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Women of Vision: Are We at Risk for Vision Morbidity?
Louise Sclafani, Diana Shechtman,, Melissa Barnett, Lori Glover, (Sue Cotter, Jill Autry at AOA)
As ODs we need to place a higher priority on those individuals at increased risk for vision-threatening
ocular disease. It has been estimated that the female gender represents 2/3 of all visually compromised
individuals due to inherent risk factors and lack of access to healthcare. Our panel will take on this
challenge and discuss this population as it relates to the following conditions: optic neuritis/OCT
evaluation, AMD/nutritional controversy, psychosocial issues/management options for strabismus or
chronic vision impairment', ocular concerns for common systemic pharmaceuticals, safety issues with
ophthalmic drugs, and the hormonal influence on ocular surface disease.
I.
Women and Vision Loss –
a. Definitions
b. Demographics
c. Projections
d. Impact of vision loss on women and stakeholders
II. Determinants of Eye and Vision Care
a. Factors influencing women’s health care
b. Access to general medical and eye care
III. Improving Population Health
a. Reducing health disparities
b. Strategies for improving quality of care
OCULAR DISEASE AND WOMEN
• OPTIC NEURITIS
• Decreased vision/visual field over hours or days
• Unilateral
• Pain on eye movements
• Decreased color vision (red cap test)
• + RAPD
• Visual field defects vary
• Swollen disc or no swelling of disc (retrobulbar)
• MRI of Brain and Orbits with Flair sequencing
• Bloodwork
• MULTIPLE SCLEROSIS
• Female > Male
• 18-45 years old
• Optic neuritis
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Intermittent diplopia (usually 4 nerve)
Nystagmus
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Tingling or numbness in extremities
Uhtoff’s sign
• Worsening vision with increased body temperature
Lhermitte’s sign
• Shock-like sensation with neck flexion
OPTIC NEURITIS
TREATMENT TRIAL (ONTT)
Recommends treatment with IV methylprednisolone x 3 days
Avoid prednisone orally until AFTER treatment with IV (10-14 days)
Hastens visual recovery but not final visual outcome
Prolongs time to development of MS
Do not use oral steroids alone
DIAGNOSING
MULTIPLE SCLEROSIS
MRI of brain with Flair testing
Inspection of CSF for oligoclonal bands
Inspection of CSF for increased IgG index
VER testing shows increased latency
Neurologist
Systemic Medications and their Ocular Side Effects
• Topamax™
• Topiramate
• Tablets
• Sprinkle Capsules
• FDA Category D
• Safety not established < 2 YO
• Indications:
• Epilepsy
• Monotherapy, adjunctive therapy
• Migraines
• Prophylaxis
• Off-label
• Bipolar disorder, weight reduction, depression, neuropathic pain
• Topamax ™
• Precise Mechanism of Action: not known
• Thought to block voltage-dependent sodium channels, augments the activity of the
neurotransmitter gamma-aminobutyrate at some subtypes of the GABA-A receptor,
antagonizes the AMPA/kainate subtype of the glutamate receptor, and inhibits the
carbonic anhydrase enzyme, particularly isozymes II and IV
• ???
• Topamax™
• Ocular side effects
• Acute myopia and 2° angle closure
• May be associated with supraciliary effusion resulting in anterior displacement
of the lens and iris
• ± mydriasis
• Usually within first month
• Pediatric population too!
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• First line treatment is d/c Topamax
• Conjunctivitis
• Diplopia
• Nystagmus
• Topamax™
Ocular Changes Associated with Topiramate
• Ozturk et al
• Current Eye Research, 36(1), 47–52, 2011
• N = 76 eyes
• 3 month f/u
• Significant myopic shift and an increase in RNFLT were observed
• Further studies are warranted
Tamoxifen™
Nolvadex
Estrogen antagonist
Interferes with binding of estradiol to its target tissues
Indications
• Breast
• Ovarian
• Pancreatic
• Malignant melanoma
Tamoxifen™: Ocular Effects
Prospective Studies
• 1992 study
• 20 mg qd
• 25 months
• 6.3% incidence
• #1 – retinopathy
• 1999
• 65 patients taking 20 mg qd
• 12% incidence
• As early as 6 months
Tamoxifen™ : Ocular Effects
keratopathy
• white-yellow subepithelial opacities
retinopathy
• +/- macular edema
cataracts
• asc
optic neuropathy
• Rare
Macular holes?
• International Ophthalmology 2005; 26(3)
• Tamoxifen™ Retinopathy
Bilateral yellow-white crystals in ring-like pattern
• 13-35 microns
• Location is debatable: NFL, RPE, IPL, OPL
• Superficial to vasculature
 macular edema
Crystals usually do not resolve with discontinuation of therapy
Plaquenil ™
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Hydroxychloroquine
Indications
• Malaria
• Lupus erythematosus
• Rheumatoid arthritis
Precise mechanism of action: not known
• Acute effects on metabolism of retinal cells
Ocular Side Effects
• Bilateral ring of RPE depigmentation sparing the fovea
Plaquenil ™
Increased risk of retinopathy:
• > 5 years use
• Cumulative dose > 1000 g
• Daily dose > 400 mg/day
• Elderly
• Kidney or liver disease
• Concurrent retinal/macular disease
Plaquenil™
Revised recommendations on screening for chloroquine and hydroxychloroquine retinopathy
• Ophthalmology. 2011 Feb;118(2):415-22
Screening:
• mfERG or SD-OCT or FAF
• 10-2 VF (white-on-white)
• Repeat promptly if changes
• Fundus examination
• Fundus photography
• Not for screening; may be useful for documentation
• No longer: Amsler grid, color vision, FA, etc.
Plaquenil™
Baseline examination
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• Within 1 year of therapy
• Counsel patient about risk
Annual screening
• MINIMAL guidelines
• Begin immediately if high risk
• Begin after 5 years of use
• All patients
If toxicity
• Consider discontinuing medication
• Slow clearing
• Visual function may continue to deteriorate
• PSEUDOTUMOR CEREBRI
PHARMACOTHERAPY AND THE PREGNANT AND NURSING PATIENTS
• FDA Pregnancy Categories for Drugs
• Stay Informed…
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Ophthalmic Drug Facts
Epocrates
• Pregnancy Categories
Drugs@FDA
• Drug Package Inserts
Websites
• LactMed
• Drugs and Lactation Database
In the Works…
Proposed Rule for Pregnancy and Lactation Labeling
• FDA
• began in 1997
Will eliminate Pregnancy Letter Categories
Standardized statements
Narrative descriptions
• Risk summary
• Clinical considerations section
• Data
• Human
• Animal
Soft Tissue Infections
Penicillins
• Augmentin
• Dicloxacillin
Cephalosporins
• Cephalexin
• Cefaclor
Azithromycin
Erythromycin
Category B Topical Antibiotics
Erythromycin ointment
Azasite
Tobramycin
Dual Acting
Anti-Allergy Medications
Other Anti-Allergy Medications
What Would You Do?
New patient
• 33 YOF
• IOP
• 35 mmHg OD and OS
• ON thinning
• Corresponding VF defect
• FHx of POAG
The Facts…
Up to 30% have ↑IOP during pregnancy
Group of UK Ophthalmologists (282)
• 25% have pregnant glaucoma patients
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Glaucoma and Pregnancy
Consider:
• No treatment?
• IOP often decreases during pregnancy
• SLT
Brimonidine
• Alpha-agonist
• Category B
• Discontinue if breast feeding
• CNS effects in infants due to penetration of BBB
Other Glaucoma Medications…
Avoid Prostaglandins at all stages of pregnancy
• PG important during labor
• Potentially
• Induce miscarriage
• Premature labor
Other Category C Medications
Beta-blockers
• Low MW
• Length of fetal exposure to drug may be much longer than adult
• Recirculation
• Lower blood volume
• T1/2 life may be 4-6X longer
• Use TXE if needed
Carbonic anhydrase inhibitors
Pilocarpine
MIGRAINES
Women>Men; 3:1
Generally starts before 20 years of age
Often have family history
May have nausea and vomiting, fatigue, photophobia
Headaches predominantly on same side;may occasionally switch sides
Headache triggers
-Stress
-Chocolate
-Bright lights
-Alcohol
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-BC pills
-Pregnancy
MIGRAINE RELATED AURA
Flashing lights, heat waves, jagged objects, tunnel vision, colored spots
Lasting 15 to 30 minutes
May or may not be accompanied by HA
Acephalic migraine
ACEPHALGIC MIGRAINE
Visual symptoms only without onset of HA
More typical as patient ages
Common in patient with history of classic migraines when younger
Flashes of light, scotoma, etc. still last 10-15 minutes with abrupt cessation
No headache
MACULAR HOLE
Progress from Stage 1 to Stage 4
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Women 3.3 X greater than Men
Older>Younger
Idiopathic mostly, occasionally traumatic
Best diagnosed with OCT
Full-thickness holes generally 20/200 VA
Round, dark red colored area in the center of the macula
Often with yellow, lipofuscin granules
MACULAR HOLE
Distinguish from ERM pseudohole
• Macular hole perfectly round
• Poor vision with macular hole
• Positive Watzke-Allen with macular hole
• Pseudohole with tortuous surrounding vessels
Can follow Stage 1 and 2 holes but get macular OCT for follow-up
Amsler grid
MACULAR HOLE
Why are women more likely to develop holes?
Macular hole pathogenesis is thought to be secondary to tangential and anteroposterior
vitreomacular traction
“Relaxin” theory
• Relaxin, a hormone produced during pregnancy, induces matrix metalloproteinases
associated with the loss of collagen and glycosaminoglcans in cartilage
This process could occur in the vitreous
• Premature vitreous syneresis and anomalous PVD
MACULAR HOLE SURGERY
Vitrectomy with membrane peel (ILM)
Gas fluid exchange
Face-down positioning for 2 weeks until gas bubble absorbs
Watch IOP closely with gas bubble
No flying until gas bubble completely resorbs
Can use silicone oil but need second surgery
Thyroid Eye Disease
Graves Disease
Excess secretion of thyroid hormone
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Usually in 4 -5 decade
F>M
Most common cause of proptosis in adults
Thyroid ophthalmopathy
• 10-25% of cases no evidence of thyroid dysfunction
Risk Factors
Smoking
Gender
Radioiodine
Genetics
Clinical Manifestations of Thyroid Ophthalmopathy
Eyelid retraction
Soft tissue involvement
Proptosis
Restrictive thyroid myopathy
Dysthyroid optic neuropathy
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Thyroid associated dermopathy
Optic Neuropathy
Current Treatment
Smoking cessation
Artificial tears, etc.
Steroids
• Usually need high dose
Orbital radiotherapy
Orbital decompression
Other surgeries
Rule out Thyroid Disease If…
Superior limbic keratoconjunctivitis
Chronic dacryoadenitis
Lagophthalmos
Globe subluxation
Acanthosis nigricans
Central Serous Chorioretinopathy (CSC)
I. Introduction
Case presentation
Serous detachment of neurosensory retina in macular area
A. Blister-like with shallow & round edges
B. Loss of foveal light reflex
II. Clinical picture
A. Acute presentation
B. Unilateral
C. Males>>Female (2:10)
D. Young 20-50 years old
E. Type A personality
III. Related conditions
Systemic
VKH
Lupus
Organ transplants
Sleep apnea
H. Pylori
Pregnancy
Drugs
Viagra
Steroids
Pseudoephedrine
Sorafenib
III. Symptoms
A. Acute symptoms
B. Blurred vision
C. Relative scotoma or metamorphopsia
D. Color desaturation
IV. Pathophysiology: Leakage from choriocapillaries through the RPE
V. The woman & ICSC
Why would a woman be affected?
Related conditions
pregnancy : resolve 1-2M s/p delivery
lupus
Clinical characteristics
Most resolve spontaneously
Good recovery of final VA
Subretinal precipitates may be seen in as many as 50% of cases
Older patients
VI. Natural history
A. Spontaneous resolution in most cases (~3-6 months)
B. AS many as 50% may be recurrent (common within 1st yrs after initial presentation)
VII. Management/Treatment Options
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Role of OCT imaging
FA/ICG
Autoflourescence
Most cases are managed with careful routine observation
If treatment is necessary photocoagulation or photodynamic therapy are viable options. PDT
is more commonly implemented in chronic/recurrent cases
F. Consider differential diagnosis of associated CNV in non characteristic cases
VIII.
AMD Management
A. Lutein
B. O3
Hormone Influence on Ocular Surface Disease
1. Intrinsic factors
a. Female gender
b. Older age
c. Changing hormone levels / decreased androgens
d. Hormone replacement therapy
2. Extrinsic factors
a. Contact lens wear
b. Postmenopausal estrogen therapy
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c. Medications
d. Vitamin A deficiency
Autoimmune disorders
a. Rheumatoid Arthritis
b. Sjogren’s Syndrome
c. Systemic Lupus Erythematous
d. Irritable bowel syndrome
e. Crohn’s disease
Thyroid disease
a. Grave’s disease
b. Hyperthyroidism
c. Hypothyroidism
Diabetes
Treatments
a. Gene therapy to treat dry eye related hormonal diseases
b. New molecules to target the core mechanisms of dry eye disease.
c. Anti-inflammatory / immune-modulatory drugs
d. Secretagogues
e. Lubricants
f. Hormones
g. Autologous serum
Adult Strabismus – Scope of the Problem
II. Types of Patients
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Adult onset
Childhood onset
III. Spectrum of Patient Concerns
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Diplopia
Visual confusion
Poor stereopsis
Anomalous head posture
Psychosocial concerns – Quality of Life
IV. Clinical Evaluation
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Eye Alignment
Motor Fusion
Sensory Fusion
Management
 Goals
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Treatment options
Lenses
Prism
Vision therapy
Surgery