Download "Hey Doc, I Can`t See!" - Ophthalmology 101 for Primary Care

Hey Doc, I Can’t See!
Ophthalmology 101 for Primary
Care Physicians
Jennifer Somers Weizer, MD
June 13, 2016
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No financial interests
Agenda
How the eye works
 Common eye problems
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Red eye
Cataract
Age-related macular degeneration
Glaucoma
Retinal blood vessel blockages
Migraines
When to refer
How the Eye Works
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The cornea is
transparent and bends
light to focus on the
retina
The sclera is the white
part of the eye that
provides structure for
the eyeball
How the Eye Works
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The iris is the colored
part of the eye. Its
color is determined by
its amount of
melanocytes.
The pupil dilates and
constricts to let more
or less light into the
eye.
How the Eye Works
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The lens focuses light.
When it gets cloudy, it
is called a cataract.
The retina lines the
back (vitreous) cavity
of the eye and collects
and processes light to
form images.
How the Eye Works
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The macula is the
center part of the
retina responsible for
central vision.
The optic nerve carries
signals from the retina
to the brain so you can
see. It contains about
1 million nerve fibers
at birth.
How the Eye Works
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There are 6 muscles
that attach to each
globe. They work
together to move both
eyes in tandem.
The orbit is the eye’s
socket. Besides the
eye, it contains
muscles, nerves, fat,
blood vessels, and the
lacrimal system.
The Visual Pathway
Refractive error
Nearsightedness – eye is
too long
Farsightedness – eye is too
short
Factoid: Optical Illusion
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Many people wonder if eye exercises can
reduce their need for glasses or contact
lenses.
– In the vast majority of cases, the answer is no.
– It is better to wear glasses or contact lenses if
they help you achieve your optimum vision.
Red Eye
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Conjunctivitis
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Viral
Bacterial
Allergic
Toxic
Subconjunctival hemorrhage
 Episcleritis/scleritis
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Viral Conjunctivitis
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Often due to adenovirus
Redness
Watery discharge
Itchiness/irritation
No antibiotic drops
needed!
Can use artificial tears or
cool compresses
Contagious
– Contact precautions
Bacterial Conjunctivitis
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Appears similar to
viral except may be
more severe
Pus-like discharge
Needs antibiotic drops
May be contagious
Allergic or Toxic Conjunctivtiis
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Appears like viral but
may have more
prominent
follicles/papillae,
itching
May be bilateral
Allergic – can try
OTC antihistamine
drops (Zaditor)
Toxic – remove
offending agent
Subconjunctival Hemorrhage
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Idiopathic
Blood thinning meds
Rarely, HTN or
bleeding disorder
Resolves
spontaneously
Can use artificial tears
PRN
Episcleritis
• See eye doctor to r/o other
problems
• Usually idiopathic and selflimited
Scleritis
• See eye doctor
• 50% associated with
connective tissue dz
• Treated with oral
immunosuppression,
steroids
Factoid: True or False?
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You can harm your eyes by reading or
watching TV too much.
– False – spending time reading or watching TV
will not help or hurt your eyes.
Cataract
Most lenses are clear when you are born
 Lenses gradually get cloudier and thicker as
one gets older (middle-age to elderly)
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Cataract
Courtesy Campus Eye Group
Factoid: True or False?
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Cataracts cause a small percentage of the
world’s blindness.
– False – cataracts cause 48% of the world’s
blindness, according to the World Health
Organization.
Cataract
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Treatment: cataract
surgery
(phacoemulsification)
Uses ultrasound to
break up cataract lens,
remove pieces through
2.75mm incision,
replace lens with
plastic intraocular lens
implant
Cataract surgery
Most people see better afterwards
 Risks of major problems 1% or less
 Outpatient surgery
 Monitored anesthesia care, not general
anesthesia
 Takes about 1 month to heal fully
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Factoid: What is an Eye Doctor?
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Ophthalmologist (MD) – physician (college,
medical school, residency)
– Treats patients medically and surgically
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Optometrist (OD) – college, optometry
school
– Does not perform surgery
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Optician – fits patients for glasses
Age-Related Macular
Degeneration
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Definition
– A spectrum of disease in which aging material
deposits under the central retina, or macula
– Can cause problems with central vision
– Affects 30% of people aged 75-85 in the US
Age-Related Macular
Degeneration
Normal Vision
Severe AMD
Courtesy National Eye Institute
Age-Related Macular Degeneration:
Two main types
Normal retina
Wet
Dry
Courtesy American Academy of Ophthalmology
Wet AMD
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Leaky abnormal
blood vessels grow
under the retina and
can bleed
True or False?
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Age-related macular degeneration can cause
total blindness.
– False – While this disease can be scary, it only
affects the center retina and not the total retina.
– Most people with macular degeneration
maintain vision that allows them to get around
on their own.
Age-related Macular
Degeneration
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Risk factors
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Caucasian race
Family history
High blood pressure and/or heart disease
Smoking
Ultraviolet light exposure
Fatty diet
Age-related Macular Degeneration:
Treatment
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Dry type
AREDS antioxidants
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500 mg vitamin C
400 iu vitamin E
80 mg zinc
2 mg copper
5 mg Lutein
1 mg Zeaxanthin
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Wet type
Intravitreal injections of
anti-VEGF (vascular
endothelial growth factor)
medicines
Laser
Needs PCP approval
– Interaction with blood
thinners
Courtesy American Academy of Ophthalmology
Glaucoma
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Definition
– A disease of the optic nerve that is often linked
to high eye pressure that causes primarily side
vision loss
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Can cause blindness if left untreated
Glaucoma
Affects about 2% of adults >40 years old in
US
 Higher rates in African Americans and
Hispanics
 Risk of developing glaucoma increases with
age and having a family history
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True or False?
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Having a close relative with glaucoma
increases your risk of the disease by 4-9
times
– True
Glaucoma
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Spectrum of disease
Normal optic
nerve
Mild cupping
Severe cupping
Glaucoma
Normal side vision or early glaucoma
Moderate
glaucoma
Advanced
glaucoma
End-stage
glaucoma
Courtesy vision-and-eye health.com
Glaucoma
Most glaucoma is diagnosed by routine eye
exams
 Treatment
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– Lowering eye pressure using:
» Eye drops
» Laser
» Surgery
Courtesy glaucomaconsultantsmd.com
Retinal artery and vein blockages
Central or branch retinal artery occlusion
 Central or branch retinal vein occlusion
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– Retinal blood vessels become blocked from
atherosclerosis and/or thrombosis
» Like a “stroke” to the retina
Retinal artery occlusions
Fatty debris lodges in a retinal artery
 Central retinal artery occlusion: the main
arterial branch to the retina is blocked
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– Poor visual outcome
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Branch retina artery occlusion: a smaller
branch of the main artery that feeds part of
the retina is blocked
– Outcome depends which part of the retina is
affected
Retinal artery occlusion
Normal retina
Central retinal artery
occlusion
Cilioretinal artery sparing
Retinal artery occlusion
Normal retina
Branch retinal artery
occlusion
Retinal vein occlusions
A clot lodges in a retinal vein
 Central retinal vein occlusion: the main
venous branch from the retina is blocked
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– Visual outcome is variable
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Branch retina vein occlusion: a smaller
branch of the main vein that drains part of
the retina is blocked
– Outcome depends which part of the retina is
affected, and to what degree
Retinal vein occlusion
Normal retina
Central retinal vein occlusion
Retinal vein occlusion
Normal retina
Branch retinal vein occlusion
Risk factors for retinal blood
vessel blockages
Age >50
 Risk factors for and history of heart disease,
stroke
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– Diabetes, high blood pressure, hyperlipidemia
Symptoms of retinal blood vessel
blockages
Sudden, painless vision loss in one eye
 If that happens, see an ophthalmologist right
away
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Diagnosing retinal blood vessel
blockages
Your ophthalmologist will examine your
eyes and will probably dilate them
 Some photographic testing may be
performed
 You may be referred to your PCP to look
for and manage vascular risk factors
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Treating retinal artery blockages
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Acutely: some ophthalmologists will try to
lower your eye pressure to ease the
blockage with medications or a needle in
the eye
– This can help rarely
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Long-term: you may be followed monthly
for several months to look for complications
of blockage
– Your ophthalmologist will look for abnormal
blood vessels growing in the eye
Treating retinal blood vessel
blockages
Abnormal blood vessels can grow as a
result of retinal artery or vein blockages
(neovascularization)
 These abnormal vessels can leak, bleed, or
cause glaucoma by growing and clogging
the eyeball’s natural drainage angle
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Abnormal retinal blood vessels
Normal retina
Neovascularization of the
optic disc
Treating retinal blood vessel
blockages
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To make neovascularization regress:
– Laser
– Injecting steroid medication into the eye
– Injecting anti-Vascular Endothelial Growth
Factor drugs (often used to treat wet macular
degeneration) into the eye
Normal retina
Laser = panretinal
photocoagulation
Factoid: True or False?
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Each of us has a dominant eye and a nondominant eye, like being right- or lefthanded.
– True
Ocular migraine
Migraine = spasm of arteries in the brain
 Ocular migraines affect the part of the brain
that senses vision (visual cortex)
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Migraine
34% women aged 15-20 have had at least 1
migraine
 Classic headache symptoms
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Throbbing pain
One-sided
Light and sound sensitivity
Nausea +/- vomiting
Lasts minutes to hours
Aura in some cases
» Visual, smell, sound
Ocular migraine
Visual aura from migraine = ocular
migraine
 Ocular migraines are sometimes associated
with headache, but not always
 Neurologic deficits tend to resolve after
each episode
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– Rarely, neurologic defects from migraine can
be permanent
Ocular migraine
Migraine treatment
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Over-the-counter and prescription
medications are available to treat migraine
– Abort current attack
– Prevent future attacks
See neurologist or PCP
 Get enough sleep
 Avoid stress and tension
 Avoid triggers
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– Keep diary to identify triggers
Common migraine triggers
Foods
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Alcohol
Caffeine and caffeine
withdrawal
Citrus, nuts, onions, peanut
butter
Chocolate
Dairy products
MSG, pickled foods
Meats with nitrates
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Other
Changes in weather
Some medications
Cigarette smoke
Flashing lights
Hunger
Intense physical exertion
Menstruation/menopause
Perfumes
Sunlight/glare
Stress
Sleep disturbances
When to Refer to an
Ophthalmologist
Loss of vision
 Significant eye pain
 Eye symptoms with neurologic findings
 Eye symptoms after trauma
 New-onset double vision
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