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From Carrots to Keratitis:
An Eye Update for Non-Ophthalmologists
Objects in mirror are closer
than they appear.
Rachel Bishop, MD, MPH
CDR, USPHS
Chief, Consult Service, National Eye Institute, NIH
Objectives
• Update: what’s new for the “Big 4”?
– Glaucoma
– Diabetic eye disease
– Macular degeneration
– Cataract
• A few words on preventive ophthalmology
• Managing acute eye problems
Normal Anatomy
Glaucoma
Glaucoma Management: What’s new? Not much.
• Prevention: none
• Treatments
– Medical: pressure lowering drops
– Laser to the trabecular meshwork
– Surgery: shunt
• Good news: most patients maintain vision
Diabetic Retinopathy
non-proliferative
proliferative
Diabetic Retinopathy Management
• Prevention: control chronic
medical conditions
• Treatment
– Macular edema:
focal laser
– Proliferative
retinopathy:
scatter laser
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Diabetic Retinopathy
• NEW: VEGF inhibitors
– Bevacizumab (Avastin)
– Ranibizumab (Lucentis)
– Aflibercept (Eylea)
• Intravitreal injection
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Age-Related Macular Degeneration
Dry
Neovascular (“Wet”)
Macular Degeneration: Management
Dry AMD: Prevention
– NEW: anti-oxidants
Neovascular AMD
– NEW: VEGF inhibitors
pre: 20/100
post: 20/50
Cataract
• Prevention: UV protection (but not really…)
• Treatment: surgery
• NEW: multifocal and accommodating
intraocular lenses
Refractive Error
• Half of Americans
– myopia, hyperopia, astigmatism
– excludes presbyopia
• 11 million Americans have impaired vision
(<20/40) due to uncorrected refractive error
• Accounts for 80% of vision impairment
Preventive Ophthalmology
Preventive Lifestyle Tips: Not Much New
• Dilated eye exams
• “Healthy Living”
• Protective eyewear:
safety, UV-blocking
Managing Acute Ocular Problems
• The red eye
• Ocular trauma
• Flashes and
floaters
• Acute loss of
vision
The Tool Box
DDx: The Red Eye
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Cellulitis
Conjunctivitis
Episcleritis and scleritis
Subconjunctival hemorrhage
Corneal abrasion
Corneal or conjunctival foreign body
Corneal ulcer
Keratitis
Angle closure glaucoma
Uveitis
Cellulitis
• Pre-septal vs. orbital
• Pain with eye
movements?
• Uncertain? CT orbits
Conjunctivitis
• Majority: viral
• Purulent discharge
– Bacterial
– Topical ABX (NOT gent)
• Other
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allergic
irritant
dry eye
blepharitis
Episcleritis/Scleritis
• Often sectoral
• Episcleritis
– Minimal pain
– Blanches with neo
– Treatment: NSAIDS
• Painful? …Scleritis
– Refer
Sub-Conjunctival Hemorrhage
Treatment: observation only
Corneal Abrasion
• Treatment: ABX ointment and close f/u
• If large, refer to ophthalmology
• Do not patch
Corneal or Conjunctival Foreign Body
• Remove with Q-tip or
small clean instrument
• Topical ABX and f/u until
healed
• Refer if rust or deep
penetration
Corneal Ulcer
• Contact lens user?
– Think: pseudomonas
• Refer
• Initiate ABX
treatment if referral
will be delayed
• Close follow-up
Angle Closure Glaucoma
• Start pressure lowering drops and Diamox
• Urgent referral
• Treatment
– peripheral laser iridotomy
Uveitis
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History of same?
Auto-immune DZ?
Ciliary flush?
Refer
Ocular Trauma
Blunt Ocular Trauma
• Assess vision
(if possible)
• Refer if…
– Floaters and/or flashes
– Change in vision
– Eye too swollen to
examine
– Blood in eye
– Suspected blow-out FX
Suspected Penetrating Trauma: “Ruptured Globe”
• Protect the eye
• NPO
• Urgent referral
Chemical Injury
• Defer vision check and
detailed history
• Copious irritation
• Antibiotic ointment
• Urgent referral
Floaters and Flashes
• Chronic floaters
– Benign vitreous changes
• New floaters
– Refer
• Photopsias
– Urgent referral
Acute Loss of Vision
• Refer urgently to ophthalmology
• Differential diagnosis is extensive
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Acute angle closure glaucoma
Retinal vascular disease
Vitreous or retinal hemorrhage
Retinal detachment
Optic neuropathy
Optic neuritis
CNS disease
Concluding Pearls
• Most vision impairment is correctable or
avoidable
• Dilated eye exams necessary for detection of
eye disease
• Urgent referral if significant change in vision or
trauma
• If in doubt: email a picture to your favorite
ophthalmologist!
QUESTIONS?
Objectives
• Update: what’s new for the “Big 4”?
– Glaucoma: 2.2million
– Diabetic eye disease: 5.3 million
– Macular degeneration: 1.8 million
– Cataract: 20 million
• A few words on preventive ophthalmology
• Managing acute eye problems
Herpetic Keratitis
• Herpes simplex keratitis
– Risk of corneal scarring
– Ophtho referral for
aggressive Rx
• Herpes zoster (VZV)
– Acyclovir
– Artificial tears
– Erythromycin ointment
The Assessment
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Chief complaint
Ocular and medical history
VISION
Pupil exam
Visual fields: less important
Ocular motility
How does the eye look?