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BHS 212 – Ocular Physiology Notetaker: Vivien Yip Date: 08/14/2013, 1st hour Page1 Questions regarding how to fill out yellow sheets for optometry lab - Do not write abbreviations, i.e. CMA – Compound Myopic Astigmatism - Line up numbers for assessment and plan i.e. 1. Allergic Conjunctivitis OU 1. Medication Prescribed, 2. Compound myopic astigmatism 2. SRx released - For every assessment, have to have a corresponding plan, don’t be wordy, just keep it complete and concise - On ocular page, write down the conditions regarding the eye, if unresolved leave date resolved blank (repeat what you wrote down for assessments) - Under systemic conditions, write down today’s date, diabetes x 4 years - If no medications, allergies or systemic conditions: write none, do not leave blank - NKMA or NKDA no known medical/drug allergies Small Vessel Disease High Blood Pressure – large vessel changes Diabetes Mellitus (DM) – smaller vessel changes, elevated prostaglandin levels Diabetes Pathophysiology Pericytes – cells that support blood vessels, loss of support when loss of pericytes in DM, causes damage to endothelium Lack of oxygen causes neovascularization to try to bring oxygen in Type 1 Insulin Dependent IDDM Genetic predisposition Usually occurs under age 30 Autoimmune rxn: destruction of beta cells that produce insulin Peak incidence at puberty Tx: insulin, diet, exercise Type 2 Non Insulin Dependent NIDDM Primarily cases at IEI and practice Strong genetic predisposition Usually after age 30 Causes: cell receptor defect preventing glucose uptake, decrease in insulin production from pancrease, excessive glucose production from liver Increase prevalence in blacks, Hispanics, Native Americans Frequently obese Tx: diet, exercise, hypertension, oral meds Diabetic Case History - Ask pt everytime if diabetic: o LBS, last blood sugar o Glycated hemoglobin (HbA1c or A1c) Blood sugar average, aim for <7% o Disease duration, when they were diagnosed o Medications (oral type II vs injection type I) Clicker Q: A 45 yo pt presents with a medical history +ve for diabetes x 8 years. The patient takes 2 pills by mouth per day and just began 1 injection after every meal for the condition, which of the following diabetes classification best fits this pt? 1. Well controlled IDDM 2. Poorly controlled IDDM 3. Well controlled NIDDM 4. Poorly controlled NIDDM Just began injections – this person has been on medications, not working, has had condition for a while, need to step up treatment for the disease BHS 212 – Ocular Physiology Notetaker: Vivien Yip Date: 08/14/2013, 1st hour Page2 Ophthalmic Changes - Chronic conjunctival injection - Corneal curvature changes o Water balance changes, difference in K readings - Premature cataracts o High levels of blood sugar can get more sugar in the aqueous leading to lens changes - Cranial nerve III, IV, VI palsy - Large fluctuations in refraction o An issue when prescribing glasses, may change over short period of time - Retinopathy - Won’t see all of these in every patient Refractive error Spectacles and Contact Lenses - Do not prescribe glasses for diabetic patient on first visit if it is not controlled, will have to remake glasses - Refer patient out to get them on medication for glucose control - Do not prescribe glasses unless their blood glucose is stable Please refer to these pictures below in colour online! Subtypes of Diabetic Retinopathy Non Proliferative – early stages Dot/Blot hemorrhages Lipoproteins, vessel leakage, vision not affected if in periphery Edema – if in macular area will have visual acuity White areas = cotton wool spots Circumscribed exudates present Maculopathy Hypertensive – will not complain of changes in visual acuity If condition affects the macula (edema or leakage) for DM – will affect vision BHS 212 – Ocular Physiology Notetaker: Vivien Yip Date: 08/14/2013, 1st hour Page3 If person is treated at this point (control blood sugar level), Leakage of vessel can be reversible Vitreous is at the top Indentation is the fovea on the left = Normal Macular area is swollen on the right = abnormal, loss of acuity If OCT is unavailable, can look at with a 90D lens and ophthalmoscope, see some changes in macula Proliferative Later stages of disease, more serious Sight threatening stage Changes around disc area, increased vessels Retinal changes around the disc Clicker Q A new 60 y/o AAM presents for a CEE. (+) Newly diagnosed NIDDM (2 weeks) All of the following information needs to be documented in the case history EXCEPT 1. LBS, last blood sugar 2. Glycosylated hemoglobin (A1c) 3. Breakfast that morning 4. Current meds Retinopathy Pathophysiology VEGF is separate from PKC, creates an increase in blood vessel growth New blood vessels do not have proper support and are leaky, adding to the microaneurysm problem, forming cotton wool spots and exudates Clicker Q Which of the following retinal findings is most likely to cause a reduction in a patients best corrected vision? BHS 212 – Ocular Physiology Notetaker: Vivien Yip 1. 2. 3. 4. Date: 08/14/2013, 1st hour Page4 Macular edema Cotton wool spots Micro aneurisms Dot blot hemorrhages Transdermal Pressure TP = Pi – Po Pi = pressure inside vessel Po = pressure outside vessel Summary - Increase in PKC, leads to increase in VEGF - Increase in Pi, leading to increase in transdermal pressure - Vision loss comes later in the disease proliferative o Leading cause of vision loss, when people finally come in for an exam it’s too late to reverse damage Diabetes vs Hypertension - DM does not necessarily have high BP - Hemorrhage type: dot blot in diabetes o Flame in hypertension - Exudate pattern: more circular in diabetics o Radial or star shaped in hypertension - Fluctuation in refraction: o Lens changes in water content Clicker Q: Hypertension in a large vessel disease, which of the following vessel types does diabetes have the GEATEST affect upon? 1. Arterioles 2. Capillaries 3. Venules Contact Lens technology - Can test blood sugar levels via contact lens - Measures changes in tear film glucose levels and changes colour of contacts - Person can tell if blood sugar is elevated by looking at the contact lens - Developing lenses with medication delivery Bring blood pressure cuff and stethoscope to lab next week!