-syndrome/symptoms. 4. Ramos-Casals M, Brito-Zeron P, Siso-Almirall A, Bosch X. Primary Sjogren’s Syndrome. BMJ 2012;344:e3821

17 6/7/2017

Sarcoidosis

• Systemic inflammatory disease forming granulomas in organs (lungs, lymph nodes, skin, ) • Often young, African American females • Enlarged lymph nodes • Shortness of breath • Fatigue • Diagnostic Testing • Chest X-ray • Elevated ACE • PPD: TB vs. Sarcoid • Biopsy of nodule

Photo accessed from http://www.e-radiography.net/radpath/s/sarcoidosis.jpg

Sarcoidosis Purified Protein Derivative (PPD) • Ocular manifestations • Redness, pain welling of lids or lacrimal gland • Painless subcutaneous nodular mass of eyelids • Skin test to screen for • tuberculosis • • Cicatrizing conjunctival inflammation • Intradermal injection of 0.1ml • Conjunctival nodules of soluble antigen from a given • Keratoconjunctivitis sicca TB organism in forearm • Positive test – 5 – 15 • induration in 2-3 days • Granulomatous anterior or posterior uveitis • • • Specificity increased with chest x-ray • Retinal periphlebitis or neovascularization • disease or glaucoma • False positives include prior exposure to TB

18 6/7/2017

QuantiFeron TB Gold (QTF-G) Tuberculosis • An alternative to skin testing of cell-mediated immune response to antigens simulating the mycobacterial proteins • Poverty is the primary risk factor ESAT-6, CFP-10, and TB7.7 • Lungs most commonly affected • < 12 hours • Uveitis is the most common eye complication • A positive result indicates that Mycobacterium tuberculosis • Immune suppression infection is likely • Fever, Night Sweats, Fatigue • Positive tests should be followed by further medical and diagnostic • Posterior and Pan-uveitis most common evaluation for tuberculosis disease (eg, acid-fast bacilli smear and culture, chest x-ray). • QuantiFERON-TB Gold is usually negative in individuals vaccinated with Mycobacterium bovis bacille Calmett-Guerin

Angiotensin Converting Enzyme (ACE) Sarcoidosis

• Produced by a variety of cells including granulomatous cells • Treatment • Serum ACE levels reflect the total amount of granulomatous • Aforementioned blood work • Uveitis topical and possible oral steroids tissue in the body • Dacryoadentitis treated with systemic steroids • Screen for sarcoidosis • Consult with PCP • 75% sensitive • 95% specific • False positives include: • TB • Lymphomas • Leprosy • Consider serum lysozyme / calcium assay

19 6/7/2017

Most Prescription Treatment Options Have a Incidence of Allergic Symptoms Limited Effect on the Inflammatory Cascade Eye Symptoms Are the Second Most Common Allergy Presentation Early-Phase Late-Phase 100 Mediators Membrane Mediators Phospholipids 90 Mast Cell Stabilizers (MCS)1 80 Work Here 70 60 Combination Phospholipase A2 50 /MCS1 Activity Work Here Arachidonic Acid

40 Incidence % Incidence 30 Heparin Proteases PAF Cyclooxygenase NSAIDs Lipoxygenase (tryptase, chymase) Pathway Work Pathway 20 Here

1 Hydroperoxides 10 Antihistamines Cyclic Endoperoxides Work (5-HPETE) 0 Here Nose/Throat Eyes Skin Headache Prostacyclin Thromboxane A 2 HHT, MDA Leukotrienes 6 out of 10 allergy patients suffer ocular allergy symptoms (PGF2α, PGD2, PGE2) (PGI2) (TXA2) (LTC4, LTD4, LTE4, LTB4) The 1999 Gallup Study of Allergies and Allergic Symptoms Affecting the Nose, Throat, Eyes, and Skin 1. Adapted with permission from Donnenfeld ED. Refract Eyecare. 2005;9(suppl):12-16. 2. Slonim CB. Rev Ophthalmol. 2000:101-112.

Graded Pharmacotherapy Specific Allergy Therapy

Stepwise Treatment Strategies for • Preventive Mild Avoidance, cold compresses, , over-the-counter medications • Palliative Topical antihistamines/mast cell stabilizers • Alternative Oral antiallergics (allergists may already have patients on orals; • Immunotherapy may exacerbate the ocular condition while improving the nasal condition) Montelukast • Pharmacologic Moderate + Mast cell stabilizers (treats allergy before mediator is released) • Topical, Nasal, Inhaled • + Combination /mast cell stabilizers Dermatologic • Systemic + Topical corticosteroids (most beneficial for severe outbreaks) Severe Topical corticosteroids (short course; fluorometholone/dexamethasone/loteprednol/prednisolone) Topical immunomodulating agents (tacrolimus, cyclosporine) Oral steroids

80

20 6/7/2017

Singulair (montelukast sodium) 12 Patient Allergy Tips

• Leukotriene receptor antagonist • Never rub your eyes • Indications: • Wash your hands • Prophylaxis and chronic treatment for • Acute prevention of exercise-induced brochoconstriction • Use allergy free pillows • Relief of symptoms of allergic • Stay indoors • 10 mg tablet qd • Use drops for eyes, sprays for nose • Side effects • Avoid “get the red” out vasoconstrictors • Behavior or mood changes, URI, fever, headache, sore throat, • Chill your drops cough, stomach pain, diarrhea, ear ache or ear infection, flu, • runny nose, and sinus infection Use cool compresses • Apply allergy drops proactively • Pets out of the house or bedroom • Know and avoid your personal antigens 82 • Try Montelukast: no sedation, no drying

Cataract / Refractive Surgery Complications Benign Prostatic Hyperplasia

• Operative Complications • Histologic diagnosis characterized by proliferation of the cellular • Surgeon makes the call elements of the prostate

• • An estimated 50% of men demonstrate histopathologic BPH by age Post-operative Complications 60 years. This number increases to 90% by age 85 years • Co-managing doctor makes the call

• Symptoms: Urinary frequency and urgency, Hesitancy, Incomplete • Successful cataract surgery is the result of continuous bladder emptying, Straining, Decreased force of stream communication!!

21 6/7/2017

OmidriaTM Flomax (tamsulosin) (phenylephrine and ketorolac injection) 1% / 0.3%

• Indication for the treatment of benign prostatic hyperplasia • OMIDRIA™ is an α1-adrenergic receptor agonist and nonselective cyclooxygenase inhibitor indicated for: • Maintaining pupil size by preventing intraoperative • Reducing postoperative ocular pain • Intraoperative floppy iris • syndrome OMIDRIA is added to an irrigation solution used during cataract surgery or intraocular lens replacement.

• Importance to communicate prior to cataract surgery

Neuropathy is end stage organ damage

• Diabetics know this first hand • All diabetics get dry eye, few complain about it.

http://sagespoonliving.com/wp-content/uploads/2012/11/diabesity.jpg accessed on 10/15/15

22 6/7/2017

Epidemiology Eye Care Disease Prevalence What You Might Not Know

• Systemic, microvascular disease affecting (not limited to) the liver, kidneys, and eyes. • Type I caused by destruction of the Islets of Langerhans in the Pancreas. • Type II caused by the body’s developed resistance to insulin. • It is the most common cause of blindness in the 20-70 year old population. • Diabetic is prevalent in 30% of the diabetic population.

Eye Disease Management A Key Component of Diabetes Care People with diabetes do have a higher risk of prominent eye conditions and blindness than people without diabetes. Prevalent diseases include: • Occurs due to a breakdown in the retina’s ability to auto regulate its blood supply properly. People with diabetes are 40% more likely to suffer from glaucoma than • Hyperglycemia increases retinal blood flow and therefore causes “capillary people without diabetes. The longer someone has had diabetes, the more hypertension.” common glaucoma is. Risk also increases with age. [5] • This hypoxic environment causes an up-regulation of the angiogenic factor VEGF. Many people without diabetes get , but people with • VEGF stimulates the growth of new blood vessels to meet the needs of the diabetes are 60% more likely to develop this eye condition. People starving retina. with diabetes also tend to get cataracts at a younger age and have them progress faster. [6]

Diabetic retinopathy accounts for approximately 12% of all new cases of blindness each year. It can cause vision loss in two ways: Macular Edema and Proliferative Retinopathy and Vitreous Hemorrhage [7]

23 6/7/2017

ETDRS Classification of DR Risk factors for developing DR DR Level Retinal Findings

Mild NPDR At least one MA and 1 or more of following • Duration of DM • Retinal hemorrhages • Hard exudates • Control of DM will not prevent but delays • Soft exudates • Fasting BS <126 and A1C <7% • Hypertension/Hyperlipidaemia Moderate NPDR Hemorrhages and MA or soft exudates, VB, and IRMA present • Renal Disease • Pregnancy Severe NPDR Any of the following and no signs of PDR (4-2-1 rule) • >20 intraretinal hemorrhages in each of 4 quadrants • Sleep apnea • Definite venous beading in 2 or more quadrants • Obesity • Prominent IRMA in 1 or more quadrants • Smoking • Anaemia

Very Severe NPDR • 2 or more of lesions of Severe NPDR

PDR One of either • Neovascularization • Vitreous/preretinal hemorrhage

AOA Optometric Clinical Practice Guideline® Diabetic Mellitus. St. Louis, MO. American Optometric Association.

ETDRS PDR New Treatments Diabetic Retinopathy • Presence of Neovascularization with/without pre-retinal hemes. • Early/Low-risk PDR: • Proliferative Disease: • Any size NVE without vitreous heme. • Pan Retinal Photocoagulation or Focal Laser • NVD <1/4 in size without vitreous heme. • Ranivizumab (lucentis) and Aflibercept (Eylea)-anti-VEGF • High-Risk PDR - 1 or more of the following • Diabetic Macular Edema: • NVD approximately 1/4DD- 1/3DD or more in size • Dexamethasone (Ozurdex),Fluocinolone acetonide • NVD less than ¼ DD in size when fresh VH or PRH is present (Iluvien) • NVE greater than or equal to 1/2DD in size when fresh VH or • Anti-VEGF (above) PRH is present • If a patient is at this stage, severe vision loss is likely if no treatment initiated. • RISE/RIDE studies showed a 3 line VA improvement in diabetic eyes treated with anti VEGF

24 6/7/2017

PDR Treatment Treatment for PDR: Vitrectomy • Indicated after weeks to months of • LASER: Light Amplification blood not clearing from vitreous by the Stimulated Emission heme of Radiation • Best results if done within 6 months • Focal of heme (DRVS) • Grid • Usually done at 6 weeks • Panretinal photocoagulation • Alleviate retinal traction, ERM • Anti-VEGF ocular injections • When PRP is not enough • Cataracts!

Photo accessed from http://www.eyecentersofsetexas.com/college_location/treatments.php?qi=78

Diabetic Macular Edema DME

• DME incidence based on duration and type of diabetes • DME is also closely associated with degree of DR present • IDDM • Mild NPDR ~ 3 % incidence • <8 years rare • Moderate- Severe NPDR ~40% incidence • 10 years 7-10% incidence DME • 20 years 25-30% incidence DME • PDR ~71% incidence • NIDDM • 10 years 5% incidence DME • 20 years 15% incidence DME • NIDDM w/ insulin use • 10 years 10% incidence DME • 20 years 30-35% incidence DME

25 6/7/2017

DME Current Treatment

• Signs: circinate ring of exudates, retinal thickening, retinal elevation. • New mainstay treatment: Intravitreal Injections • Clinically Significant Macular Edema: • Lucentis (FDA) • Thickening of retina at or within 500 microns of the center of the macula • Eyelea (recent FDA) • Hard exudates at or within 500 microns of the center of the macula • Ozurdex (recent FDA) • A zone or zones of retinal thickening 1 disc area or larger in size that is within • Avastin 1 disc diameter of the center of the macula. • Triamcinolone • Focal laser with intravitreal injection

Before Injections OD After Injections OD Case Study • 2/13 ROV: 52 YO Asian Female / Follow up 4 month dry eye check. Intermittent foreign body sensation and fogged vision over 1 year • Ocular Hx: DES, LASIK 12.08.11 • Ocular Medications: Restasis BID OU • Medical Hx: Allergies, Borderline Diabetes, Acid Reflux • Systemic Medications: Multivitamin, Iron

26 6/7/2017

Slit Lamp Examination Diagnostic Testing • External: normal OU • BCVA • Conjunctiva: 2+ injection • Screening questionnaire • • OD 20/25- Cornea: 1+ Diffuse SPK OU • Blink rate • OS 20/20- • Tear Eval: • 4 sec NIBUT • Tear meniscus • MR • Schirmer 8/9 • Tear film osmolarity • OD pl – 0.75 x 005 • Iris: flat OU • Tear film break up time • OS -0.50 DS • A/C: deep & quiet OU • Ocular surface staining • Lens: clear OU • Schirmer / Red Thread Test • Lid Evaluation • Lid and MG morphology • MG Expression • Tear interferometry • Presence of MMP-9

Superior Limbic Keratitis SLK and Treatment • Definition • Pathogenesis • Lubrication • Botulinum toxin • Uncommon chronic disease • Blink-related trauma • Acetylcysteine • Supratarsal steroid injection • Superior bulbar and tarsal • Tear film insufficiency conjunctiva and limbus • Mast cell stabilizers • Excess of lax conjunctival tissue • Resection • Bilateral • Steroids • Middle aged women • Inflammatory process • Conjunctival ablation • Self-perpetuating cycle • Cyclosporin A • Abnormal thyroid function • Consider thyroid evaluation • Symptoms worse than signs • Soft • Remission occurs spontaneously • Silver nitrate • Autologous serum

27 6/7/2017

Thyroid Disease Causes Symptoms: Hypo vs. Hyper

• Hypothyroidism • Hyperthyroidism • Hypothyroidism • Hyperthyroidism • Hashimotos Disease • Autoimmune (Grave’s Disease) • Fatigue, sleepiness • Nervousness • Thyroid removal • Toxic adenomas • Weight gain (decreased appetite) • Anxiety • Pituitary gland malfunctions (TSH) • Subacute thyroiditis • Cold intolerance • Increased perspiration • Low iodine intake* • Pituitary gland malfunctions • Depression • Heat intolerance • Lithium exposure (TSH) • Menstrual disturbances • Hyperactivity • Cancerous growths in thyroid • Hair loss • Palpitations • Dry skin • Weight loss

Ocular Manifestations

• Anterior segment Thyroid Eye Disease • Evaporative DES • SLK (65% have thyroid dysfunction)* • Lid retraction (Dalrymple’s sign) • No signs or symptoms • Lid lag • • Only signs (limited to upper lid retraction and stare, • Posterior Segment with or without lid lag) • • Soft tissue involvement (conjunctiva, lids, etc.) • Optic nerve swelling/compression • Chorioretinal striae • Proptosis • Intra-Orbital • Extraocular muscle involvement (diplopia) • EOM restriction (IM SLO) • EOM enlargement • Corneal involvement () • Optic nerve compression • Sight loss (due to optic nerve involvement)

28 6/7/2017

Thyroid ED Thyroid ED

• • Symptoms are easy to expect, when process is understood. • Women > Men (3-10 times) • Antibodies affect , orbital fat, and the levator, causing swelling and immobility. th th • Occurs in 4 – 5 decade of life • Swelling of EOM can cause optic nerve compression, and result in • When men are affected, symptoms are worse exophthalmos • Levator involvement results in lid retraction and lag • Ocular manifestation generally appear 2.5 years after onset of • Antibodies can also affect lacrimal gland disease • 25-50% Grave’s dz patients develop ocular manifestations. • Most common in Hyperthyroid, but can occur with hypothyroidism

*http://www.eyecalcs.com/DWAN/pages/v5/v5c021.html ** Yanoff & Duker Ophthlmology 3rd edition. ^Kendler DL, Lippa J, Rootman J. The initial clinical characteristics of Graves’ orbitopathy vary with age and sex. Arch Ophthalmol. 1993;111:197–201.

Diagnosis/Testing Thyroid Eye Disease

• Tonometry (primary gaze and up gaze) • Optic Nerve Compression • Exophthalmeter • Visual field defects • Contrast abnormalities • Appearance • Color vision defects • Thyroid panel/ Autoimmune markers • RAPD • Imaging (CT and MRI) • Decreased Visual Acuity • Pale atrophic • Forced duction/motility • Rare: Occurs in 10% * • 40-50% of patients with compression have normal appearing fundus^*.

29 6/7/2017

Treatment options Transient Vision Loss

• Self Limiting: Graves’ disease usually runs a progressive course for 3– • 78 yo F 5years and then stabilizes.* • Concern is patient comfort and treatment of Dry eye concerns. • Noted 5-8 seconds of fluctuating • Lid weights/taping/tarsorraphy may be required to decrease vision exposure • Qualify vision loss

Similar Case 82 yowf Sudden Loss of VA 78 yo Male with headache (of any shape or form)

•What three • Ocular history: • Medical history: questions should • Primary open angle • Arthritis glaucoma OU • Hypertension • come to mind? • High Cholesterol Epithelial basement • Peripheral Neuropathy membrane dystrophy OU • Restless leg Syndrome • Pseudophakia OU • GERD • Early Dry ARMD OU

30 6/7/2017

Case Example • VAcc: • OD: LP • Ocular Medication • Systemic Medication • OS: 20/50 +2 • Combigan BID OS • Crestor 5mg • Amlodipine-Benazepril 5/10mg • • Travatan Z QHS OU • Pramipexole 0.125mg • OD: 1+ APD • OS: round and reactive • Tramadol HCL • Nexium 40mg • • Lidoderm patch EOM • Full OU • Gabapentin 300mg • Celebrex 200mg • • Iron supplement CVF • OD: constricted inferior 180 • Krill oil supplement • OS: Full to finger counting

• IOP: 18mmHg/18mmHg by Goldmann

• Assessment • Lab Results: • Ischemic OD • ESR: 95 (High) • Pt denied any jaw pain, headaches, shoulder or hip pain, change in weight and malaise • CRP: 7.09 (High) • Plan • Platelet: 465 (High) • Labs ordered: ESR, CRP, CBC w/diff • Medication: Prednisone 20mg 3 PO QD and Ranitidine 150mg BID PO • Temporal artery biopsy scheduled in 2 weeks • Meds are not to be started before having blood drawn • Follow up in 1 week pending lab results

31 6/7/2017

Giant Cell Arteritis

• Temporal Artery Biopsy Result • The most common vasculitis in >50 years old • Active arteritis with rare giant cells, consistent with temporal arteritis • Mild arteriosclerosis • Disruption and focal loss of internal elastic lamina • Incidence increases with age, peaking in the 8th decade

• Informed the patient that her PCP will monitor her labs from now on and adjust her oral prednisone dose accordingly. She is to continue on the 60mg/day • More common in females and in those of northern European dosing for right now until he instructs her otherwise descent/Scandinavians

• Follow up in 1 month • Large autopsy studies strongly suggest that the true prevalence of GCA may be ~1% of the population

Giant Cell Arteritis Giant Cell Arteritis

• Any elderly pt with headache • Ask • Ischemic symptoms • Systemic inflammation • Any elderly pt with diplopia • Temporal tenderness • Headache symptoms • Pain with combing hair, wearing • Scalp pain • Polymyalgia rheumatica • Any elderly pt with transient glasses, hats • Jaw Claudication • Fatigue vision loss • Pain with chewing, swallowing • Malaise • Fever • Anorexia/weight loss • Night sweats

32 6/7/2017

GCA – Ocular Manifestations Now what?

• Anterior Ischemic Optic Neuropathy • Differentials for unilateral swollen nerves • Rapid, profound vision loss • Anterior Ischemic Optic Neuropathy • (+) APD • NAION • • AAION A swollen optic nerve with a chalky white appearance • • VF defect varies • CRVO • Central Retinal Artery Occlusion • Compression (Mass/lesion, Thyroid) • Inflammation • ~ 10% of CRAO’s are caused by GCA • Infection • Cranial Nerve Palsy • Rare and usually CN 6

GCA - Testing AAION Treatment

• Blood Work • ESR, CRP, CBC w/diff • Standard of care: Corticosteroids • In acute cases of AAION (same day) patients should be started on IV 250-1000mh x 3 days • Possible vision recovery, most importantly save the other eye (?) • TA Biopsy • Oral Prednisone 80-100mg/day if vision loss is not acute

• Referral to internist / rheumatology • Simultaneous color Doppler and • Will taper steroids to the lowest required dose duplex ultrasonography • Usually GCA patients require treatment for 2 or more years • Recurrences can happen

33 6/7/2017

Oral Corticosteroid Considerations Ranitidine

• Accurate diagnosis is essential • Histamine-2 blockers • Indicated for acute inflammatory eye, orbital and • Works by reducing the amount of acid your stomach produces eyelid conditions • 150 mg BID po • Generally well tolerated • Pregnancy category C • HA • Dosepaks available • 24 mg, 30 mg, 60 mg with taper • Best taken with meals • Short term rarely has ocular side effects

Viagra (sildenafil citrate)

• Selective inhibitor of • Side effects of long term steroids use: phosphodiesterase type 5 • Bone fractures • Infections • GI Bleeding/perfusion • Impairment of color discrimination • Hypertension (B/G) • Diabetes mellitus • Non-arteritic ischemic optic • New Alternatives neuropathy • Methotrexate • can be useful as steroid-sparing agents in patients who require prolonged treatment with high doses of steroids (more than 5-10 mg/d) and those who experience significant steroid-related complications

Accessed from www.thisisthelast.net/cartoons/images/viagra.jpg on 4/8/11

34 6/7/2017

NAION Can Anything be Done?

• Vascular insufficiency from small vessel • Risk factors: • Hayreh SS, Zimmerman MB. Non-arteritic anterior disease • Diabetes (#1) • There is insufficient perfusion of the optic • Hypertension ischemic optic neuropathy: Role of systemic nerve head which causes infarction of the corticosteroid therapy. Graefes Archives of Clinical Exp prelaminar region • Ischemic heart disease 2008; 246:1029-1046. • Occurs usually between ages 40-60 • Nocturnal hypotension • Hypotensive agents taken at night • Loss of vision occurs upon wakening in majority of cases • Sleep Apnea • Smoking • More common in Caucasians • Initial VA 20/70 or worse, treated within 2 weeks of • Viagra or other ED medication onset of symptoms • Recent surgery (cardiac or neck sx, any ocular surgery) • Visual outcome at 6 mo • Treated eyes 70% improved • Untreated eyes 41%. • Visual Fields • Treated – 40.1% improvement • Untreated – 24.5% improvement

Remember! Cordarone (amiodorone)

• Indicated for the treatment of life- • AAION • NAION threatening recurrent ventricular • >60 years • 40-60 years • VA loss is profound, often 20/200 or arrhythmia worse • VA can be as good or better than • Prodromal symptoms 20/60 • Side Effects • Chalky white swollen disc • Hyperemic swollen disc • Halos • ONH c/d can be any size • Disc at risk • • Photosensitivity Cup enlarges when edema resolves • Pallor’d cup when edema resolves • FA shows patchy choroidal perfusion and late disc leakage • FA will show delayed filling and late • Optic neuropathy • Risk of fellow eye involvement is high disc leakage • Optic neuritis and can occur in days • Fellow eye may occur years later • Disc swelling

35 6/7/2017

Differentials for Vortex Keratopathy Fabry Disease

• Drug induced • X-linked disorder due to a deficiency of alpha-galactosidase resulting • Amiodorone in the buildup of globotriaosylceramide • Chloroquine • Signs and symptoms include: • Tamoxifen • Severe pain in the extremities • Ibuprofen • Exercise intolerance • Indomethacin • Renal involvement • Stem cell deficiency • Skin lesions – angiokeratoma corporis discusum consists of clusters of • Fabry’s disease superficial cutaneous dark-red angiokeratomas • Tortuosity of conjunctival and retinal vessels

THANK YOU

[email protected]

36