Survey
* Your assessment is very important for improving the workof artificial intelligence, which forms the content of this project
* Your assessment is very important for improving the workof artificial intelligence, which forms the content of this project
Dry eye syndrome wikipedia , lookup
Idiopathic intracranial hypertension wikipedia , lookup
Vision therapy wikipedia , lookup
Visual impairment wikipedia , lookup
Cataract surgery wikipedia , lookup
Mitochondrial optic neuropathies wikipedia , lookup
Visual impairment due to intracranial pressure wikipedia , lookup
Retinitis pigmentosa wikipedia , lookup
Vision and Eye Problems: How to recognize them and what we can do about them Nicholas J. Volpe, MD Tarry Professor and Chairman Department of Ophthalmology Feinberg School of Medicine Northwestern University Volpe Healthy Transitions ‘14 Goals • common visual symptoms in elderly people • followed by a discussion of what we do to make the diagnosis • how we treat common problems including dry eye, glaucoma, cataract, eyelid problems, diabetic retinopathy, macular degeneration and double vision" Volpe Healthy Transitions ‘14 Strategies to Preserve Your Vision • Prevention is our most potent tool in the quest to reduce disease (and healthcare costs) • Choose your parents well and stop aging!!! OR • Don’t Smoke • Wear Glasses that are UV protective – Safety glasses for high risk activities • Pay Attention to Nutrition and Vitamins • Don’t Ignore Symptoms • Get Regular Eye Examinations Volpe Healthy Transitions ‘14 Major Causes of Chronic Visual Loss Preventable and Treatable • • • • Cataracts Glaucoma Macular degeneration Diabetic retinopathy • Other Issues – Dry eye – Double Vision – Eyelid Abnormalities – Presbyopia near vision blurring Volpe Healthy Transitions ‘14 Stop Smoking • Clearly a risk factor for cataracts – 3X the risk • Clearly a risk factor for macular degeneration and its response to treatment Volpe Healthy Transitions ‘14 Nutrition • Healthy tear film • Macular degeneration • Fruits and Green Leafy Vegetables – Carotenoid pigments (lutein) accumulate in macula and prevent light damage • Omega fatty acids • Lutein and Zeaxanthin – Studied in AREDS 2 • Vitamins A,C, E Volpe Healthy Transitions ‘14 Regular Check Ups • • • • Many diseases can be detected Every 2-3 years from age 40-65 Every 1-2 years after age 65 More frequently with diabetes or family history of glaucoma or macula degeneration • Young adults, in the absence of symptoms, do not require routine examinations Volpe Healthy Transitions ‘14 Common Eye Symptoms • Foreign body sensation • Itching and burning • Blurred vision • flashes and floaters • Distortion of shape • Blind spots • Loss of peripheral vision • Double vision • Eyelid position changes Volpe Healthy Transitions ‘14 Foreign Body Sensation,Itching and Burning • • • • Dry eye Blepharitis Allergy Eyelid malposition Volpe Healthy Transitions ‘14 Dry Eye • Tears • Cyclosporine • Punctal plugs Volpe Healthy Transitions ‘14 Ptosis, Entropion, Ectropion Volpe Healthy Transitions ‘14 Flashes and Floaters Volpe Healthy Transitions ‘14 (ahujaeyecenter.com) Cataracts • Expected if ≥ 60 years old 50% - 65 - 75 years old 70% > 75 years old • Most common cause of decreased vision • Symptoms – – – – Loss of acuity Difficulty with colors Glare at night Trouble reading small print Volpe Healthy Transitions ‘14 Age Steroids (PSC) Trauma Inflammation Diabetes Other drugs Subcapsular cataract Anterior Volpe Healthy Transitions ‘14 Posterior Nuclear cataract Progression • Exaggeration of normal nuclear ageing change • Increasing nuclear opacification • Causes increasing myopia • Initially yellow then brown Volpe Healthy Transitions ‘14 Cataract Surgery • • • • • • • • • • Outpatient Very successful > 95% Almost all with intraocular lenses Most common surgical procedure in U.S. >1.4 million/year Most successful surgical intervention Complications uncommon sight threatening IOL technology continues to evolve for astigmatic correction and presbyopia • Newest modality is femtosecond laser Volpe Healthy Transitions ‘14 Cataract Prevention • Smoking cessation – Reduces Vitamin C in the eye – Vitamin C levels are high in the eye and this helps remove prooxidants • Ultraviolet light • Fruits and vegetables – 5 fold decrease at 3-4 servings per day • Regular alcohol consumption increases risk of cataract • Steroids and inflammatory conditions are risks for cataracts Volpe Healthy Transitions ‘14 Age- Related Macular Degeneration • Age-related macular degeneration (AMD) is the most common cause of severe, irreversible vision loss in older Americans and Europeans • Worldwide, AMD disease affects 25-30 million people. • Etiology is complex and poorly understood – Free-radical mediated damage to the photoreceptors and the RPE – Angiogenesis is a feature of neovascular AMD – AMD may be associated with a systemic vascular disorder – Genetic and environmental factors – Variation in the complement factor H gene Volpe Healthy Transitions ‘14 AMD Risk Factors • • • • • • Gender ♀ > ♂ Race/Ethnicity Smoking Family History Atherosclerosis Hypertension Volpe Healthy Transitions ‘14 • Symptoms • early = None, mild distortion • late = acute loss of vision Atrophic AMD Progression Initially drusen and non-specific RPE changes Late RPE (geographic) atrophy Volpe Healthy Transitions ‘14 Atrophic AMD Fluorescein angiogram Management Hyperfluorescence from RPE window defect Low-vision aids if appropriate Volpe Healthy Transitions ‘14 Choroidal Neovascularization (CNV) • • • Less common than atrophic AMD but more serious Metamorphopsia is initial symptom Many lesions are not visible clinically Suspicious clinical signs Gray-yellow subretinal lesion with fluid Volpe Healthy Transitions ‘14 Subretinal blood or lipid Current Status of Therapies for CNV • Antiangiogenic therapy • Lucentis, Avastin, Eylea – CATT trial (Avastin vs Lucentis) • Photodynamic therapy with verteporfin • Steroids • Thermal Laser Volpe Healthy Transitions ‘14 Treatment w/Anti VEGF Volpe Healthy Transitions ‘14 Volpe Healthy Transitions ‘14 Treatment for Dry AMD -Age-related Eye Disease Study (AREDS) –role of antioxidants • • • • • vitamin E, 400 IU vitamin C, 500 mg beta carotene, 15 mg (approximately 25,000 IU Vitamin A) zinc 80 mg as zinc oxide copper, 2 mg, as cupric oxide – Copper should be taken with zinc, because high-dose zinc is associated with copper deficiency. Volpe Healthy Transitions ‘14 Established Age Related Macular Degeneration • Use Amsler Grid to monitor central vision • • • • • • AREDS-Occuvite Preservision B carotene vs. Lutein and Zeaxanthin (AREDS 2) Vitamin C Vitamin E Zinc Oxide (?necessary and ? Stomach upset) Copper • NB: No beta carotene for smokers and others at risk for lung cancer • Others??? Lutein Eyes, PhoVision, Perspective, Ocuforce Volpe Healthy Transitions ‘14 AREDS Results Recommendations • Evaluation: • Persons over 55 years old receive a dilated eye exam to assess risk of advanced AMD. • Contraindications to Treatment: • Smokers and ex-smokers should not use beta carotene, because previous studies have suggested an association with lung cancer and beta carotene in smokers. • There were no benefits from treatment shown in the AREDS for patients with no AMD (Category 1) and early AMD (Category 2). Volpe Healthy Transitions ‘14 AREDS 2 • Adding omega 3’s did not help • Taking away B Carotene did not hurt and lutein and zexanthine may have been a bit more protective • Reducing zinc dose did not hurt and less side effects • No prevention of cataracts Volpe Healthy Transitions ‘14 Diabetic Retinopathy •most common cause of • new blindness among adults 20-64 yo • Blindness in working adults •affects over 5.3 million Americans age >18 (2.5% of this population) •Prevention- worse in HTN, obesity, renal failure, hyperlipidema, smoking, anemia, pregnancy and POOR glycemic control Volpe Healthy Transitions ‘14 Clinical Findings in NPDR • Microaneurysms • Earliest clinical sign of diabetic retinopathy • Appear as small red dots in the superficial retinal layers • Rupture produces blot/flame hemorrhages Volpe Healthy Transitions ‘14 Macular Edema (CSME) • Leading cause of visual impairment in patients with diabetes Volpe Healthy Transitions ‘14 Volpe Healthy Transitions ‘14 Macular Edema Treatments • ETDRS – focal laser surgery for CSME reduces the incidence of moderate visual loss (doubling of visual angle or roughly a 2-line visual loss) from 30% to 15% over a 3-year period • Steroids -peri-ocular -intraocular Anti-VEGF agents Volpe Healthy Transitions ‘14 Ischemic diabetic maculopathy • • Macula appears relatively normal Poor visual acuity Volpe Healthy Transitions ‘14 • • Capillary non-perfusion on FA Treatment not appropriate PDR • Proliferation of new blood vessels due to ischemia • NVD Disc • NVE Elsewhere • NVI Iris • NVA Angle Volpe Healthy Transitions ‘14 PDR - cont. • • • • • Treatment Options Pan-retinal photocoagulation Peripheral Retinal Cryotherapy Vitrectomy Anti-VEGF Volpe Healthy Transitions ‘14 Retinopathy Screening • Type 1 diabetes - screen within 3-5 years of diagnosis after age 101 • Type 2 diabetes - screen at time of diagnosis1 • Pregnancy - women with preexisting diabetes should be screened prior to conception and during first trimester1 • Follow-up depends on severity of disease Volpe Healthy Transitions ‘14 Diabetic Eye Care • Like glaucoma, you will NOT HAVE SYMPTOMS UNTIL IT IS TOO LATE! • 95-100% treatable with early detection • Regular eye exams at 6 or 12 month interval depending on what MD sees • Bleeding, swelling and growth of blood vessels • Diabetes control (Hemoglobin A1c) is the most important way to reduce your risk • High blood pressure is a risk • Diet and exercise Volpe Healthy Transitions ‘14 Glaucoma • Optic nerve • 1.2 million nerve fibers • Ganglion cells in retina exit to brain as optic nerve Volpe Healthy Transitions ‘14 Definition of Glaucoma • A group of optic neuropathies in which retinal ganglion cells die by apoptosis with resultant optic disc cupping and characteristic visual field deficits – Optic neuropathy – Retinal ganglion cell apoptosis – Optic disc cupping or excavation – Loss of visual function -IOP is too high for the nerve??? • Most common cause blindness: • African-Americans COMPLETE/TOTAL BLINDNESS Volpe Healthy Transitions ‘14 Volpe Healthy Transitions ‘14 Volpe Healthy Transitions ‘14 Glaucoma • Loss of visual field • Site of visual field loss corresponds to area of damage on optic disc, e.g., “cupping” Volpe Healthy Transitions ‘14 Angle Closure Glaucoma • Acute pain, redness, tearing • Associated with dilation of pupil • Natural (e.g., movie theater) • Pharmacologic • Nausea & vomiting often in ER with “acute abdomen” Risk factor of narrow angle can be detected on screening exam (esp hyperope) and prophylactic iridotomy is preventative of attack in 100% Volpe Healthy Transitions ‘14 Acute angle-closure glaucoma Signs • Severe corneal edema • Ciliary injection • Dilated, unreactive, vertically oval pupil • Shallow anterior chamber • Complete angle closure Medical rx to lower IOP, followed by laser (Yag) iridotomy Volpe Healthy Transitions ‘14 Primary Open-Angle Glaucoma • The most prevalent type of glaucoma in the United States • Elevated intraocular pressure is not part of the diagnostic criteria – 25% of patients with primary open-angle glaucoma in the US have normal intraocular pressure • Asymptomatic – Some loss of visual field – Most common type – Familial, bilateral – “Sneak thief of sight” Volpe Healthy Transitions ‘14 Primary Open-Angle Glaucoma • • • • Evidence that IOP reduction is beneficial Collaborative Normal-Tension Glaucoma Study (CNTGS) Advanced Glaucoma Intervention Study (AGIS) Early Manifest Glaucoma Study (EMGT) – 25% IOP reduction RoP 62% to 45% at a median of 6 years. • Ocular Hypertension Treatment Study (OHTS) Volpe Healthy Transitions ‘14 Treatment for POAG • Lower the IOP • Medical therapy • Prostaglandin , Bblockers,Sypathomimetic s, Carbonic-anyhrase inhibitors • Laser surgery (ALT, SLT) • Incisional surgery (Trab, shunt) Volpe Healthy Transitions ‘14 Tube Shunts Volpe Healthy Transitions ‘14 Double Vision • Monocular vs binocular • Eye misalignment • Stroke, tumor, cranial nerve palsy • However most are benign • Thyroid Eye Disease • Patch, prism, surgery Volpe Healthy Transitions ‘14 Utsavaeyelinic.com Summary • FBS, itching burning • Floaters and flashes • Diabetic Retinopathy •Prevention, treatment • Cataract –Surgical treatment continues to improve • Double Vision – Most benign-eye misalignment – Must be evaluated • Glaucoma –Silent blindness, family history –Medical and surgical rx • ARMD Volpe Healthy Transitions ‘14 Strategies to Preserve Your Vision • Prevention is our most potent tool in the quest to reduce disease (and healthcare costs) • Choose your parents well and stop aging!!! OR • Don’t Smoke • Wear Glasses that are UV protective – Safety glasses for high risk activities • Pay Attention to Nutrition and Vitamins • Don’t Ignore Symptoms • Get Regular Eye Examinations Volpe Healthy Transitions ‘14