Eyecare Review

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Eyecare ReviewFor Primary Care Practitioners
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Primary Care Practitioners

• See variety of eye problems
• Discuss treatment options
• Facilitate referrals
• Positioned to explain optometry's role as
  primary eye care providers

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Outline

• Anatomy
• Optics
• Turned Eyes
• Lazy Eye
• External Conditions
• Internal Conditions
• Diabetic Retinopathy

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ANATOMY
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Basic Anatomy
Choroid
Sclera
Retina
Cornea
Fovea
Pupil
Lens
Optic Nerve
Iris
Ciliary Body
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Lids

• Lashesprotection from foreign material
• Glandslubricate anterior surface
• Meibomian glands
• Glands of Zeis
• Glands of Moll

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Conjunctiva

• Thin, transparent, vascular layer lining
• Backs of eyelids
• Fornices
• Anterior sclera

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Sclera

• Tough outer shell
• Composed of collagen bundles
• Protects from penetration

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Cornea

• Composed of regularly oriented collagen fibers
• 5 layers

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Anterior Chamber

• Space between cornea and iris
• Filled with aqueous humor produced by ciliary
  body

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Iris

• Iris gives eye color
• 2 muscles
• Dilatoropens
• Sphincterconstricts

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Pupil

• Allows light to enter
• Enables view to back of eye and eye health
  evaluation

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Lens

• Located behind iris
• Focuses light on retina
• Allows for accommodation
• Normally transparent
• Where cataracts form

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Ciliary Body

• Primary functions
• Pulls on lens for accommodation
• Epithelium secretes aqueous fluid that fills
  anterior chamber

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Red Reflex

• Light reflection off retina
• Useful for assessing media clarity
• Affected by any opacity of cornea, lens,
  vitreous
• White reflex leukocoriaRefer immediately!

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Vitreous Humor

• Gel-like fluid that fills back cavity
• Serves as support structure for blood vessels
  while eye formedbefore birth
• After birth, just hangs out in there
• Where floaters are located

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Fundus

• Interior surface of eye
• Includes
• Optic nerve
• Retina
• Vasculature

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Optic Nerve Head

• Collection of nerve fibers and blood vessels from
  retina
• Transfers info to brains visual cortex
• Slightly yellow-pink when healthy
• White full moon appearance can mean trouble!

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Optic Nerve Head

• Cup is natural depression in center of nerve
• Cup size varies between people
• Very large cup, or change in appearance over
  time, can indicate glaucoma

Optic Disc
Physiologic Cup
Optic Nerve
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Macula

• Dense collection of cone photoreceptors
• Fine detail and color vision
• Macular degeneration affects this area

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Retinal Vessels

• Include arteries and veins
• Only place in body where you can directly
  visualize blood vessels
• Excellent indicators of systemic diseases
• HTN
• Diabetes
• High cholesterol
• Carotid disease

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Peripheral Retina

• Can only be evaluated with dilated pupil
• Important to evaluate periodically to fully
  assess eye health

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OPTICS
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Optics Review

• Myopia
• Hyperopia
• Astigmatism
• Presbyopia

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Myopia

• Nearsightedness
• See well up close but blurry in distance
• Eye is too long
• Light focuses in front of retina

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Hyperopia

• Farsightedness
• See well in distance
• Eye is too short
• Focus point is behind retina

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Hyperopia

• Blurry image on retina
• Lens focuses to compensate
• Hyperopes often asymptomatic much their of lives
• Can cause headaches or eyestrain with extended
  reading
• These problems can get worse after age 40

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Astigmatism

• Surface of cornea isirregular or misshapen
• Light focuses at various points causing
  distorted vision
• Often combined with nearsightedness and
  farsightedness

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Presbyopia

• Normal, age-related change
• Near vision becomes difficult
• Mid-40s lens becomes less elastic and
  losesability to change focus
• Time for bifocals

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MISALIGNED EYES
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Turned Eyes - Strabismus

• Eye misalignment
• One or both turn in, out, up or down
• Caused by muscle imbalance
• 3 Kinds of Strabismus
• Esotropia
• Exotropia
• Hypertropia

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1. Esotropia

• Eye turns in towards nose

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3 Types of Esotropia

• Infantile (congenital)
• Develops in first 3 months of life
• Surgery usually recommendedalong with vision
  therapy and glasses
• Accommodative
• Usually noted around age 2
• Child typically farsighted
• Focusing to make images clear can cause eyes to
  turn inward
• Treated with glasses but vision therapy may also
  be needed

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3 Types of Esotropia

• Partially Accommodative
• Combination of
• accommodative dysfunction and
• muscle imbalance
• Glasses and vision therapy wont completely
  correct eye turn
• Surgery may be required for best binocularity

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If you see Esotropia

• Refer to pediatric optometrist or ophthalmologist
• Sooner the better for best chance of good vision

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2. Exotropia

• Eye turns outward
• Congenitalpresent at birth
• Surgery usually needed to re-align
• Many exotropias are intermittent
• May occur when patient is tired or not paying
  attention
• Concentration can force eyes to re-align
• Vision therapy and/or glasses can help

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2. Exotropia

• When intermittent
• Brain sometimes receives info from both eyes
  (binocular)
• Less chance of amblyopia
• However, important to be seen by eyecare provider
  when deviation noted

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3. Hypertropia

• One eye vertically misaligned
• Usually from paresis of an extra-ocular muscle
• Typically much more subtle for patient to
  describe and provider to diagnose

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2 Types

• Congenital
• Most common type
• Patients can compensate for years by tilting head
• Can be discovered by looking at childhood photos

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2 Types

• Acquired
• TraumaExtra-ocular muscle trapped by orbital
  fracture
• Vascular infarctSystemic diseases that affect
  blood supply to nerves can cause temporary nerve
  palsy
• Diabetes and HTN most common
• Palsies tend to resolve over weeks or months
• NeurologicalIn rare cases a tumor or aneurysm
  can cause symptoms

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LAZY EYE
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Lazy Eye - Amblyopia

• Decreased vision uncorrectable by glasses or
  contactsnot due to eye disease
• For some reason, brain doesnt fully acknowledge
  images seen

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Lazy Eye - Amblyopia

• 3 Types of Amblyopia
• Strabismic
• Anisometropic
• Stimulus deprivation

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1. Strabismic Amblyopia

• One eye deviates from other and sends conflicting
  info to brain
• Brain doesnt like to see doubleso turns off
  info from deviated eye
• Results in under developed visual cortex for that
  eye
• Can usually be reversed or decreased if treated
  during first 9 years
• Need to visit eyecare provider ASAP to determine
  cause

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Treatment

• If caught early, treatment can teach brain how to
  see better
• Vision therapy/patching
• Glasses
• Surgical re-alignment
• Early vision screenings are critical!

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2. Anisometropic Amblyopia

• Anisometropiasignificant difference in Rx
  between eyes
• Commonly one eye more farsighted
• Farsighted eye works hard to see clearlyand
  sometimes gives up
• Brain relies on info from other eye

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2. Anisometropic Amblyopia

• If not caught, one eye wont learn to see as well
  as other
• Vision therapy and glasses are both beneficial
• Sooner the better

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3. Deprivational Amblyopia

• Any opacity in visual pathway can be devastating
  to developing visual system
• Congenital cataracts
• Corneal opacities
• Ptosis (droopy eyelid)
• Other media opacities

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EXTERNALCONDITIONS
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Common External Ocular Conditions

• Blepharitis
• Hordeolumstye
• Preseptal cellulitis
• Orbital cellulitis
• Pterygium
• Corneal ulcer

• Conjunctivitis
• Viral pink eye
• Adenovirus
• Bacterial
• Allergic
• Hyperacute
• Chlamydial

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Blepharitis

• Inflammation of eyelids (anterior or posterior)
• Symptoms
• Itching
• Burning
• Crusting
• Dry eye sensation
• Foreign body sensation

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Blepharitis

• Signs
• Crusts on lid margins
• Thickened, reddened eyelids
• Plugged or inspisated meibomian glands along
  eyelid

• Treatment
• Warm compresses, 10 minutes 1-2 x/day
• Lid scrubs with diluted baby shampoo
• Artificial tears
• Erythromycin ointment at night

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Hordeolum (stye)

• Abscessed meibomian gland
• Raised, tender nodule
• Often gets larger over days to a week

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Hordeolum

• Signs
• Raised nodule protruding out from or under lid
• Red, swollen lid
• Capped glands at site of infection

• Treatment
• Warm compresses, BID-TID for 10 mins
• Topical meds dont penetrate abscess
• Oral antibiotics if no response to traditional
  treatment

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Preseptal Cellulitis

• Bacterial infection of eyelid anterior to orbital
  septum
• Can arise from
• concurrent sinus infection
• penetrating lid trauma
• dental infection
• hordeolum
• insect bite

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Preseptal Cellulitis

• Signs
• Painful, swollen lid extending past orbital rim
• May be unable to open eye
• No decreased vision, restricted ocular motility
  or proptosis
• White conjunctiva

• Treatment
• Amoxicillin (augmentin) 500 mg PO TID
• Treat infection quickly to minimize risk of
  orbital cellulitis

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Orbital Cellulitis

• Serious infection of soft tissues behind orbital
  septum
• Can be life-threatening
• Causes
• Sinus infection
• Extension of preseptal cellulitis
• Dental infection
• Penetrating lid injury
• After ocular surgery

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Orbital Cellulitis

• Signs
• Tender, warm periorbital lid edema
• Proptosis
• Painful ophthalmoplegia
• Decreased vision
• Severe malaise, fever and pain

• Treatment
• Medical emergency
• Hospitalization with IV antibiotics
• Consider orbit/head CT to look for abscess
• Consult pediatrician or infectious disease
  specialist

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Preseptal vs. Orbital Cellulitis

• Preseptal
• Painful, swollen lid extending beyond orbital rim
• Normal vision
• Full EOMs
• White conjunctiva
• No proptosis
• No fever

• Orbital
• Painful, swollen lid that stops at orbital rim
• Decreased vision
• Restricted ocular motilities
• Proptosis
• Fever/malaise

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Pterygium

• Triangular-shaped growth of conjunctival tissue
  onto cornea
• Causes
• UV exposure
• Dryness
• Irritants
• Smoke
• Dust

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Pterygium

• Signs
• Dry eye
• Irritation
• Redness
• Blurred vision

• Management and Treatment
• UV tint on glasses
• Avoid irritating environments
• Artificial tears
• Topical vasoconstrictor or mild steroid
• Surgery

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Corneal Ulcer

• Infection of cornea
• Bacterial
• Fungal
• Acanthamoeba
• Causes
• SCL wearer
• Trauma
• Compromised cornea from pre-existing condition

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Corneal Ulcer

• Signs
• Pain
• Photophobia
• Blurred vision
• Discharge
• Hypopyon

• Treatment
• Start immediately
• Fortified antibiotics
• Fluoroquinolones
• Culture may not be necessary if ulcer is small
• Must be monitored daily!

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Conjunctivitis (red eye)

• Various Causes
• Viral/Adenovirus
• Bacterial
• Allergic
• Chlamydial
• Herpetic
• Toxic

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Conjunctivitis

• Signs
• Irritation
• Burning/stinging
• Watering
• Photophobia
• Pain or foreign body sensation
• Itching

• Discharge
• Watery
• Mucoid
• Mucopurulent
• Purulent

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1. Viral Conjunctivitis (pink eye)

• Most viral infections are fairly mild and
  self-limiting
• Signs Symptoms
• Watering
• Redness
• Photophobia
• Discomfort/foreign body sensation
• Palpable preauricular node

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1. Viral Conjunctivitis

• Patients often have recent history of URI
• Treat symptoms
• Cool compresses
• Artificial tears
• Topical vasoconstrictors or mild
  anti-inflammatory
• Frequent handwashing
• Usually runs course in 1-3 weeks

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2. Adenoviral Conjunctivitis

• Highly contagious
• Most common types
• Pharyngoconjunctival fever (PCF) can be caused
  by adenovirus types 3, 4 7
• Epidemic keratoconjunctivitis (EKC)caused most
  commonly by adenovirus types 8 19

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2. Adenoviral Conjunctivitis

• Signs
• Watering
• Conjunctival follicles
• Subconjunctival hemorrhages
• Chemosis
• Pseudomembranes
• Lymphadenopathy
• Keratitis

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3. Bacterial Conjunctivitis

• Common, especially in children
• Usually self-limiting
• Signs/symptoms
• Acute redness
• Burning/grittiness
• Mucopurulent discharge
• Lids stuck shut in morning

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3. Bacterial Conjunctivitis

• Common organisms S. aureus, S. epidermidis,
  S. pneumonia, H. influenza (esp. peds)
• Usually self-limiting
• But important to use broad-spectrum antibiotic
  until discharge cleared (5-7 days)
• Antibiotics
• Tobramycin
• Polytrimpolymyxin trimethoprim
• Fluoroquinolones like Ocuflox or Ciloxan

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5. Hyperacute Conjunctivitis

• Cause
• Sexually transmitted
• Neisseria gonorrhoeae
• Signs
• Swollen, tender lids
• Copious purulent discharge
• Significant conjunctival redness and swelling
• Lymphadenopathy

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5. Hyperacute Conjunctivitis

• Treatment
• Lavage
• Take scrapings for culture and sensitivity
  testing
• Patients usually hospitalized and started on IM
  Ceftriaxone
• Topical antibiotics not effective

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6. Chlamydial Conjunctivitis

• Cause
• Sexually transmitted ocular infection
• Signs
• Patients typically have mild but persistent
  follicular conjunctivitis non respondent to
  topical antibiotics
• Any conjunctivitis lasting longer than 3 weeks
  despite therapy should be suspect

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6. Chlamydial Conjunctivitis

• Patients can have concomitant genital infection
  (could be asymptomatic)
• Refer for work-up if necessary
• Treatment
• OralAzithromycin 1g, doxycycline 100mg bid x 7
  days, erythromycin 500mg qid x 7 days. Also
  need to tx partners!
• Topicalerythromycin, tetracycline, or
  sulfacetamide ung bid-tid x 2-3 weeks

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4. Allergic Conjunctivitis

• Can be seasonal or acute
• Signs/symptoms
• Itching is hallmark
• Conjunctival redness
• Chemosis
• Lid edema
• Thin, watery discharge
• No palpable preauricular nodes

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4. Allergic Conjunctivitis

• Treatment
• Eliminate offending agent
• If mild
• Cool compresses
• Artificial tears/vasoconstrictors
• If moderate or severe
• Topical antihistamine/mast-cell stabilizer (ie.
  Patanol)
• Topical NSAID
• Topical steroid
• Oral antihistamine

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INTERNALCONDITIONS
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Internal Ocular Conditions

• Glaucoma
• Cataracts
• Macular Degeneration
• Retinal detachment

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Glaucoma

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

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Glaucoma

• Pathophysiology of progression not well
  understood
• Increased IOP
• Damages nerves as they leave eye, causing cell
  death
• Reduces blood supply to ONH, indirectly
  destroying cells by starving them of oxygen and
  nutrients
• Abnormal levels of neurotransmitter (glutamate)
  cause cells to die off

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Glaucoma

• Monitoring
• IOP
• ONH appearance
• Visual field testing
• Newer methods include
• HRT (Heidelberg Retinal Tomograph II)
• GDx Nerve Fiber Analyzer
• Genetic testing

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Glaucoma

• IOP reduction is mainstay of treatment
• Decrease aqueous production
• B-blockers
• Alpha-agonists
• Carbonic anhydrase inhibitors
• Increase uveoscleral outflow
• prostaglandin analogs

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Cataract

• Clouding of natural lens
• Patients experience
• Blurred/dim vision
• Glare, especially at night
• Halos around lights
• Doubling or ghost images of objects

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Etiology

• Everyone develops them if they live long enough!
• Types of cataracts
• Age-relatedsenile
• Traumablunt or perforating injury
• Systemic conditionsdiabetes
• Medicationssteroids

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Main Types

• Age-related
• Nuclear sclerotic
• Cortical spokes
• Posterior sub-capsular
• Mature cataract

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Treatment

• Surgery
• When loss of vision interferes with daily
  activities
• Driving
• Reading
• Hobbies

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Outpatient Surgery

• 5-10 minutes with skilled surgeon
• Incision through cornea or sclera under upper lid
• Circular tear in anterior capsule
• Lens broken up with ultra sound instrument
• Fragments suctioned out
• Lens implant inserted

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Secondary Cataract

• Cloudiness forms on posterior capsule after
  cataract surgery
• 30-50 of patients
• YAG laser used to create opening
• Vision quickly restored

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Macular Degeneration

• 1 cause of blindness in Americans over age 65

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Pathophysiology

• Causes not well understood
• Theorized link to
• UV light exposure
• subsequent release of free radicals
• oxidation within retinal tissues
• Another theoryareas of decreased vascular
  perfusion in retina, lead to cell death

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Two Types

• Dry (atrophic)
• 90 of those diagnosed
• Wet (exudative)
• 10 of those diagnosed
• But accounts for 90 of blindness caused by
  disease

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Symptoms

• None
• Blurred vision
• Metamorphopsiastraight lines appear wavy or
  distorted
• Scotomasmissing areas in vision

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Dry Form

• Slow, progressive loss of central vision
• Breakdown of underlying retinal tissues,
  resulting in mottling or clumping of normal
  pigment
• Drusen begin to accumulate
• Geographic atrophy can also occur

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Wet Form

• Can quickly degrade central vision
• Break in underlying tissues allows new blood
  vessels or fluid to come through
• New blood vessels are weak so frequently break
  and bleed

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Treatment for Dry Form

• Regular eye exams
• Careful discussion regarding family history
• Education
• UV protection
• Antioxidants
• AREDS
• PreserVision
• Stop smoking

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Treatment for Wet Form

• Refer to retinal specialist
• Photocoagulation
• Photo-dynamic therapy (PDT)
• Submacular surgery
• Macular translocation
• Anti-angiogenic drug therapy

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Retinal Detachment

• Several types
• Rhegmatogenouscaused by break in retina
• Exudativecaused by fluid accumulation beneath
  retina
• Tractionalproliferative fibrovascular vitreal
  strands

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Signs Symptoms

• Flashing lights in peripheral vision
• New floatersblack spots or cobwebs
• Peripheral scotomadark shadow or curtain
  blocking vision

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Emergency

• Patients with these symptoms must see eyecare
  provider immediately
• Additional risk factors
• Highly nearsighted
• Diabetic
• Recent trauma/injury

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Treatment

• Laser photocoagulation or cryotherapy
• Pneumatic retinopexygas bubble to tamponade
  retina back into place
• Scleral buckle
• Silicone oil

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DIABETICRETINOPATHY
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Diabetic Retinopathy

• Diabetes affects retinal micro-vasculature
• One of leading causes of blindness among ages
  20-64

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Progression

• Over time, elevated and fluctuating blood sugar
  damages vessel walls
• Vessels leak fluid, lipids or blood into retina
• New vessels grow to bring more oxygen to retina

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Symptoms

• Fluctuating vision
• Blurred vision
• Distortion
• Sudden loss of vision

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Treatment

• Control blood sugar
• Refer to retinal specialist when vision
  threatened
• PRP (pan-retinal photocoagulation)
• Focal laser
• Vitrectomy
• Retinal detachment repair

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Working Together

• Together we can catch vision threatening
  conditions earlier
• Glad to answer questions
• Always happy to take your calls

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Questions?