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Eye Emergencies
You Don’t Want To Miss
Bobby Korn, MD, PhD
Assistant Professor of Clinical Ophthalmology
Shiley Eye Center
University of California, San Diego
Eye Emergencies You Don’t Want to Miss
Learning Objectives
•
•
Describe the clinical features of age-related macular degeneration and diabetic retinopathy so you will be able
to identify your patients at risk and refer them for appropriate management.
Identify at least 2 eye emergencies that can cause rapid blindness and potentially threaten life.
Faculty
Bobby Korn, MD, PhD, FACS
Assistant Professor of Ophthalmology
Shiley Eye Center
University of California, San Diego
La Jolla, California
Bobby S. Korn, MD, PhD is an assistant professor of ophthalmology in the Shiley Eye Center at the University of
California, San Diego School of Medicine (UCSD). Dr Korn completed his undergraduate degree at the Massachusetts
Institute of Technology. He then attended the medical scientist-training (MD/PhD) program at the University of Texas,
Southwestern Medical School. There, he studied the molecular mechanisms of cholesterol regulation in the laboratory
of two Nobel Laureates. He completed his ophthalmology residency at UCSD serving as the chief resident and
completed fellowship training in ophthalmic plastic, orbital and reconstructive surgery at UCSD.
Dr Korn is board certified by the American Board of Ophthalmology. He has a wide range of clinical interests
including comprehensive ophthalmic care, craniofacial disorders, reconstructive surgery of the eyelid and face,
management of thyroid eye disease, eyelid and orbital tumors and pediatric and adult disorders of the lacrimal outflow
system. In addition, Dr Korn is a member of the UCSD Thyroid Eye Center.
In addition to his busy clinical practice, Dr Korn is an active teacher on the local, national and international level. He
coordinates a prestigious international fellowship program at UCSD designed to train the future leaders in
ophthalmology as they return to their home country. At the local and national level, he actively lectures to
ophthalmologists and primary care physicians. He was the recipient of the Outstanding Research Award and Best
Teaching Awards from medical students, residents, and fellows.
Dr Korn is also an active researcher and has published numerous peer-reviewed articles and textbook chapters. His
research focuses on orbital stem cells and thyroid-related eye disease.
In his free time, he is a volunteer surgeon locally and internationally. He participates in humanitarian medical missions
in Thailand, Mexico, and the Philippines.
Faculty Financial Disclosure
As a CME provider accredited by the ACCME, it is the policy of the Pri-Med Institute to require the disclosure of the
existence of any significant financial interest or any other relationship a faculty member or a sponsor has with either
the commercial supporter or the manufacturer(s) of any commercial device(s) discussed in this educational
presentation.
Dr Korn has nothing to disclose.
Conflict of Interest Resolution Statement
When individuals in a position to control content have reported financial relationships with one or more commercial
interests, as listed above, Pri-Med Institute works with them to resolve such conflicts to ensure that the content
presented is free of commercial bias. The content of this presentation was vetted by the following mechanisms and
modified as required to meet this standard:
• Content peer review by external topic expert
• Content validation by external topic expert and internal Pri-Med Institute clinical editorial staff
Off-label/Investigational Disclosure
In accordance with Pri-Med Institute policy, faculty have been asked to disclose discussion of unlabeled or unapproved
use(s) of drugs or devices during the course of their presentations.
Drug List
Generic
acyclovir
vitamin A, C, and E; zinc, copper
verteporfin
pegaptanib sodium
ranibizumab
bevacizumab
Trade
Zovirax
I-Caps, Ocuvite PreserVision
Visudyne
Macugen
Lucentis
Avastin
Suggested Reading List
Ophthalmology for Primary Care
Kunimoto DK, Kanitkar KD, Makar MS. The Wills Eye Manual. 4th ed. Philadelphia, PA: Lippincott Williams and
Wilkins; 2004.
Trobe JD. The Physician’s Guide to Eye Care. San Francisco, CA: American Academy of Ophthalmology; 2001.
Kaiser P, Friedman N, Pineda R. Massachusetts Eye and Ear Infirmary Illustrated Manual of Ophthalmology. 2nd ed.
WB Saunders; 2003.
Vision Problems in the U.S.: Prevalence of Adult Vision Impairment and Age-Related Eye Disease in America.
National Eye Institute, Prevent Blindness in America; 2002.
The Red Eye and Ocular Trauma
Korn TS. The red eye: current concepts for primary care physicians. Resid Staff Physician. 2005;51(7):37-43.
American Academy of Ophthalmology Cornea/External Disease Panel. Preferred Practice Patterns: Conjunctivitis.
American Academy of Ophthalmology; 2003: 1-24.
Macular Degeneration and Vitamin Supplementation
Park SS. Age-related macular degeneration: clinical features and therapeutic options. Resid Staff Physician.
2005;51:13-18.
Klein R, Klein BE, Linton KL. Prevalence of age-related maculopathy: the Beaver Dam Eye Study. Ophthalmology
1992;99:933-943.
Brown GC, Brown MM, Sharma S, et al. The burden of age-related macular degeneration: a value-based medicine
analysis. Trans Am Ophthalmol Soc. 2005;103:173-184.
Friedman DS, O’Colmain BJ, Munoz B, et al; for the Eye Diseases Prevalence Research Group. Prevalence of agerelated macular degeneration in the United States. Arch Ophthalmol. 2004;122:564-572.
Holz FG, Wolfensberger TJ, Piguet B, et al. Bilateral macular drusen in age-related macular degeneration.
Ophthalmology. 1994;101:1522-1528.
Bressler SB, Maguire MG, Bressler NM, et al. Relationship of drusen and abnormalities of the retinal pigment
epithelium to the prognosis of neovascular macular degeneration. Arch Ophthalmol. 1990;108:1442-1447.
Hyman L, Schachat AP, He Q, et al; for the Age-Related Macular Degeneration Risk Factor Study Group.
Hypertension, cardiovascular disease, and age-related macular degeneration. Arch Ophthalmol. 2000;117:351-358.
Smith W, Mitchell P, Leeder SR, et al. Plasma fibrinogen levels, other cardiovascular risk factors, and age-related
maculopathy: The Blue Mountains Eye Study. Arch Ophthalmol. 1998;116:583-587.
Seddon JM, Ajani UA, Sperduto RD, et al. Dietary carotenoids, vitamin A, C, and E, and advanced age-related macular
degeneration: Eye Disease Case-Control Study Group. JAMA. 1994;272:1413-1420.
Age-Related Eye Disease Study Research Group. A randomized, placebo-controlled, clinical trial of high-dose
supplementation with vitamins C and E, beta-carotene, and zinc for age-related macular degeneration and vision loss:
AREDS Report No. 8. Arch Ophthlamol. 2001;119:1417-1436.
Omenn GS, Goodman GE, Thornquist MD, et al. Risk factors for lung cancer and for intervention effects in CARET,
the beta-carotene and retinol efficacy trial. J Natl Cancer Inst. 1996;88:1550-1559.
Brown BG, Zhao XQ, Chait A, et al. Simvastatin and niacin, antioxidant vitamins, or the combination for the
prevention of coronary disease. N Engl J Med. 2001;345:1583-1593.
Cheung MC, Zhao XQ, Chait A, et al. Antioxidant supplements block the response of HDL to simvastatin-niacin
therapy in patients with coronary artery disease and low HDL. Arterioscler Throm Vasc Biol. 2001;21:1320-1326.
Gragoudas ES, Adamis AP, Cunningham ET Jr, et al; VEGF Inhibition Study in Ocular Neovascularization Clinical
Trial Group. Pegaptanib for neovascular age-related macular degeneration. N Engl J Med. 2004;351:2805-2816.
VEGF Inhibition Study in Ocular Neovascularization (V.I.S.I.O.N.) Clinical Trial Group; Chakravarthy U, Adamis
AP, Cunningham ET Jr, et al. Year 2 efficacy results of 2 randomized controlled clinical trials of pegaptanib for
neovascular age-related macular degeneration. Ophthalmology. 2006;113:1508.e1-e25.
Rosenfeld PJ, Brown DM, Heier JS, et al; MARINA Study Group. Ranibizumab for neovascular age-related macular
degeneration. N Engl J Med. 2006;355:1419-1431.
Brown DM, Kaiser PK, Michels M, et al; ANCHOR Study Group. Ranibizumab versus verteporfin for neovascular
age-related macular degeneration. N Engl J Med. 2006;355:1432-1444.
Cruickshanks KJ, Klein R, Klein BEK, et al. Sunlight and the 5-year incidence of early age-related maculopathy: The
Beaver Dam Eye Study. Arch Ophthalmol. 2001;119:246-250.
Seddon JM, Ajani UA, Sperduto RD, et al. Dietary carotenoids, vitamin A, C, and E, and advanced age-related macular
degeneration: Eye Disease Case-Control Study Group. JAMA. 1994;272:1413-1420.
Seddon JM, Cote J, Rosner B. Progression of age-related macular degeneration: association with dietary fat,
transunsaturated fat, nuts and fish intake. Arch Ophthalmol. 2003;121:1728-1737.
Federman DG, Kravetz JD. Carotenemia associated with vitamin supplementation used for treatment of age-related
macular degeneration. Commentary by Cirigilano MD. Resid Staff Physician. 2005;51:19-21.
Diabetic Retinopathy and Ocular Neovascularization
Bhavsar AR. Diabetic retinopathy: the latest in current management. Retina. 2006;26(6 suppl):S71-S79.
Frank RN. Diabetic retinopathy. N Engl J Med. 2004;350:48-58.
Lee P, Wang CC, Adamis AP. Ocular neovascularization: an epidemiologic review. Surv Ophthalmol. 1998;43:245269.
Murphy RP. Management of diabetic retinopathy. Am Fam Physician. 1995;51:785-796.
Retinal Artery Occlusions
Hayreh SS, Kolder HE, Weingeist TA. Central retinal artery occlusion and retinal tolerance time. Ophthalmology.
1980;87:75-78.
Rumelt S, Brown GC. Update on treatment of retinal arterial occlusions. Curr Opin Ophthalmol. 2003;14:139-141.
Mohan K, Gupta A, Jain IS, Banerjee CK. Bilateral central retinal artery occlusion in occult temporal arteritis.
J Clin Neuroophthalmol. 1989;9:270-272.
Pettersen JA, Hill MD, Demchuk AM, et al. Intra-arterial thrombolysis for retinal artery occlusion: the Calgary
experience. Can J Neurol Sci. 2005; 32:507-511.
Weber J, Remonda L, Mattle HP, et al. Selective intra-arterial fibrinolysis of acute central retinal artery occlusion.
Stroke. 1998;29:2076-2079.
Leucocoria and Retinoblastoma
McLaughlin C, Levin AV. The red reflex. Pediatr Emerg Care. 2006;22:137-140.
Melamud A, Palekar R, Singh A. Retinoblastoma. Am Fam Physician. 2006;73:1039-1044.
Simon JW, Kaw P. Commonly missed diagnoses in the childhood eye examination. Am Fam Physician. 2001;64:623628.
Neuro-ophthalmic Emergencies
Banik, R. Neuro-ophthalmic emergencies: three diagnoses not to be missed in primary care. Resid Staff Physician.
2005;51:13-18.
Lee AG, Hayman LA, Brazis PW. The evaluation of isolated third nerve palsy revisited: an update on the evolving role
of magnetic resonance, computed tomography, and catheter angiography. Surv Ophthalmol. 2002;47:137-157.
Biousse V, Newman NJ. Third nerve palsies. Semin Neurol. 2000;20:55-74.
Jacobson DM, McCanna TD, Layde PM. Risk factors for ischemic ocular motor nerve palsies. Arch Ophthalmol.
1994;112:961-966.
Willinsky RA, Taylor SM, TerBrugge K, et al. Neurologic complications of cerebral angiography: prospective analysis
of 2899 procedures and review of the literature. Radiology. 2003;227:522-528.
Glaucoma
Song, J. Glaucoma: The silent killer of eyesight. Resid Staff Physician. 2005;51:28-32.
Orbital Cellulitis
Givner LB. Periorbital versus orbital cellulitis. Pediatr Infect Dis J. 2002;21:1157-1158.
Temporal (Giant Cell Arteritis)
Unwin B, Williams CM, Gilliland W. Polymyalgia rheumatica and giant cell arteritis. Am Fam Physician.
2006;74:1547-1554.
Chan CC, O'Day J. Oral and intravenous steroids in giant cell arteritis. Clin Experiment Ophthalmol. 2003;31:179-182.
Salvarani C, Cantini F, Boiardi L, et al. Polymyalgia rheumatica and giant-cell arteritis. N Engl J Med. 2002; 347:
261-271.
Liu GT, Glaser JS, Schatz NJ, et al. Visual morbidity in giant cell arteritis. Clinical characteristics and prognosis for
vision. Ophthalmology. 1993;101:1779-1785.
Retinal Detachment
Subramanian ML, Topping TM: Controversies in the management of primary retinal detachments. Int Ophthalmol
Clin. 2004;44:103-114.
Gariano RF, Kim CH. Evaluation and management of suspected retinal detachment. Am Fam Physician. 2004;69:16911698.
Ocular Herpes Zoster
Liesegang TJ. Herpes zoster virus infection. Curr Opin Ophthalmol. 2004;15:531-536.
Zaal MJ, Volker-Dieben HJ, D'Amaro J. Prognostic value of Hutchinson's sign in acute herpes zoster ophthalmicus.
Graefes Arch Clin Exp Ophthalmol. 2003;241:187-191.
Amsler Grid – Home Vision Screener for Patients
• Test one eye at time – Wear your reading glasses or bifocals if necessary to
see the grid.
• Hold grid 12-14 inches from you nose.
• With the other eye covered, stare at the central dot in the grid.
• Note any areas of missing, blurred, or distorted lines and any areas of black
spots. Outline these areas with a pencil.
• Use the first self-examination as your baseline for each eye and give them to
your physician.
• Repeat this self-examination at the recommended interval and call your
physician immediately if you note any significant changes from your baseline.
Making the Correct Diagnosis
in the Primary Care
• Some eye diseases can
cause permanent
blindness
• Some eye diseases can
threaten life
Eye Emergencies
You Don’
Don’t Want To Miss
Bobby S. Korn, MD, PhD
Assistant Professor of Ophthalmology
Shiley Eye Center
University of California, San Diego
Eye Emergencies in Primary Care
Eye Exam Checklist
Lecture Goals
• Eye Emergencies
– Vision Threatening
– Life Threatening
• Examination & Diagnostic Pearls
• Clinical Updates
– Age Related Macular Degeneration
– Diabetic Retinopathy
ƒ
Visual Acuity
ƒ
Pupils
ƒ
Ocular Motility
ƒ
Confrontational Visual Fields
ƒ
External Exam
Lids, Conjunctiva, Cornea,
Anterior Chamber, Iris, Lens
• 12 Interactive Clinical Case Scenarios
ƒ
ƒ
Direct Ophthalmoscope
Measuring Visual Acuity
ƒ
Test each eye separately with best
correction (glasses or contact lens)
ƒ
20/15, 20/20, 20/30, 20/40 ....
ƒ
20/100
ƒ
20/200
ƒ
20/400
ƒ
Counting fingers at 1 ft, 2 ft ...
ƒ
Hand motion detection at 1 ft, 2 ft ...
ƒ
Light perception only
ƒ
No light perception
Clinical Case 1
1
Retinal Artery Occlusions
Take Home Pearls
Retinal Artery Occlusions
• Occlusion of retinal artery by thrombosis or embolism
• Symptoms
• Dislodge the retinal clot 1
– Ocular massage
– IV acetazolamide or oral glycerol
– Painless vision loss
– Transient (Amaurosis fugax)
• STAT Sedimentation Rate to rule out temporal (giant cell) arteritis 2
• STAT ophthalmology consult
• Emboli from heart or carotid arteries
– Permanent (Artery Occlusion)
– Anterior chamber paracentesis
• Complete thrombosis
• Systemic workup
• Signs
– Pale retina with cherry red spot in macula
– Narrow arterioles with Hollenhorst plaques
– Afferent Pupillary Defect (APD)
• Irreversible retinal damage 90-120 minutes after onset of
symptoms if complete thrombosis occurs 1
•
– Embolic workup (carotid arteries, heart)
– Atherosclerotic workup (lipid profile, coronary artery health)
– PT, PTT, CBC
– Patients < 50 yr Æ ANA, RF, anti-phospholipid antibodies
Intra-arterial thrombolysis benefit unknown - limited clinical studies 3-4
1- Rumelt S, Brown GC. Curr Opin Ophthalmol. 2003 Jun;14(3):139-41.
2 - Mohan K, et al. J Clin Neuroophthalmol. 1989 Dec;9(4):270-2.
3 - Pettersen JA, et al. Can J Neurol Sci. 2005; 32(4):507-11.
4 - Weber J, et al. Stroke. 1998; 29(10):2076-9.
1- Hayreh SS, Kolder HE, Weingeist TA. Ophthalmology. 1980;87:75–78
Orbital Cellulitis
Recognize key signs
•
•
•
•
Clinical Case 2
Decreased vision
Proptosis
Reduced ocular motility
Afferent pupillary defect (Marcus
Gunn Pupil)
• All of the above signs are normal in patients with
preseptal cellulitis
Preseptal / Orbital Cellulitis
Take Home Pearls
Recognize deep tissue, orbital apex involvement (Orbital
Cellulitis)
ƒ
ƒ
ƒ
ƒ
ƒ
Proptosis
Reduced ocular motility
Decreased vision
Afferent pupillary defect (Marcus Gunn Pupil)
ƒ
ƒ
ƒ
ƒ
Imaging of Cavernous Sinus and Orbit
Rule out infection
Rule out diabetic ketoacidosis (adults)
Rule out mucormycosis (adults)
ƒ
ƒ
Clinical Case 3
Prompt Hospital Admission for Orbital Cellulitis
ƒ
ENT Consultation
Aggressive Management and Follow-up for Preseptal Cellulitis in
Pediatric Patients
Givner LB. Pediatr Infect Dis J. 2002 Dec;21(12):1157-8
2
Herpes Zoster Ophthalmicus
Take Home Pearls
Herpes Zoster Ophthalmicus
• Hutchinson’s Sign
• Refer to eye care provider if
– Skin lesions involving the nasal tip = increased risk of HZV ocular
involvement 1
–
–
–
–
–
–
–
• Acute Retinal Necrosis
– Retinal necrosis caused by virus leading to retinal hemorrhages and
retinal detachment
– Increased risk if HIV Positive2
– Key Symptoms
•
•
•
•
•
Hutchinson’s sign (nasal involvement)
Conjunctival injection
Corneal staining
Light sensitivity
New onset floaters, flashes of light or shadows worse with eye movement
Sudden vision loss or decreased acuity
HIV positive
• Eye lubrication
Floaters
Flashes of Light
Shadows
Hutchinson’s Sign
DECREASED VISUAL ACUITY
– Preservative free artificial tears
• Systemic anti-viral therapy (acyclovir)
• Prevent secondary bacterial infection of skin lesions
• Rule out HIV or immunocompromised condition if age < 40
1- Zaal MJ et al. Graefes Arch Clin Exp Ophthalmol. 2003 Mar;241(3):187-91.
2 - Liesegang TJ. Curr Opin Ophthalmol. 2004 Dec;15(6):531-6.
Kunimoto D, et al. The Wills Eye Manual, 4th edition 2004; Lippincott.
Leukocoria ( White Pupil )
Differential Diagnosis
• Retinoblastoma - Medical Emergency
• Congenital Cataract – Urgent if unilateral cataract
because of ambylopia risk
• Retinal Detachment
• Retinopathy of Prematurity
• Coat’s Disease
• Persistent Hyperplastic Primary Vitreous (PHPV)
• Ocular Toxoplasmosis
• Ocular Toxocariasis
Clinical Case 4
Melamud A et al. Am Fam Physician. 2006 Mar 15;73(6):1039-44.
Retinoblastoma
Take Home Pearls
• Early Recognition
– Abnormal white pupil reflex (leukocoria)
– New onset strabismus
– Red eye with hypopyon
Clinical Case 5
• Head CT Scan – intraocular calcifications
• Pediatric ophthalmology and oncology consults
McLaughlin C, Levin AV. The red reflex. Pediatr Emerg Care. 2006 Feb;22(2):137-40
Simon JW, Kaw P. Am Fam Physician. 2001 Aug 15;64(4):623-8
Melamud A et al. Am Fam Physician. 2006 Mar 15;73(6):1039-44.
3
Diagnostic Test for Scleritis
Phenylephrine Challenge
Scleritis
▪ Recognize symptoms
• Boring eye pain
• Eye painful to touch
ƒ Apply one drop of 2.5% phenylephrine and re-examine eye in 15
minutes1
• Eye pain on movement
ƒ Eye remains red in scleritis
• Scleral injection
ƒ Eye turns white in all other conditions (conjunctivitis)
▪ Refer to rheumatology
and ophthalmology
ƒ Avoid use in
ƒ Uncontrolled hypertension
• Systemic immunosuppression required to prevent scleral
ulceration / perforation and life threatening vasculitis1
in majority of cases
ƒ Narrow angle glaucoma
ƒ Children under general
anesthesia2
1 - Patel SJ, Lundy DC. Am Fam Physician. 2002;66(6):991-8.
2 – Groudine SB, et al. Anesthesiology 2000;92: 859-864.
1 - Jabs DA, et al. Am J Ophthalmol. 2000 Oct;130(4):469-76.
Iris Neovascularization
• Presence of iris vessels indicates
underlying systemic or eye disease
• Differential Diagnosis
–
–
–
–
–
Clinical Case 6
Diabetes Mellitus
Carotid Artery Occlusive Disease
Retinal Vein Occlusions
Head or Nasal Radiation Therapy
Intraocular Tumors (rare)
Iris Neovascularization
Take Home Pearls
•
•
•
•
•
Examine each iris
Examine the optic nerves for neovascularization
Control any underlying diabetes
Rule out carotid artery occlusive disease
Prompt referral to ophthalmology for laser
treatment to prevent angle closure-glaucoma
Clinical Case 7
Kunimoto D, et al. The Wills Eye Manual, 4th edition 2004; Lippincott.
4
Examining the Optic Nerve
Take Home Pearls
Optic Nerve Swelling
Differential Diagnosis
ƒ Always examine both optic nerves for any
ƒ visual disturbances
ƒ headaches
ƒ neck pain
ƒ eye pain or ocular discomfort
ƒ diminished visual acuity
ƒ abnormal pupils
ƒ Direct Ophthalmoscope Pearls
ƒ Dark exam room
ƒ Start dial at zero, use your best distance
vision (glasses, contacts)
ƒ Pharmacological pupil dilation if necessary
(2.5% neosynephrine)
• Increased Intracranial Pressure (Papilledema)
Malignant Hypertension
Optic Neuritis
Meningitis
Encephalitis
Arteriovenous Malformations
Intracranial Venous Sinus Thrombosis
Optic Nerve Tumors
Ischemic Optic Neuropathy
Infiltration of the Optic Nerve (Tumors, Infection, Inflammation)
Pseudopapilledema (Optic Nerve Drusen)
Kunimoto D, et al. The Wills Eye Manual, 4th edition 2004; Lippincott.
National Age-Specific Prevalence
Rates for Glaucoma
Optic Nerve
Take Home Pearls
0.14
• Is the nerve swollen?
0.12
– Optic Disc Edema (Normal Intracranial Pressure)
0.1
• Optic Neuritis
• Anterior Ischemic Optic Neuropathy
0.08
White
0.06
Black
0.04
Hispanic
– Papilledema (Increased Intracranial Pressure)
• What is the color of the optic nerve?
– Pink (normal)
– Pallor (suspect neurological disease)
• What is the size of optic cup?
Other
0.02
– Large size (suspect glaucoma)
80
+
80
+
M
al
e
50
-5
4
60
-6
4
70
-7
4
al
e
50
-5
4
60
-6
4
70
-7
4
0
Vision Problems in the U.S. National Eye Institute 2002 Report
National Age-Specific Prevalence Rates for
Age-Related Macular Degeneration (AMD)
0.20
0.18
0.16
0.14
Clinical Case 8
0.12
White
0.10
Black
0.08
Hispanic
0.06
Other
0.04
0.02
85
+
0.00
Fe
m
al
e
55
-5
9
65
-6
9
75
-7
9
Fe
m
•
•
•
•
•
•
•
•
•
•
Tumor
Pseudotumor Cerebri
Subarachnoid Hemorrhage
Subdural or Epidural Hematomas
85
+
M
al
e
55
-5
9
65
-6
9
75
-7
9
–
–
–
–
Vision Problems in the U.S. National Eye Institute 2002 Report
5
Age-Related Macular Degeneration (AMD)
Age-Related Macular Degeneration (AMD)
• Etiology: Unknown
• Risk Factors1-3: aging,
hypertension, obesity,
atherosclerosis, elevated
plasma fibrinogen, cigarette
smoking, poor diet
• AMD causes central blindness
– Peripheral vision is unaffected
– Slow bilateral progressive deterioration of central retina
(fovea or macula)
• 2 Types of AMD
– Dry AMD – 90% of all AMD patients
• Asymptomatic
• Stable or slow deterioration
– Wet AMD - 10% of all AMD patients
• Most severe form that causes rapid central blindness
1- Hyman L, Schachat AP, He Q, et al. Arch Ophthalmol. 2000; 117: 351-358.
2 - Smith W, Mitchell P, Leeder SR, et al. Arch Ophthalmol. 1998; 116: 583-587.
3- Seddon JM, Ajani UA, Sperduto RD, et al. JAMA. 1994; 272: 1413-1420.
Dry AMD
Wet AMD
• Affects 90% of all AMD patients
• Slow progression
• Small yellow-white deposits called drusen
accumulate beneath the retina
• Risk of Progression to Wet AMD1
• Most severe form of AMD
• Occurs in 10% of all AMD patients1
• Abnormal blood vessels beneath the retina cause
bleeding, scarring, and retinal photoreceptor
damage in macula
• Sudden, rapid loss of central vision
– More drusen lesions
– Larger drusen lesions
– Presence of retinal pigmentation (metabolism waste
products)
– UK Moorfield Eye Hospital Study2
•
•
•
•
Bilateral Dry AMD patients
8-9% incidence after 1st year of diagnosis
16% incidence after 2nd year
24% incidence after 3rd year
1 – Bressler SB, Maguire MG, Bressler NM, et al. Arch Ophthalmol. 1990; 108: 1442-7.
2 – Holz FG, Wolfensberger TJ, Piguet B, et al. Ophthalmology 1994; 101: 1522-8.
1 - Park SS. Resident and Staff Physician 2005; 51(7): 13-18.
Anti-VEGF
Wet AMD Treatments
Destructive Wet AMD Treatments
• pegaptanib – modified oligonucleotide that
binds to VEGF (2004)
• ranibizumab – recombinant monoclonal
antibody that binds to VEGF (2006)
• Direct Laser Treatment
• Photodynamic Laser
Therapy (PDT) verteporfin
6
MARINA Study Group:
Ranibizumab Monthly Injections
for Advanced Neovascular (Wet) AMD*
ANCHOR Study Group:
Ranibizumab Monthly Injections vs PDT Laser Treatment
for Neovascular (Wet) AMD*
* Minimally classic or occult lesions
* Classic well defined lesions
Average two line acuity GAIN
Average one line acuity GAIN
21 letter difference
(95% CI 17.5, 24.6), P<0.01
22 letter difference
(95% CI 18.1, 24.2), P<0.01
Average two line acuity LOSS
Average 2-3 line acuity LOSS
■ Ranibizumab 0.5 mg (n=139)
● PDT (Laser Treatment)
■ Ranibizumab 0.5 mg (n=240)
○ Sham Placebo (n=238)
(n=143)
Adapted from Rosenfeld PJ et al. N Engl J Med. 2006 Oct 5;355(14)
Adapted from Brown DM et al. N Engl J Med. 2006 Oct 5;355(14)
Age-Related Macular Degeneration
Take Home Pearls
Summary of Current
Age-Related Macular Degeneration (AMD)
Treatments
Treatment
Method of
Medication
Delivery
Induced
Macular
Damage
Delays
Vision
Loss
IMPROVES
VISION
COST
Conventional
Laser Treatment
none
yes
+
NO
$
Photodynamic
IV injections
Laser Treatment
(PDT – verteporfin)
selective
damage
++
NO
$$
Pegaptanib
Eye injections
none
+++
NO
$$$
Ranibizumab
Eye injections
none
+++++
YES
$$$$$
Bevacizumab*
Eye injections
none
?
?
$
ƒ Refer all patients > 50 years for dilated eye exams of the
retina1
ƒ First degree relatives of AMD patients
ƒ Any yellow discoloration or lesions in the macula
ƒ
ƒ
ƒ
ƒ
Stop smoking2
Sunlight and UV protection2
Diet rich in green, leafy vegetables and fish3,4
Daily Amsler grid self-monitoring
ƒ Any acute grid distortions Æ Immediate referral to ophthalmology
1 - Park SS. Resident and Staff Physician 2005; 51(7): 13-18.
2- Cruickshanks KJ, Klein R, Klein BEK, et al. Arch Ophthalmol. 2001; 119: 246-250.
3- Seddon JM, Ajani UA, Sperduto RD, et al. JAMA. 1994; 272: 1413-1420.
4- Seddon JM, Cote J, Rosner B. ProgreArch Ophthalmol. 2003; 121: 1728-1737.
* Off-label, FDA unapproved use
AREDS Daily Vitamin Formulation
for Wet AMD Prevention*
Amsler Grid
•
•
•
•
•
• ideal for self-monitoring of wet
AMD
• sensitive for self-detection of
early macular (central retina)
disease
• Test each eye separately
• any new distortion noted implies
macular disease and requires
referral
Vitamin A 15 mg (573% RDA)
Vitamin C 500 mg (753% RDA)
Vitamin E 400 IU (1333% RDA)
Zinc 80 mg (464% RDA)
Copper 2 mg (80% RDA)
* Intermediate risk AMD in both eyes or advanced AMD in one eye only
Age-Related Eye Disease Study Research Group. Arch Ophthlamol. 2001; 119: 1417-1436.
7
AGE RELATED EYE DISEASE STUDY (AREDS)
Probability of Developing
Advanced Macular Degeneration in One Eye*
AREDS STUDY
Probability of Visual Acuity Loss* in
Intermediate Risk AMD Patients
Probability of Visual Acuity Loss
Probabllity of Advanced AMD
0.4
0.35
0.3
Placebo
0.25
Antioxidants
Zinc
0.2
Antioxidants + Zinc
0.15
0.1
0.05
0
1
2
3
4
Time (Years)
5
* 15 letters or more
0.45
0.4
0.35
0.3
Placebo
Antioxidants
Zinc
0.25
0.2
Antioxidants + Zinc
0.15
0.1
0.05
0
1
6
2
3
4
5
6
7
Time (Years)
* Intermediate risk patients
Adapted from AREDS Research Group. Arch Ophthlamol. 2001; 119: 1417-1436.
Adapted from AREDS Research Group. Arch Ophthlamol. 2001; 119: 1417-1436.
Macular Degeneration AREDS Vitamins
Take Home Pearls
ƒ Consider AREDS Vitamins in all patients with macular
degeneration
ƒ Watch out for High Dose Vitamin A
ƒ Increased Lung Cancer Risk2
ƒ Alteration of Serum Lipids – decreased efficacy with oral
statin therapy 3,4
ƒ Caroteinemia – skin discoloration 5
Clinical Case 9
ƒ Always inquire about the patient’s vitamin therapy and
history
1 - AREDS Report No. 8 Arch Ophthlamol. 2001; 119: 1417-1436.
2 - Ommen GS et al. J Natl Cancer Inst. 1996; 88: 1550-1559.
3 - Brown BG et al. N Engl J Med. 2001; 345: 1583-1593.
4 - Cheung MC et al. Arteriorscler Throm Vasc Biol. 2001; 21.
5 - Federman et al. Resident and Staff Physician 2005, 51: 19-21.
Retinal Detachments
Take Home Pearls
Retinal Detachments
• Incidence 1 in 8000 1
• Risk Factors 2
–
–
–
–
–
ƒ A direct ophthalmoscope cannot detect a retinal tear
or detachment
ƒ Refer promptly for a dilated eye examination for
Prior retinal detachment in other eye
History of complicated cataract surgery
Extreme myopia (near-sightedness)
Prior eye trauma
Family history of retinal detachment
ƒ
ƒ
ƒ
ƒ
1- Subramanian ML et al. Int Ophthalmol Clin 2004; 44(4): 103-14
New onset floaters accompanied with flashes of light
Shadows or curtains
Symptoms reproducible with head or eye movement
Any of above with loss of peripheral vision
American Academy of Ophthalmology Retina Panel. Preferred practice pattern:
posterior vitreous detachment, retinal breaks, and lattice degeneration, 2003.
2- Gariano RF et al. Am Fam Physician. 2004 Apr 1;69(7):1691-8.
8
Temporal (Giant Cell) Arteritis
• Vasculitis of medium sized blood vessels
• Medical Emergency
– Cerebral and cardiac vasculitis
• Ophthalmic Emergency
– Ischemic optic neuropathy
– Retinal artery occlusions
– Ischemia to cranial nerves (palsies)
• Symptoms1
Clinical Case 10
– Age > 50 years
– Headache, fatigue, scalp tenderness, jaw claudication, malaise,
unexplained fever, amaurosis fugax (transient vision loss)
• Diagnosis2-3
– Elevated CRP
– Elevated Sedimentation Rate (ESR)
• Male Normal ESR = age divided by 2
• Female Normal ESR = (10 + age) divided by 2
– Temporal Artery Biopsy
1 - Banik, R. Resident and Staff Physician 2005; 51(8): 13-18.
2 - Unwin B, Williams CM, Gilliland W. Am Fam Physician. 2006 Nov 1;74(9):1547-54.
3 - Salvarani C, Cantini F, Boiardi L, et al. N Engl J Med. 2002; 347: 261-271.
Diabetic Retinopathy
Manifestations
Temporal (Giant Cell) Arteritis
Take Home Pearls
• Always suspect in any elderly patient with new onset
headache plus
– Transient vision loss
– Sudden vision loss
– Sudden double vision (diplopia)
• Obtain STAT Sedimentation Rate
• Proliferative Neovascular Disease
– Neovascular Glaucoma (Iris)
– Vitreous Hemorrhage
– Tractional Retinal Detachments
• Diabetic Macular Edema
• Initiate systemic steroids early1
– prevent vision loss in other normal eye
– prevent systemic vasculitis (cerebral, cardiac)
• Do not wait for the temporal artery biopsy result – initiate
steroids promptly if suspicious2
– Central blindness from pericyte vessel damage
and leakage into the fovea photoreceptors
1- Chan CC, O'Day J. Clin Experiment Ophthalmol. 2003 Jun;31(3):179-82.
2 - Liu GT, Glaser JS, Schatz NJ, et al. Ophthalmology 1993; 101: 1779-1785.
Bhavsar AR. Retina. 2006 Jul-Aug;26(6 Suppl):S71-9
National Age-Specific Prevalence
Rates for Diabetic Retinopathy
Diabetic Retinopathy
Take Home Pearls
0.20
0.18
• Optimize systemic diabetes management1
• Timely dilated eye examinations at recommended
intervals
• Good communication with eye care provider
• Use your ophthalmoscope
0.16
0.14
White
0.12
0.10
Black
0.08
Hispanic
0.06
– Iris Neovascularization
– Optic Nerve Neovascularization
Other
0.04
0.02
75+
65-74
50-64
40-49
18-39
75+
Male
65-74
50-64
40-49
18-39
Female
0.00
Vision Problems in the U.S. National Eye Institute 2002 Report
1 - Murphy RP. Am Fam Physician. 1995 Mar;51(4):785-96.
9
Acute Third Nerve Palsy
• Potential Life Threatening Emergency
• Symptoms
– Ptosis (Droopy Eyelid)
– Diplopia when eyelid lifted (Double Vision)
• Signs
Clinical Case 12
– Eye down and out
– Affected eye only able to abduct (look away
from nose)
Biousse V, Newman NJ. Semin Neurol. 2000;20(1):55-74.
Third Nerve Palsy
Take Home Pearls
Third Nerve Palsy
Examine the Pupils
• Normal Pupil
Posterior communicating
artery
– Vascular Disease
• Diabetes
• Hypertension
• Atherosclerosis
• Dilated Pupil
– Brain Aneurysm
– Brain Tumor
• Early recognition
• Inspect pupils carefully
• Prompt neurology and neurosurgery
consultations
• Ancillary testing
Third Nerve
Aneurysm
compresses
pupillary
fibers
Pupil
Pupil Dilated
dilation
Vascular
disease leads
to infarct of
central third
nerve fibers
– Brain imaging (MRI / MRA)1
– Cerebral angiogram
• Risk of stroke in ischemic patients2
Normal Pupil
1 - Lee AG, Hayman LA, Brazis PW. Surv Ophthalmol. 2002 Mar-Apr;47(2):137-57.
2 - Willinsky RA, Taylor SM, TerBrugge K, et al. Radiology. 2003; 227: 522-528.
Summary of Guidelines
for Prompt Consultation / Referral
ARS – 15 (Survey)
• Any sudden, unexplained vision loss
• Flashes of light, shadows, curtains worse with eye or head
movement
• Sudden ptosis, double vision, abnormal pupil
• New headache, transient or permanent vision loss in older
patients
• Abnormal pupils
How confident do you think
you are now at
accurately diagnosing
eye disease?
1 – LEAST CONFIDENT
2
3
4
5 – MOST CONFIDENT
– Afferent Pupillary Defect
– Asymmetrical Size
– Non reactive pupil
• Abnormal blood vessels
– Iris
– Optic Nerve
• Abnormal optic nerves
• Central vision distortion or central vision loss
– Amsler Grid Distortion
10
?