Download What Ques*ons To Ask? - Southern College of Optometry

COURSE 6
Diagnosing and Managing Ocular
Emergencies and Urgencies
COPE Course 43805-SD
COURSE 7
Pre- and Post-Operative
OCT Evaluation of Retinal Disease
COPE Course 43986-PO
COURSE 8
Optometric Management of Children
with Special Needs
COPE Course 43881-FV
COURSE 9
Pill Problems:
Ocular Complications from Systemic Medications
COPE Course 35069-OP
4/6/15
Diagnosing and Managing Ocular
Emergencies and Urgencies
Blair Lonsberry, MS, OD, MEd., FAAO
Diplomate, American Board of Optometry
Clinic Director and Professor of Optometry
Pacific University College of Optometry
[email protected]
1
What Classifies an Emergency?
•  Any condition in which the patient has the
potential for:
–  vision loss,
–  currently experiencing vision loss,
–  permanent structural damage,
–  pain or discomfort,
–  or is an “emergency” for the patient.
•  It is important to be able to triage a walk-in
patient and, more importantly, a call-in patient.
What ques*ons to ask? Onset
suddenly noticed or sudden onset?
Visual Loss
any loss of vision?
loss vs. blurry vision
one eye or both
part of visual field or all
transient vs. permanent
Pain
is there pain? constant? scale (1-10)
Redness
is there any redness? location?
Associated
Factors
contact lens wear? trauma?
discharge?
photophobia? medical history (eg.
DM)
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Common Types of Ocular Emergencies •  Vision Loss:
–  Gradual vs. sudden onset
–  Vision loss with or without pain
•  Trauma
•  Red eyes
Visual Loss
•  Visual loss varies greatly in meaning from patient
to patient
–  ranging from blur to complete blindness and may affect
one or both eyes
•  Components include:
–  acuity,
–  visual field,
–  color and brightness may be affected jointly or
separately
•  Detailed history and extent of vision loss crucial
Profound Loss of Vision
•  Referring to a complete or greatly diminished
vision affecting the whole field
•  Common causes of severe vision loss:
Vascular
central retinal vein occlusion,
central retinal artery occlusion,
vitreous heme
Inflammatory
optic neuritis
Infiltrative
Mechanical
optic neuropathy
retinal detachment
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Monocular vs. Binocular
•  Ocular or optic nerve pathology causes monocular vision
loss
•  lesion at or posterior to chiasm causes binocular vision loss
–  VF defects become more congruous the further back in
the visual pathway
–  Homonymous VF defects noted posterior to chiasm
•  Difference between mono vs. bino usually straightforward,
keeping the following in mind:
–  Patients occasionally mistake homonymous
hemianopsia (similar loss of visual field in both eyes) for
a monocular loss
Visual Defects Monocular
•  Differentiate between eyes that have lost all
useful vision and those that have blurred vision
•  Blurring of vision is not localized and may be
caused by pathology anywhere from cornea to
optic nerve
•  Need to get anatomical diagnosis first before
considering the cause
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General Appearance
•  Level of consciousness
–  When introducing yourself be
aware of the patient’s gross level
of consciousness?
•  Is the patient awake, alert and
responsive?
•  Personal Hygiene and Dress
–  Is it appropriate for the
environment, temperature, age
and social status of the patient?
–  Is the patient malodorous or
disheveled?
General Appearance
•  Posture and Motor control
–  What posture does patient assume while sitting in
the exam chair
–  Are there any signs of involuntary motor activity
such as tremors
•  E.g. damage to the cerebellum may produce a tremor that
usually worsens with movement of the affected limb
Case Example
•  48 yr old white female presented for
diabetic eye exam on referral from her
PCP
–  She was scheduled 2 weeks previously but had fallen
and was unable to make that appointment
–  She reports that her vision in her right eye seems to
be getting worse over the past several weeks.
–  Was diagnosed with diabetes 1.5 years ago
•  BS control has been erratic with range between
120-240
•  Last A1C: 9.1
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Blood Sugar
•  Throughout a 24 hour period blood sugar typically
maintained between 70-145
–  Diabetes is diagnosed with a fasting BS of > 126 or
an A1c value of > 6.5
•  Hypoglycemia is typically defined as plasma glucose
70 or less
–  patients typically become symptomatic of
hypoglycemia at 50 or less
Entrance Skills/Health Assessment
VA: OD: finger count
OS: 20/40
CVF: OD: unable to assess
OS: temporal
hemianopsia
Pupils: sluggish reactivity with a
2+ RAPD OD
SLE: corneal arcus noted, no
other significant findings
IOP: 16, 16 mmHG OD, OS
DFE: see photos
Note: not patient photos
http://content.lib.utah.edu/cdm4/
item_viewer.php?CISOROOT=/
EHSL-WFH&CISOPTR=159
Physical Presentation
•  Upon entering the room I noted that her right hand
was twitching
–  I asked her how long that had been going on and
she said about 2-3 weeks
–  I asked her if she experienced headaches, to which
she said she had bad headaches that even woke her
up at night
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Referral
•  Contacted her PCP who reported that she had
examined the patient 3 weeks prior and had not
noted any of these findings
•  Referred the patient for an immediate MRI
– wasn’t able to be scheduled until the next day
Imaging/Surgery Referral
•  MRI revealed large mass in
her brain
–  Patient was diagnosed with a
Craniopharyngioma
–  She was referred for
immediate surgery
–  Neurosurgeon reported that
she removed a tangerine
sized Craniopharyngioma
–  was the largest tumor she
has ever removed
Note: not patient MRI
http://neurosurgery.ucla.edu/images/
Pituitary%20Program/
Craniopharyngioma/
Cranio_Sag_Preop_fullylabeled.jpg
Craniopharyngioma
•  Craniopharyngioma:
–  slow-growing,
–  epithelial-squamous origin,
–  calcified cystic tumor
–  arises from remnants of the craniopharyngeal duct
•  Craniopharyngiomas have a benign histology but
malignant behavior
–  they have a tendency to invade surrounding structures
and recur after what was thought to be total resection
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Craniopharyngioma
•  Visual field examination
may reveal various patterns
of visual loss
–  most frequently
bitemporal
hemianopsia
•  suggestive of
compression of the
optic chiasma and/
or tracts
Our Patient
•  Patient had a complete resection of the tumor in
addition to radiation therapy
•  She developed several significant perioperative
complications:
–  Leakage of CSF which resulted in her having to have
a shunt
•  She subsequently developed an infection post surgically
–  She is NLP in her right eye, but did regain 20/40
vision in her left eye
•  Retains a temporal hemianopsia OS
–  Diabetes control became erratic and was put on
several hormone replacement medications
Neurological Screening: Cerebrum •  Frontal lobe
–  Emotions, drive, affect,
self-awareness, and
responses related to
emotional states
–  Motor cortex associated
with voluntary skeletal
movement and speech
formation (Broca)
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Right vs Left Brain Injury
•  So what happens if one side of the brain is injured?
– People who have an injury to the right side of
the brain "don't put things together" and fail to
process important information.
•  As a result, they often develop a "denial
syndrome" and say "there's nothing wrong with
me.“
Right vs Left Brain Injury
•  The left side of the brain deals more with language and
helps to analyze information given to the brain.
–  If you injure the left side of the brain, you're aware that
things aren't working (the right hemisphere is doing its
job) but are unable to solve complex problems or do a
complex activity.
–  People with left hemisphere injuries tend to be more
depressed, have more organizational problems, and have
problems using language.
Case
•  20 year old male presents
with a red painful eye
–  complains about red/painful right
eye
–  Started that morning when he
woke up
–  reports a watery discharge, no
itching, and is not a contact lens
wearer
•  SLE:
–  See attached image with NaFl
stain
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Question
What would you begin treatment
with?
1.  oral acyclovir 400 mg 5 times a
day
2.  topical trifluridine (Viroptic) 1
drop every 2 hours
3.  Topical ganciclovir (Zirgan) 5
times per day
4.  Topical trifluridine (Viroptic)
every two hours plus FML BID
5.  both oral and a topical
Herpes Simplex Keratitis: Clinical
Features
•  Characterized by primary outbreak and subsequent
reactivation
•  Primary outbreak is typically mild or subclinical
•  After primary infection, the virus becomes latent in
the trigeminal ganglion or cornea
•  Stress, UV radiation, and hormonal changes can
reactivate the virus
•  Lesions are common in the immunocompromised
(i.e. recent organ transplant or HIV patients)
Dendri*c Ulcers 2
7
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Herpes Simplex Keratitis
•  Topical:
–  Viroptic (trifluridine) q 2h until epi healed then taper
down for 10-14 days.
•  Viroptic is toxic to the cornea.
–  Zirgan (ganciclovir) available, use 5 times a day until
epi healed then 3 times for a week (US only)
•  Oral acyclovir (2 g/day) has been reported to be as
effective as topical antivirals without the toxicity
–  Valtrex (valcyclovir)) 500 mg TID for 7-10 days
–  Famvir (famciclovir) 250 mg TID for 7-10 days
•  If stomal keratitis present, after epi defect has healed,
add Pred Forte QID until inflammation reduced and then
slowly taper
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Prophylaxis??
•  Prophylaxis of 400 mg acyclovir BID vs placebo for 1 year
resulted in a lower recurrence in the treatment arm (19%
vs 32%)
–  Valtrex 500 mg qd was found to be equivalent to
acyclovir BID
•  Pitfalls to Prophylaxis:
–  Reduction of recurrence does not persist once drug
stopped
–  Resistance????
•  van Velzen, et. al., (2013) demonstrated that long-­‐
term ACV prophylaxis predisposes to ACV-­‐refractory disease due to the emergence of corneal ACVR HSV-­‐1. Dendritic ulceration before
treatment with Zirgan
Cornea after treatment with Zirgan
HERPES ZOSTER
OPHTHALMICUS
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Herpes Zoster
Herpes Zoster Ophthalmicus 35
Herpes Zoster
•  Presents with:
–  pain and tingling in region of skin supplied by V
few days before lesions,
–  malaise and fever,
–  papulomacular then pustular rash,
–  mucopurulent conjunctivitis,
–  uveitis, glaucoma, episcleritis, keratitis, and retinitis
can all occur.
–  neurological complications include cranial nerve
palsies and optic neuritis.
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Herpes Zoster •  Associated factors include increasing age, immune deficiency and stress. •  Only people who had natural infec*on with wild-­‐type VZV or had varicella vaccina*on can develop herpes zoster. •  Children who get the varicella vaccine appear to have a lower risk of herpes zoster compared with people who were infected with wild-­‐type VZV. •  A person's risk for herpes zoster increases sharply aRer 50 years of age. •  Almost 1 out of 3 people in the United States will develop herpes zoster during their life*me. •  A person’s risk of developing post-­‐herpe*c neuralgia also increases sharply with age. Herpes Zoster •  Management includes: –  oral an*virals: •  800mg acyclovir 5x/day •  valacyclovir (Valtrex) 1g TID, •  famciclovir (Famvir) 500 mg TID –  effec*veness of therapy is best started within 72 hours –  oral steroids, and –  management of pain (tricyclic an*depressants, gabapen*n). –  If ocular complica*ons, consider topical steroids (Pred Forte QID). Vaccine (Zostavax®) •  The Advisory Commidee on Immuniza*on Prac*ces (ACIP) recommends zoster vaccine (Zostavax®) for people aged 60 years and older. •  The vaccine reduced the overall incidence of shingles by 51% and the incidence of PHN by 67% •  Even people who have had herpes zoster should receive the vaccine to help prevent future occurrences of the disease. •  In adults vaccinated at age 60 years or older, vaccine efficacy wanes within the first 5 years aRer vaccina*on, and protec*on beyond 5 years is uncertain 13
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Corneal Ulcers • 
• 
Infec*ve bacterial and fungal corneal lesions cause severe pain and loss of vision Signs and Symptoms: –  Pain, photophobia, tearing –  Mucopurulent discharge with generalized conjunc*val injec*on –  Decreased VA (esp if on visual axis) –  Possible AC reac*on and hypopyon –  Dense infiltrate –  Satellite lesions around main lesion may indicate fungal infec*on 14
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Sterile vs Infec*ous Infiltrates Peripheral (Sterile) Corneal Ulcer Infectious Corneal Ulcer 15
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Corneal Ulcers
•  The Steroids for Corneal Ulcers Trial (SCUT)
•  Conclusions:
–  no overall difference in 3-month BSCVA and no safety
concerns with adjunctive corticosteroid therapy for
bacterial corneal ulcers
–  researchers did find significant vision improvement for one specific subgroup of the study by using steroid therapy on pa*ents with severe ulcers
•  Application to Clinical Practice:
–  Adjunctive topical corticosteroid use does not improve 3month vision in patients with bacterial corneal ulcers
unless in the severe category
Corneal Ulcers
• 
• 
Infective bacterial and fungal corneal lesions cause severe
pain and loss of vision
S and S:
–  Pain, photophobia, tearing
–  Mucopurulent discharge with generalized conjunctival
injection
–  Decreased VA (esp if on visual axis)
–  Possible AC reaction and hypopyon
–  Dense infiltrate
–  Satellite lesions around main lesion may indicate fungal
infection
Associated Factors
•  Contact lens wear, especially soft and extended wear
lens
•  Recent history of corneal trauma
•  Topical steroid use
•  History of exposure to vegetative matter (fungal
etiology)
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Protein Synthesis Inhibitors
•  These antibiotics work by targeting the bacterial
ribosome.
–  they are structurally different from mammalian
ribosomes,
–  in higher concentrations many of these antibiotics
can cause toxic effects.
•  This group includes:
–  (a) tetracyclines, (b) aminoglycosides, (c) macrolides,
–  (d) chloramphenicol, (e) clindamycin, (f)
quinupristin/dalfopristin and (g) linezolid
Tetracyclines •  This group includes:
–  Tetracycline (250mg - 500 mg cap BID-QID) needs
to be taken 1 hour before or 2 hours after a meal.
–  Minocycline (100 mg cap BID)
–  Doxycycline (20mg - 100 mg cap or tab BID)
Anti-inflammatory effects
• Degrade extracellular proteins
• Tetracyclines inhibit MMPs
• Anti-inflammatory
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Pseudomonas case report
“Doxycycline as an adjunctive
therapy…may help to stabilize
corneal breakdown and prevent
subsequent perforation.”
AM. McElvanney
750
Preseptal Cellulitis
•  infection and inflammation
anterior to the orbital septum
and limited to the superficial
periorbital tissues and eyelids.
–  Signs and Symptoms include:
•  eyelid swelling,
•  redness,
•  ptosis,
•  pain and
•  low grade fever.
Preseptal Cellulitis Treatment
Treatment:
• Mild:
–  Keflex or Ceclor 250-500mg
QID for 5-7 days
–  Augmentin 500 mg TID
–  or 875 mg BID for 5-7 days
• Moderate to severe:
–  IM Rocephin (ceftriaxone)
1-2 grams/day or
–  IV Fortaz (ceftazidime) 1-2 g
q8h.
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Case •  65 year old Caucasian patient presents with
sudden onset loss/blurring of vision in the right
eye
•  PMHx: HTN for 15 years, takes “water pill”
•  VA’s: 20/60 OD, 20/25 OS
•  Pupils: PERRL –APD
•  CVF: Inferior defect right eye, no defects noted
in the left eye
Vision Loss Without Pain: Diabetes/Diabe*c Re*nopathy — Microvascular complications resulting in
capillary closure & abnormal permeability
— S&S include;
◦  blurring of vision (maculopathy and refractive error
shifts),
◦  sudden drop in vision (vitreous heme),
◦  dot and blot hemes,
◦  exudate,
◦  cotton wool spots,
◦  neovascularization (iris, retina and disc)
VEGF and DME
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Aug. 10, 2012: FDA approves Lucentis to treat
diabetic macular edema
•  The drug’s safety and effectiveness to treat DME
were established in two clinical studies involving
759 patients who were treated and followed for
three years.
–  patients were randomly assigned to receive monthly
injections of Lucentis at 0.3 milligrams (mg) or 0.5 mg,
or no injections during the first 24 months of the studies
–  after 24 months, all patients received monthly Lucentis
either at 0.3 mg or 0.5 mg
•  Results:
–  34-45% of those treated with monthly Lucentis 0.3 mg
gained at least three lines of vision compared with
12-18% of those who did not receive an injection.
What’s New? •  Sept. 16, 2014 -­‐-­‐ Regeneron Pharmaceu*cals, Inc. announced that the FDA has granted EYLEA® (aflibercept) Injec*on Breakthrough Therapy designa*on for the treatment of diabe*c re*nopathy in pa*ents with diabe*c macular edema (DME). •  Sept 29, 2014: The FDA approved Ozurdex (dexamethasone intravitreal implant) for the general pa*ent popula*on being treated for DME •  Sept 29, 2014: The FDA approved Iluvien (fluocinolone acetonide implant) for the treatment of DME in pa*ents previously treated with cor*costeroids who did not have a significant increase in IOP Vision Loss Without Pain: Vein Occlusion • Associated with:
–  hypertension,
–  coronary artery disease,
–  DM and
–  peripheral vascular disease.
• Usually seen in elderly patients (60-70), slight
male and hyperopic predilection.
• Second most common vascular disease after
diabetic retinopathy.
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Branch Re*nal Vein Occlusion: Signs/Symptoms —  BRVO: sudden, painless,
visual field defect.
◦  patients may have normal
vision.
◦  quadrantic VF defect,
◦  dilated tortuous retinal
veins with superficial
hemes and CWS
◦  typically occurs at A/V
crossing (sup/temp)
BRVO — BRVO more common than CRVO and has more
favorable prognosis
◦  Overall 50-60% of BRVO patients will maintain VA of
20/40 or better
— Visual loss results from:
◦  Macular edema
◦  Foveal hemorrhage
◦  Vitreous heme
◦  Epiretinal membrane
◦  RD
◦  Macular ischemia
◦  Neovascularization complications
Study Design (n=397) BRVO BRAnch retinal Vein Occlusion study safety/efficacy
Macular Edema Secondary to BRVO 1:1:1 RandomizaBon Ranibizumab Ranibizumab 0.5 mg 0.3 mg (n=131) (n=134) Monthly InjecBons (last at 5M) Rescue Laser (if eligible beginning at Month 3) Sham (n=132) 12M PRN ranibizumab for all paBents Rescue Lase
aser (if eligible beginning at Month 9) Ranibizumab Ranibizumab 0.5 mg 0.3 mg Month 6 Primary Endpoint Ranibizumab 0.5 mg 21
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Mean Change from Baseline BCVA Mean Change from Baseline
BCVA (ETDRS Letters)
Sham/0.5 mg (n=132)
BRVO 0.3 mg Ranibizumab (n=134)
0.5 mg Ranibizumab (n=131)
+18.3*
20
+18.3
18
+16.4
16
14
+16.6*
+11.6
12
10
+12.1
+10.2
8
6
+7.3
+3.1
4
2
0
07
2
4
Day 0–Month 5
Monthly Treatment
6
Month
8
10
12
Months 6–11
PRN Treatment
The gain of additional 3 lines occurred at a rate of 61% of 0.5 AVT grp, 55% for
0.3 AVT & 29% placebo
Central Re*nal Vein Occlusion: Signs/Symptoms — CRVO: thrombus occurring at
lamina is classical theory but
new evidence indicates that the
occlusion is typically in the optic
nerve posterior to the lamina
cribrosa
◦  decreased VA ranging from
near normal to hand motion
with majority 20/200 range
◦  dilated tortuous vessels,
with numerous retinal
hemes and CWS
Central Re*nal Vein Occlusion •  Visual morbidity and blindness are primarily from:
–  persistent macular edema,
–  macular ischemia and
–  neovascular glaucoma
•  CRVO’s can be ischemic or non.
–  Classical definition of ischemic is 10-disc area of nonperfusion found on angiography
–  RAPD and ERG maybe better predictor
–  VA’s typically worse in ischemic
–  Increased number of cotton wool spots with decreased VA
maybe predictive
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Central Re*nal Vein Occlusion — Ischemic CRVO may lead to iris
neovascularization and neovascular
glaucoma
◦  Estimated apprx 20% of CRVO’s are ischemic with
45% of those developing neo
— Regular examinations (1-2 wks) to monitor
for ischemia or neo development
◦  should include gonio as angle neo can precede iris
rubeosis
Study Design CRUISE (n=392) CRVO Central Retinal vein occlUsIon Study: Efficacy & safety
Macular Edema Secondary to CRVO Sham (n=130) 1:1:1 RandomizaBon Ranibizumab 0.5 mg (n= 130) Ranibizumab 0.3 mg (n=132) Monthly InjecBons (last at 5M): 6M tx period 12M trial PRN LucenBs available for for all paBents: 6M tx period 0.5 mg
Ranibizumab 0.3 mg Month 6 Primary Endpoint Ranibizumab 0.5 mg Mean Change from Baseline BCVA Mean Change from Baseline BCVA (ETDRS Le\ers) Sham/0.5 mg (n=130) CRVO 0.3 mg Ranibizumab (n=132) 18 16 0.5 mg Ranibizumab (n=130) +14.9* +13.9 +13.9 14 12 +12.7* 10 8 +7.3 6 4 +0.8 2 0 -­‐2 0 7 2 4 Day 0–Month 5 Monthly Treatment 6 8 10 12 Months 6–11 Month PRN Treatment Pts with >/= 3 line improvement was noted in 48% of .5 AVT, 26 of .3 AVT & 17% of sham 23
4/6/15
Hot Off The Presses! •  October 8, 2014: The FDA has expanded the indica*on of aflibercept (Eylea, Regeneron) injec*on to include all forms of macular edema aRer re*nal vein occlusion (RVO), including branch RVO (BRVO) and CRVO (previously approved). Vision Loss Without Pain: Artery Occlusion •  Primarily embolic in nature from cholesterol,
calcifications, plaques.
•  Usually occurs in elderly associated with:
–  hypertension (67%),
–  carotid occlusive disease (25%),
–  DM (33%) and
–  cardiac valvular disease.
•  Sudden loss of unilateral, painless vision
–  defect dependent upon location of occlusion
Vision Loss Without Pain:
Artery Occlusion
•  BRAO typically
located in
temporal retinal
bifurcations.
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CRAO
•  CRAO has profound vision
loss with history of
amaurosis fugax.
–  Vision is usually CF
(count fingers) to LP (light
perception) with positive
APD.
–  Diffuse retinal whitening
with arteriole
constriction, cherry red
macula.
Ophthalmic Emergency — Treatment is controversial due to poor prognosis
and questionable benefit.
— Treat immediately before workup, if patient
presents within 24 hours of visual loss:
◦  Digital ocular massage,
◦  systemic acetozolamide (500 mg IV or po),
◦  topical ocular hypertensive drops (Iopidine, B-blocker),
◦  anterior chamber paracentesis,
◦  consider admission to hospital for carbogen Tx (high
carbon dioxide)
Flashes and Floaters •  Pa*ents oRen present complaining of “spots” or “cobwebs” in front of their eyes •  Causes of floaters include: posterior vitreous detachment (PVD), re*nal tear, vitreous heme, uvei*s. •  Since PVD and re*nal tears present the same way, a RT has to be eliminated •  Ask the pa*ent whether spots move with eye and con*nue to move aRer the eye has stopped •  Large spots could be blood clots 25
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Posterior Vitreous Detachment (PVD)
Vitreous Heme
Retinal Tear
26
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PDS Clinical Features
•  Posterior segment
–  Latce degenera*on occurs in 8-­‐11% of the general popula*on •  The incidence of atrophic holes in latce degenera*on ranges from 18-­‐42%
–  Lattice retinal degeneration has been
reported to be evident in 20–33% of
cases of PDS and PDG
•  greater than would be expected for the
associated myopia
PDS Clinical Features
•  Posterior segment
–  retinal breaks occur more frequently
than in normal eyes, affecting 12%
of eyes with PDS and PDG
–  risk of re*nal detachment is only 0.1-­‐0.7% in the “normal” phakic eye
•  retinal detachments have been reported
to occur in 5.5–6.6% of PDS cases
•  higher than expected for the degree of
myopia and is independent of miotic
use
Flashes and Floaters
•  Sudden onset typically means a PVD, retinal tear or
heme
•  If the spots appear after flashing light, then retinal tear
must be eliminated
•  Myopes tend to have floaters and will notice them for a
long time
•  Key is to rule out potentially sight threatening condition
for the floaters, ie retinal tear.
•  Patients with retinal condition such as lattice
degeneration and myopes need to be educated about
S&S of RD (flashes and floaters)
–  8-11% population has lattice
–  Risk of RD with lattice is <1%
–  30-50% of patients with a RD have lattice
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Flashes and Floaters:
Management
•  A pa*ent who presents with a sudden onset PVD without re*nal breaks or hemorrhage requires repeat peripheral examina*on in six weeks, as the risk of re*nal complica*ons is highest within the six weeks following vitreous detachment. •  If no re*nal breaks are seen at that point, rou*ne yearly examina*on is all that is needed
Ques*on 75 white female complains of sudden decreased vision left
eye. From picture above what is most likely cause?
1. BRVO
2. Ischemic optic neuropathy
3. Papilledema
4. Low tension glaucoma
Epidemiology
•  Nonarteritic: usually seen in
younger patients
–  Fellow eye involved in
25-40% of cases
–  Associated with
hypertension and diabetes
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Epidemiology — Arteritic: usually seen in >55 yrs old (mostly over 70)
◦  fellow eye involved in 75% of cases within 2 weeks without
treatment
Symptoms
•  Acute visual loss (arteritic>non)
•  dyschromatopsia
•  Arteritic may also have associated:
–  Headache, fever, malaise,
–  weight loss, scalp tenderness, jaw claudication,
–  amaurosis fugax, diplopia, and eye pain.
Ocular Signs
•  Sudden, unilateral, painless
decreased vision and color
vision
•  Positive RAPD
•  Altitudinal visual field defect
(usually inferior and large)
•  Swollen optic disc
•  Fellow nerve often crowded
with small or absent cup
(“disc at risk”)
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Additional Testing
•  Lab tests:
–  STAT ESR (rule out arteritic form)
–  CBC (low hematocrit, high platelets)
–  Fasting blood sugar
–  C reactive protein,
–  VDRL/FTA-ABS
–  ANA
•  Check blood pressure
Management
•  Arteritic:
–  Systemic steroids to prevent fellow eye involvement
•  methylprednisolone 1 g IV qd in divided doses for 3 days
then,
•  prednisone 60-100 mg po qd with a slow taper
–  Check PPD, blood glc and chest radiographs before
starting systemic steroids
•  Non-arteritic:
–  Consider daily aspirin
Vision Loss Without Pain: TIA/TMB/Amaurosis Fugax — Refers to temporary visual impairment of variable
duration (seconds to hours)
◦  TIA: transient ischemic attack-can be cerebral or retinal
◦  TMB: transient monocular blindness secondary to a
retinal TIA
◦  Amaurosis Fugax: same as TMB
— Abrupt onset, progression to involve all or part of
visual field, sight usually returns
— Within affected area, visual acuity maybe dimmed or
completely lost
30
4/6/15
TIA’s
•  Stroke is 3rd leading cause of mortality in developed
countries and most common cause of neurological
disability
•  15-20% of patients with stroke have a preceding TIA,
though guidelines for referral and evaluation are
debated
–  Traditional guidelines suggested that assessment
should be complete within 1 week of TIA
TIA’s
•  Risk of stroke after TIA has traditionally been
considered relatively low, but
–  new studies indicate that the risk is much
higher than previously thought and the time
window for prevention is short.
•  Effective secondary prevention depends on
reliable identification of those at high risk and
targeting treatment.
TIA’s: High Risk Factors
— Five (5) risk factors are associated with a high
risk (30%) of recurrent stroke at 3 months:
◦  Age over 60
◦  Symptom duration greater than 10 minutes
◦  Motor weakness
◦  Speech impairment
◦  Diabetes
— Isolated sensory of visual symptoms were
associated with low risk of stroke!
31
4/6/15
TIA: Early Treatment — Several treatments are likely to be effective in
preventing stroke in the acute phase after a TIA:
◦  Aspirin
◦  Anticoagulants
◦  Statins
◦  Endarterectomy (for >50% carotid stenosis)
◦  Further research needed for:
–  Lowering blood pressure acutely after TIA
–  Prophylactic use of neuroprotective drugs
Amaurosis Fugax:TMB
•  Most common cause is:
–  thromboembolic disease (eg carotid artery disease throwing
emboli) or
–  vasospasm
•  Described as “curtain falling over vision”
•  Risk of stroke or death is about 3-5%,
–  which is significantly lower than for a cerebral TIA (15-20%)
•  Px still require work-up to determine cause:
–  e.g. carotid doppler
Alkali Chemical Burns
• 
Alkali exposure results in:
– 
– 
– 
– 
Loss of corneal and conjunctival
epi, stromal keratocytes and
endothelium
Loss of clarity is secondary to
stromal hydration
Damage to the vascular
endothelium of conjunctival and
episcleral vessels
Intraocular structures such as iris,
lens and ciliary body are rapidly
damaged if alkali penetrates cornea.
32
4/6/15
Acidic Chemical Burns
• 
• 
Epithelium provides
effective barrier to weak
acids. Stronger acids cause
protein precipitation in
epithelium and stroma
which creates a barrier to
further penetration.
Very strong acids penetrate
as quickly as alkalis
Chemical Burn Treatment
•  Immediate irrigation is of paramount importance
•  Most patients are disabled by severe blepharospasm
and disorientation so require assistance away from
harm and to initiate irrigation.
•  Make sure to remove any solid particulate matter
prior to beginning irrigation
•  Minimum of 15 minutes constant irrigation (some
recommend 30 minutes)
Chemical Burn Treatment
•  Water is commonly recommended however it is
hypotonic to corneal tissue and can result in
increased water intake into the corneal and
subsequent diffusion of corrosive materials
deeper into cornea.
•  Recommend fluids of higher osmolarity such as
sterile lactated Ringers and balanced saline
solution.
33
4/6/15
Chemical Burn Treatment
•  Effectiveness of irrigation can be assessed using
pH paper and continued as long as pH outside
of the normal range.
•  For grade I and II burns will typically heal
without permanent damage.
–  Topical steroid/antibiotic drops/ung recommended
and daily follow up.
–  Cycloplegia for pain and further reduction of
inflammation.
Chemical Burn Treatment
•  Severe ocular burns are difficult to treat and
may require months of healing
•  Basic treatment of these eyes is to reduce
inflammatory response caused by necrotic tissue
–  Corticosteroid use
–  Prophylactic antibiotics (consider doxycycline as it
inhibits proteinase activity)
–  May require surgical intervention with debridement
of necrotic tissue and possibly reconstructive
surgery.
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1/16/2015
S/P RD Repair
Pre- and Post-operative OCT
evaluation of retinal disease.
Jorge Calzada, MD
S/P RD Repair
Inferior Perimacular RD
Inferior Juxtafoveal RD
Mirror
Image
Artifact
1
1/16/2015
Sup RD and AMD
Postop Sup RD + AMDm
CNV
Mac Off RD in 7 year old
Fovea OFF RD
Photoreceptor loss post RD
And a month later…EMM
2
1/16/2015
Diabetic TRD
Diabetic TRD
TRD postop
Subfoveal fluid post RD
VA: 20/100 -> Redetachment, silicone oil glaucoma -> NLP
Bullous Sup RD
Mac OFF
3
1/16/2015
Dense EMM post RD
Outer retinal cords post RD repair
Recurrent RD under oil with
foveal atrophy
Persistent subfoveal fluid post RD
1 month later
Fovea OFF RD
4
1/16/2015
Shallow fovea off RD
Chronic Inf RD with foveal atrophy
Mac ON RD
Macular Hole
MH postop 1 month
EMM Rip
5
1/16/2015
Macular Hole
MH postop 1 month- Foveal Atrophy
Chronic RD with Subretinal PVR
Chronic RD + Subretinal PVR
Subretinal PVR
6
1/16/2015
7
3/16/15 Copyright K. Kehbein 2015-COPE# 43881FV
OPTOMETRIC MANAGEMENT
OF CHILDREN WITH SPECIAL
NEEDS
Karen A. Kehbein, OD, FCOVD
Assistant Professor
Southern College of Optometry
Copyright K. Kehbein 2015-COPE# 43881FV
Financial Disclosures
I have no financial
interests to disclose.
Copyright K. Kehbein 2015-COPE# 43881FV
Course Outline
•  Down Syndrome
•  Definition, General Physical Characteristics, Common Ocular
Findings
•  Autism
•  Definition, General Physical Characteristics, Common Ocular
Findings
•  Cerebral Palsy
•  Definition, General Physical Characteristics, Common Ocular
Findings
•  Examination Techniques
•  Binocular Vision Abnormalities
•  Prescribing Glasses
•  Vision Therapy
1 3/16/15 Copyright K. Kehbein 2015-COPE# 43881FV
DOWN SYNDROME
Copyright K. Kehbein 2015-COPE# 43881FV
Down Syndrome
•  One of the first developmental disabilities to be
recognized as a syndrome
•  Langdon Down in 1866
•  Historically diagnosed based on physical findings
•  1. Upward slanting of temporal palpebral fissures
•  2. Significant presence of epicanthal folds
Copyright K. Kehbein 2015-COPE# 43881FV
Inherited Genetic Anomaly
•  Trisomy 21
•  Inherited 3 copies of chromosome 21
•  About 94% of all cases
•  Translocation
•  Portion of chromosome 21 breaks off and attaches to another
chromosome
•  Attaching to chromosome 14 is most common
•  About 5% of all cases
•  Mosaicism
•  Some cells have 46 chromosomes and some have 47
chromosomes- 3 copies of chromosome 21
•  About 1% of all cases
2 3/16/15 Copyright K. Kehbein 2015-COPE# 43881FV
Prevalence
•  1 in 691 babies born with in the United States with Down
Syndrome
•  Affects all races and economic levels
•  Most common genetic anomaly
•  Risk Factors
•  Increasing maternal age
•  Greater risk of having a baby with Down Syndrome
•  More babies with Down Syndrome born to women under 35yo
•  Younger women are more fertile
Copyright K. Kehbein 2015-COPE# 43881FV
Physical Characteristics
http://www.doctortipster.com/3349-down-syndrome-mongolism-or-trisomy-21.html
Copyright K. Kehbein 2015-COPE# 43881FV
Speech and Language
•  Poor hearing
•  Slow processing
•  Small instruction sets
•  Wait for comprehension
•  Poor expressive speech
•  Unable to say what they want/mean
•  Able to understand what you are telling/asking them
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Common Ocular Findings
•  Refractive Error
•  Born with roughly normal amounts
•  Deficient emmetropization?
•  Moderate to High Amounts
•  Hyperopia
•  Myopia
•  Astigmatism
•  Increases with age, oblique axis
•  Reduced visual acuity with optimal correction
•  Consider modifications for home, school, work
Copyright K. Kehbein 2015-COPE# 43881FV
Common Ocular Findings cont.
•  Accommodative Insufficiency
•  Poor ability to stimulate accommodation to age-normal levels
•  Significantly high lag
•  Likely due to sensory pathway deficit
•  Higher amounts of hyperopia show higher lag
•  Lower amounts of hyperopia show lower lag
•  Use of bifocals
•  Help improve near acuity
•  Help improve accommodative functioning
•  May no longer need bifocal after improvement
Copyright K. Kehbein 2015-COPE# 43881FV
Common Ocular Findings cont.
•  Strabismus
•  Esotropia more common than exotropia
•  Commonly alternating vs. unilateral
•  If possible amblyopia
•  Follow PEDIG patching recommendations
•  Moderate amblyopia: 2 hours of patching/day with 1 hour of near work
•  Severe amblyopia: 6 hours of patching/day with 1 hour of near work
4 3/16/15 Copyright K. Kehbein 2015-COPE# 43881FV
Common Ocular Findings cont.
•  Ocular Health
•  Blepharitis
•  Cataracts
•  Keratoconus
•  Brushfield Spots
•  More common in lighter pigmented iris
•  Vessel changes in fundus
Copyright K. Kehbein 2015-COPE# 43881FV
AUTISM
Copyright K. Kehbein 2015-COPE# 43881FV
Autism
•  Group of developmental brain disorders
•  Starts before age 3yo
Autismems.net
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Autism Spectrum Disorder
Autismc.com
Copyright K. Kehbein 2015-COPE# 43881FV
Prevalence
•  Depends on study
•  2008: 1 in 88
•  Centers for Disease Control and Prevention (CDC)
•  1 in 54 boys
•  1 in 252 girls
•  Causes/Risk Factors:
•  4 times more common in males
•  Combination between environment, genetics, and biology
•  Increased risk if sibling has autism
•  Parents over 35yo
•  Mother with autoimmune condition
•  Low birth weight/ prematurity/ breech birth
Copyright K. Kehbein 2015-COPE# 43881FV
Physical Characteristics
•  Gastro-intestinal problems
•  At least 24% have one chronic problem
•  Sleep disturbances
•  Trouble falling and staying asleep
•  Mood disorders
•  Phobias, ADD/ADHD, obsessive compulsive disorder, anxiety,
depression
•  Intellectual Disability
•  Estimated to be over 60%
•  Medical costs are 7x higher for people with ASD
•  Approximately 75% need lifelong support
6 3/16/15 Copyright K. Kehbein 2015-COPE# 43881FV
Common Ocular Findings
•  Decreased eye contact
•  Poor oculomotor control
•  Deficient saccades and/ore
pursuits
•  Optic neuropathy
•  Secondary to dietary
deficiencies
Black K, McCarus C, Collins ML, Jensen A. Ocular
manifestations of autism in ophthalmology.
Strabismus. 2013;21(2):98-102.
Copyright K. Kehbein 2015-COPE# 43881FV
Early Eye Tracking
•  At-risk infants (family member with autism spectrum
disorder) vs. control infants
•  Ages 6-10 months
•  Is there a change in brain potential when a face shifts
gaze toward and away infant?
•  Used potential components which are precursors for adult facial
sensitivity
•  At-risk infants: no change in potential
•  Control infants: change in potential
•  Higher proportion of at-risk infants developed autism at 36
months
Copyright K. Kehbein 2015-COPE# 43881FV
Treatment
•  Variety of therapies
•  Applied Behavior Analysis
•  Analysis of behavior to help make changes to more socially
acceptable behavior
•  Positive reinforcement for socially acceptable behavior
•  No reinforcement for less than ideal behaviors
•  Those that could pose harm
•  Those that prevent learning
7 3/16/15 Copyright K. Kehbein 2015-COPE# 43881FV
CEREBRAL PALSY
Copyright K. Kehbein 2015-COPE# 43881FV
Cerebral Palsy
•  Group of disorders of the development of posture and
movement
•  First described by Dr. William James Little in 1862
•  Includes:
•  Limitations in activity
•  Non-progressive disturbances
•  Other disturbances
•  Sensation
•  Cognition
•  Communication
•  Perception
•  Behavior
•  Seizures
Copyright K. Kehbein 2015-COPE# 43881FV
Prevalence
•  1 to 2 per 1,000 in developed countries
•  Higher prevalence in low birth weight children
•  Higher in lower socioeconomic class, when normal birth weight
8 3/16/15 Copyright K. Kehbein 2015-COPE# 43881FV
Causes/Risk Factors
•  Prenatal
•  Intrauterine infection, death of co-twin, cerebral ischemia
•  Perinatal
•  Neonatal convulsions, jaundice, infection, multiple gestations
•  Postnatal
•  Brain damage in first few months of life
•  Congenital or Acquired
•  Congenital: development, malformations, syndromes
•  Acquired: trauma, infection, ischemia, hypoxia
Copyright K. Kehbein 2015-COPE# 43881FV
Physical Characteristics
•  Physiological Subtypes
•  1. Spastic: 70-80% of cases
•  Stiffness of muscles
•  Damage to periventricular white matter
•  2. Dyskinetic: 10-15% of cases
•  Uncontrolled, slow, writhing movements
•  Damage to basal ganglia
•  3. Ataxic: <5% of cases
•  Difficulty with balance and coordination
•  Cerebellar damage
Copyright K. Kehbein 2015-COPE# 43881FV
Physical Characteristics cont.
•  Anatomical Subtypes
•  1. Hemiplegia: 20-30% of cases
•  Dysfunction of one side of the body
•  2. Diplegia: 30-40% of cases
•  Reduced ability to use upper or lower limbs
•  3. Quadriplegia: 10-15% of cases
•  Reduced ability in all 4 limbs and trunk
•  Most severe form
9 3/16/15 Copyright K. Kehbein 2015-COPE# 43881FV
Common Ocular Findings
•  Refractive Error:
•  Low to moderate hyperopia
•  High myopia in more severe forms
•  Visual Field Defects:
•  More peripheral field defects than central field defects
Copyright K. Kehbein 2015-COPE# 43881FV
Common Ocular Findings cont.
•  Strabismus
•  Roughly 50% have strabismus
•  Equal amounts of exotropia and esotropia
•  Worsening binocularity with more severe CP
•  70% lack binocularity
•  Potential for amblyopia with constant strabismus
•  Alternating strabismus common
Copyright K. Kehbein 2015-COPE# 43881FV
Common Ocular Findings cont.
•  Oculomotor Dysfunction
•  Gross assessment of saccades/pursuits
•  NSUCO
•  25% show deficit
•  Equal amounts of saccadic and pursuit deficiency
•  Assessment of reading eye movements
•  Developmental Eye Movement Test (DEM)
•  20% have normal findings
•  80% have oculomotor dysfunction, automaticity problem or combination
of the two
10 3/16/15 Copyright K. Kehbein 2015-COPE# 43881FV
Common Ocular Findings cont.
•  Accommodative Insufficiency
•  60% have higher than normal lag
•  Consider plus reading glasses at near
•  Visual Perceptual Deficits
•  Poor visual imagery
•  Poor visual-spatial relations
Copyright K. Kehbein 2015-COPE# 43881FV
Common Ocular Findings cont.
•  Ocular Disease
•  Nystagmus
•  Optic Atrophy
•  Retinopathy of Prematurity
Fazzi E, Signorini SG, La Piana R, et.al. Neuroophthalmological disorders in cerebral palsy:
ophthalmological, oculomotor, and visual aspects.
Developmental Medicine & Child Neurology. 2012;54:730-6.
Copyright K. Kehbein 2015-COPE# 43881FV
EXAMINATION
TECHNIQUES
11 3/16/15 Copyright K. Kehbein 2015-COPE# 43881FV
Fix and Follow
•  Not able to quantify visual acuity
•  Only able to tell if patient can see object
•  Able to tell if fixation preference
•  Resistance to occlusion
•  Can be performed as part of ocular motility testing
Copyright K. Kehbein 2015-COPE# 43881FV
Preferential Looking
•  Easy to administer to young
children
•  Provides a way to assess what
the child is seeing
•  Large range of spatial
frequencies available
•  20/2400 to 20/10
•  Extended period of time to
administer
•  OD, OS, OU
•  Show card and make decision
as to where the child is looking
•  50% chance of getting it correct
Copyright K. Kehbein 2015-COPE# 43881FV
Lea Symbols
•  4 pictures
•  Circle, square, house,
apple
•  Well calibrated
•  Distance and near
12 3/16/15 Snellen
•  Recognition acuity
•  Standard for comparison of
Copyright K. Kehbein 2015-COPE#
43881FV
other techniques
•  Historical “Gold Standard”
Copyright K. Kehbein 2015-COPE# 43881FV
Binocularity/ Accommodation
•  Hirschberg
•  Assessment for strabismus vs. pseudo-strabismus
•  Bruckner
•  Assessment for difference in refractive error, strabismus, ocular
health complications
•  Cover Test
•  Assessment for binocular posture
•  MEM Retinoscopy
•  Assessment of accommodative response
•  Push-up/ Pull-away amplitude
•  Assessment of accommodative amplitude
Copyright K. Kehbein 2015-COPE# 43881FV
NSUCO
•  Northeastern State University College of Optometry
oculomotor test
•  Direct observation of saccades and pursuits
•  Type of free space testing
•  Rate patient based on
•  Ability
•  Accuracy
•  Head and body movement
•  Graded on a 1-5 scale (5 is the best)
•  Norms
•  Ages 5-14yo
•  Girls show better scores earlier
•  Boys “catch up” around 9yo
13 3/16/15 Copyright K. Kehbein 2015-COPE# 43881FV
King Devick Test
•  Visual verbal format to test
saccades
•  Type of psychometric test
•  One demonstration card
and 3 test cards
•  Patient calls out numbers as
quickly as possible
•  Evaluate time it takes to
complete card based on
age norms
•  Norms
•  Ages 6-14yo
•  Compare time taken to
average range
Copyright K. Kehbein 2015-COPE# 43881FV
Developmental Eye Movement Test
•  Visual verbal format to test saccades
•  Type of psychometric test
•  Patient asked to call off a series of
numbers as quickly as possible
•  2 vertical tests
•  1 horizontal test
•  Not allowed to use finger or ruler as
a guide
•  Time to complete each test is
recorded as well as the errors
•  Norms
•  Ages 6-34yo
•  Calculate total times and ratio
•  Calculate z-score for vertical and ratio
Refractive Error
•  Retinoscopy
•  Dry
•  Static= accommodation relaxed, distance
•  Mohindra
•  Near retinoscopy
•  Monocular in a darkened room (only light from
retinoscope)
•  50cm working distance
•  Subtract 1.25D from neutralizing lens
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43881FV
viewing
•  Dynamic= near accommodative abilities
•  Cycloplegic
•  Decreases fluctuations from accommodation
14 3/16/15 Copyright K. Kehbein 2015-COPE# 43881FV
Ocular Health
•  Intraocular Pressure
•  Tonopen
•  iCare
•  Anterior Segment
•  Slit lamp
•  20D and penlight
•  Posterior Segment
•  BIO
Copyright K. Kehbein 2015-COPE# 43881FV
Developmental Testing
Copyright K. Kehbein 2015-COPE# 43881FV
Visual Information Processing Testing
•  Visual Analysis testing
•  Investigates visual discrimination, visual memory, visual closure,
form constancy, spatial relationships, figure-ground
•  Types of tests:
•  Test of Visual Perceptual Skills (TVPS)
•  Motor Free Visual Perceptual Test (MVPT)
•  Visual Motor Integration
•  Investigates eye-hand coordination
•  Types of tests:
•  Beery VMI
•  Developmental Test of Visual Perception (DTVP)
15 3/16/15 Copyright K. Kehbein 2015-COPE# 43881FV
BINOCULAR VISION
ABNORMALITIES
Copyright K. Kehbein 2015-COPE# 43881FV
Accommodative Abnormalities
•  Accommodative Insufficiency
•  Poor ability to stimulate accommodation
•  Finding of high lag on MEM testing
•  Reduced amplitude of accommodation
•  Recommended treatment:
•  Near work glasses
•  Bifocal correction
•  How much to prescribe?
•  Does it actually work?
Copyright K. Kehbein 2015-COPE# 43881FV
Bifocals
•  Used to help improve near acuity and poor
accommodative skills
•  Found to also help improve visual perceptual skills in
patients with Down Syndrome:
•  Improvement in reading scores
•  Improvement in Visual Closure
•  Improvement in Visual Form Constancy
•  No improvement in handwriting
16 3/16/15 Copyright K. Kehbein 2015-COPE# 43881FV
Eye Tracking Abnormalities
•  Oculomotor dysfunction
•  Poor fixation, saccades, and/or pursuits
•  Testing with NSUCO
•  Autism: poor fixation skills
•  Cerebral Palsy: poor motor control
•  Testing with DEM
•  Cerebral Palsy
•  20% normal
•  20% oculomotor problem only
•  32% automaticity problem only
•  27% oculomotor and automaticity problems
Copyright K. Kehbein 2015-COPE# 43881FV
Eye Tracking Abnormalities cont.
•  Recommended Treatment:
•  Vision Therapy
•  Accommodations in the classroom
•  Use finger or ruler to follow along
•  Large print worksheets/textbooks
Copyright K. Kehbein 2015-COPE# 43881FV
Binocular Abnormalities
•  Strabismus
•  Cerebral Palsy:
•  Almost 50% have strabismus
•  Most likely to be alternating vs. unilateral
•  Equal between esotropia and exotropia
•  Down Syndrome:
•  Slightly less than 50% have strabismus
•  Esotropia more common than exotropia
17 3/16/15 Copyright K. Kehbein 2015-COPE# 43881FV
Binocular Abnormalities cont.
•  Non strabismic binocular vision abnormalities
•  Autism:
•  Poor convergence skills
•  Likely poor stereopsis
•  Recommended Treatment:
•  Vision Therapy
•  Strabismus Surgery
•  Studies have found that strabismus surgery on developmentally delayed
children may result in overcorrection when using the standard
measurements
•  Occlusion
•  Prism Glasses
Copyright K. Kehbein 2015-COPE# 43881FV
PRESCRIBING GLASSES
Copyright K. Kehbein 2015-COPE# 43881FV
Prescribing Full Correction
•  Hyperopia:
•  Consider patient’s accommodative ability
•  If poor, may struggle with seeing well in distance/ near
•  Myopia:
•  Consider patient’s accommodative ability
•  May need bifocal at near to help supplement accommodation
•  Astigmatism:
•  Improvement of visual functioning/ acuity
18 3/16/15 Copyright K. Kehbein 2015-COPE# 43881FV
Cutting the Prescription
•  Hyperopia:
•  Consider patient’s binocular vision status
•  If poor, too much plus may cause negative change in posture
•  Myopia:
•  Consider patient’s visual needs
•  If mostly at near, may not need full minus correction
Copyright K. Kehbein 2015-COPE# 43881FV
Contact Lenses
•  Patients with keratoconus
•  Patients with dry eye
Copyright K. Kehbein 2015-COPE# 43881FV
VISION THERAPY
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Goals and Expectations
•  Improvement in visual skills
•  Decrease in strabismus frequency or magnitude
•  Improved fixation and eye tracking skills
•  Flexibility of accommodation
•  Setting appropriate expectations
•  May not be “normal”
•  Did the patient show improvements in behavior?
•  Did the patient show improvements in visual skills?
Copyright K. Kehbein 2015-COPE# 43881FV
Improvement of Accommodation
•  Doctor Goals for Vision Therapy
•  Greater flexibility
•  More accurate response
•  Increased amplitude
•  Patient/Parent Goals for Vision Therapy
•  Less visual fatigue
•  Less blur
•  Improved time with near tasks
Copyright K. Kehbein 2015-COPE# 43881FV
Improvement of Eye Tracking
•  Doctor Goals for Vision Therapy
•  Increased fixation time
•  More accurate saccades/pursuits
•  Decreased head/body movement
•  Patient/Parent Goals for Vision Therapy
•  Eye contact
•  Potential for improvement in reading skills
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Improvement of Binocularity
•  Doctor Goals for Vision Therapy
•  Decrease in angle of strabismus
•  Improvement in fusion capabilities
•  Patient/Parent Goals for Vision Therapy
•  Straight eyes
•  Appreciation of depth perception
Copyright K. Kehbein 2015-COPE# 43881FV
CASE EXAMPLE
Copyright K. Kehbein 2015-COPE# 43881FV
Patient Demographics
•  10 year old Caucasian female
•  Chief complaint: alternating exotropia, equal at distance
and near
•  Ophthalmologist wants to do surgery, Mom wants a second opinion
•  Medical History: Cerebral Palsy
•  Ocular History: eye turn, glasses wear
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Preliminary Data
•  Entering aided acuities (distance and near)
•  OD: 20/20•  OS: 20/20•  Habitual Rx
•  +6.00DS OU
•  Pupils: Equal, round, reactive to light (-) APD
•  EOMs: Full, no restrictions, poor pursuits
•  Confrontation fields: full to finger count OU
•  Cover Test through Habitual Rx:
•  Distance 25∆ Alternating Exotropia
•  Near 25∆ Alternating Exotropia
Copyright K. Kehbein 2015-COPE# 43881FV
Refractive Correction
•  Took off glasses for lensometry…
•  Patient now has esotropia
•  Distance retinoscopy:
•  +6.00DS OU
•  Trial amount to get good acuity and binocularity
•  +2.00DS OU------ still had esotropia, reduced acuity
•  +4.00DS OU------ exophoria, good acuity
Copyright K. Kehbein 2015-COPE# 43881FV
Assessment and Plan
•  Assessment:
•  Hyperopia OU
•  Exotropia/Esotropia
•  Oculomotor dysfunction
•  Plan:
•  New glasses prescription: +4.00DS OU
•  Begin vision therapy to work on eye tracking and fusion activities
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Thank You
•  Karen Kehbein, OD, FCOVD
•  [email protected]
Copyright K. Kehbein 2015-COPE# 43881FV
References- Down Syndrome
•  National Down Syndrome Society
•  http://www.ndss.org/
•  Taub M, Bartuccio M, Maino D. Visual Diagnosis and Care of the
Patient with Special Needs. 2012: Lippincott Williams & Wilkins.
Chapter 4
•  Kranjc B. Ocular abnormalities and systemic disease in down
syndrome. Strabismus. 2012;20(2):74-7.
•  Anderson HA, Manny RE, Glasser A, Stuebing KK. Static and
Dynamic Measurements of Accommodation in Individuals with Down
Syndrome. Investigative Ophthalmology & Visual Science.
2011;52(1):310-7.
•  Nandakumar K, Evans, MA, Briand K, Leat SJ. Bifocals in Down
Syndrome study (BiDS): analysis of video recorded sessions of
literacy and visual perceptual skills. Clinical and Experimental
Optometry. 2011;94(6):575-85.
•  Yahalom C, Mechoulam H,Cohen E, Anteby I. Strabismus surgery
outcome among children and young adults with Down syndrome.
JAAPOS. 2010;14(2):117-9.
Copyright K. Kehbein 2015-COPE# 43881FV
References-Autism
•  Autism Speaks
•  www.autismspeaks.org
•  Autism Society
•  www.autism-society.org
•  Taub M, Bartuccio M, Maino D. Visual Diagnosis and Care of the
Patient with Special Needs. 2012: Lippincott Williams & Wilkins.
Chapter 8
•  Elsabbagh M, Mercure E, Hudry K, et.al. Infant Neural Sensitivity to
Dynamic Eye Gaze is Associated with Later Emerging Autism.
Current Biology. 2012;22(4):338-42.
•  Black K, McCarus C, Collins ML, Jensen A. Ocular manifestations of
autism in ophthalmology. Strabismus. 2013;21(2):98-102.
•  Pendergrass S, Girirajan S, Selleck S. Uncovering the etiology of
autism spectrum disorders: genomics, bioinformatics, environment,
data collection and exploration, and future possibilities. Biocomputing.
2014; 422-26.
23 3/16/15 Copyright K. Kehbein 2015-COPE# 43881FV
References-Cerebral Palsy
•  United Cerebral Palsy
•  www.ucp.org
•  Taub M, Bartuccio M, Maino D. Visual Diagnosis and Care
of the Patient with Special Needs. 2012: Lippincott
Williams & Wilkins. Chapter 3
•  Fazzi E, Signorini SG, La Piana R, et.al. Neuroophthalmological disorders in cerebral palsy:
ophthalmological, oculomotor, and visual aspects.
Developmental Medicine & Child Neurology.
2012;54:730-6.
24 Pill Problems
PILL PROBLEMS:
OCULAR COMPLICATIONS FROM SYSTEMIC MEDICATIONS
Alan G. Kabat, OD, FAAO
Memphis, Tennessee
Common Drugs with Ocular Complications












Alendronate
Amiodarone
Benztropine
Diphenhydramine
Hydroxychloroquine
Sildenafil
Tamsulosin
Tetracycline
Topiramate
Warfarin
Trade: Benadryl, numerous generic
Drug class: non-selective histamine blocker


 Primary:
nasal & non-nasal signs and symptoms of
seasonal allergy, especially allergic rhinitis
 Secondary: insomnia, vertigo, motion sickness
Ingredient in numerous cold medications and sleep aids
(e.g. Nytol, Tylenol PM)

Alan G. Kabat, OD, FAAO
Indication(s):
Typical dosage: 25-50 mg, q4h or PRN
1
Pill Problems
Ocular Complications

Dry Eye
Dry Eye

Due to anticholinergic effects of the medication1
 Diminishes
aqueous production via autonomic
innervation to the primary lacrimal gland
 Opposite
action of Salagen (pilocarpine)
 Can
also cause dry mouth, urinary retention and
constipation


Dose-dependent effect
Reversible
1. Simons FE. Advances in H1-antihistamines. N Engl J Med 2004; 351(21):2203-17.
Mah FS, O'Brien T, Kim T, Torkildsen G. Evaluation of the effects
of olopatadine ophthalmic solution, 0.2% on the ocular surface of patients with
allergic conjunctivitis and dry eye. Curr Med Res Opin. 2008 Feb;24(2):441-7.



Other Manifestations
… to evaluate the safety of olopatadine 0.2% in
a population of patients with both allergic
conjunctivitis and dry eye.

52 patients with ocular allergy and mild-to-moderate dry
eye were evaluated.

Randomized to either olopatadine hydrochloride 0.2% or a
tear saline once-daily for 1 week.

Evaluated TBUT, corneal and conjunctival staining,
fluorophotometry, Schirmer's test, injection, and symptom
evaluations.



No significant differences between the treatment
groups were observed ( p > 0.05).

Drowsiness & fatigue
Anticholinergic effects including dry mouth, urinary
retention, and constipation
Potential for cardiac complications, particularly
arrhythmias and tachycardia
Potential for recreational use/abuse
Conclusion: As there were no significant changes
in the signs & symptoms of dry eye,
olopatadine 0.2% is safe to use in ocular
allergy patients with mild-to-moderate dry eye.
Simons FE. Advances in H1-antihistamines. N Engl J Med 2004; 351(21):2203-17.
OTC vs. Rx Drugs
Similar Medications with Similar Effects






Chlorpheniramine (Chlor-Trimeton)
Brompheniramine (Dimetane)
Dimenhydrinate (Dramamine)
Meclizine (Bonine)
Loratadine (Claritin, Alavert)
Cetirizine (Zyrtec)
Alan G. Kabat, OD, FAAO

Patients do not always equate items that they buy on
store shelves with the terms “drugs” or “medications”.
Practitioners and technicians must be SPECIFIC when
screening. Checklists on intake forms work well.
2
Pill Problems
and


derivatives
Trade: Sumycin®, Tetracyn®, numerous generics
Drug class: Tetracycline antibiotic

and

Indication(s):

Includes doxycycline and minocycline, among others
Primary: infection by susceptible bacterial strains




Ocular Complications

Scleral discoloration (minocycline)
derivatives
Respiratory, skin/soft tissue, UTIs most commonly
Rarely a “first-line” antibiotic therapy
Secondary: immunomodulatory agent for sebaceous
disorders, including rosacea and MGD
Typical dosage: 250 mg QID or 500 mg BID
Ocular Complications

Pseudotumor cerebri or
Idiopathic intracranial hypertension
Miraldi V, Singh AD, Jeng BH. The whites of my eyes have turned blue! EyeNet, March 2007
Pseudotumor cerebri

0.9 per 100,000 people in general population,
including children


Increased risk in women aged 20-44 who are 20% or more
above their ideal body weight
Diagnosis - based on modified Dandy criteria
Awake and alert patient
Signs and symptoms of increased ICP
 Absence of localized neuro exam findings, except for CN VI
paresis
 Normal CSF fluid findings except for increased pressure
 Absence of deformity, displacement, and obstruction of
ventricular system
 No other identifiable cause of intracranial hypertension
Other compounds associated with PTC
Oral contraceptives
Vitamin A
 Amiodarone




Alan G. Kabat, OD, FAAO

Glucocorticoids (withdrawal)

Mineralocorticoids (withdrawal)
 e.g.
 e.g.
cortisol
aldosterone
3
Pill Problems
Other Manifestations
Tooth Discoloration
Photosensitivity


Trade: Coumadin, numerous generics
Drug class: anticoagulant (“blood thinner”)
Ocular Complications

Indication(s):

Subconjunctival hemorrhage
Prophylaxis and/or treatment of venous thrombosis and
pulmonary embolism
 Thromboembolic complications associated with atrial
fibrillation and/or cardiac valve replacement
 To reduce the risk of death, recurrent myocardial
infarction, and thromboembolic events such as stroke or
systemic embolization after myocardial infarction
 Hypercoagulable states


Typical dosage: 5-10 mg daily
Bodack MI. A warfarin-induced subconjunctival hemorrhage.
Optometry. 2007;78(3):113-8.
Ocular Complications





Hyphema
76-year-old female
Subconjunctival hemorrhage & heaadache
Case review showed concurrent therapy with
warfarin, levothyroxine, atorvastatin, metoprolol,
and paroxetine.
INR = 9.9
Alan G. Kabat, OD, FAAO
4
Pill Problems
Ocular Complications

Retinal hemorrhage
Other Manifestations

Bleeding and bruising - can be potentiated by
a variety of drugs & other substances:
Antibiotics (e.g. aminoglycosides, macrolides,
fluoroquinolones and tetracyclines)
 Beta-blockers
 Levothyroxine
 Atorvastatin
 Fish oil / Ω-3 / vitamin E
 Alcoholic beverages
 Cranberry products
 Ginseng
 Garlic
 Ginko biloba
 St. John’s wort

Management Tips


Patients on warfarin therapy need to be cognizant
of everything they put in their mouths. Medications,
food, beverages… EVERYTHING!!

Trade: Cordarone, Pacerone, numerous generics

Drug class: anti-arrhythmic agent (Class III)

Indication: for life-threatening cardiac arrhythmias
INR (International Normalized Ratio) should be
performed by PCP routinely.
Measures the extrinsic pathway of coagulation
 Normal: 0.8 – 1.2
 Target range on therapy: 2.0 – 3.0
 Dangerous: >4.0

Ocular Complications

Corneal Verticillata


hemodynamically unstable ventricular tachycardia

shock-resistant, recurrent ventricular fibrillation
Typical dosage: 200-400 mg/day
Corneal Verticillata

i.e. “vortex keratopathy”, “hurricane keratopathy”
Generally asymptomatic



Alan G. Kabat, OD, FAAO

Rarely may cause haloes or slight decrease in VA
Seen in ~90% of patients on amiodarone >6 mos,
especially those taking >400 mg/day.
No management required; Self-limiting & reversible
5
Pill Problems
WARNING: Vortex keratopathy can
also be associated with… ?
FABRY’S DISEASE

Hereditary enzyme deficiency




Ocular Complications

Pseudotumor cerebri or
Idiopathic intracranial hypertension
α-Galactosidase A
located on the X-chromosome
Leads to intracellular accumulation of
neutral glycosphingolipids in various
organs, e.g. skin, eyes, nervous tissue,
kidney and heart
Findings: angiokeratomas, pain in the
hands & feet, lesions of the mouth and
multiple ocular signs
Other Manifestations

“Blue skin”, “blue man syndrome”

Long-term use; more commonly seen with lighter skin tones
Ocular Complications



Trade: Topamax
Drug class: anticonvulsant
Indication(s):


Acute myopic shift
Acute angle-closure glaucoma
Primary: treatment of epilepsy and other seizure
disorders
 Secondary: prevention of migraine headaches in adults
 Off-label: treatment of bipolar disorder, obsessivecompulsive disorder, alcoholism, smoking cessation,
cocaine dependence, eating disorders, and neuropathic
pain.


Typical dosage: (adults) 100 – 400 mg daily
Alan G. Kabat, OD, FAAO
6
Pill Problems
Levy J, Yagev R, Petrova A, Lifshitz T. Topiramateinduced
bilateral
angle-closure
glaucoma.
Can
J
Ophthalmol. 2006;41(2):221-5.
Pathological Mechanism

Appears to be a sulfa-allergic response



35-year-old woman presenting to E.D.




c/o severe eye pain & blurry vision OU
Hx: Oral topiramate 50 mg BID X 1 week
IOP: 57 mm Hg OD, 56 mm Hg OS
B-scan revealed 360° ciliochoroidal detachment OU


Cyclocongestive glaucoma
Normal open angle
Cyclocongestive angle closure



Trade: Flomax
Drug class: alpha-adrenergic antagonist
Indication(s):
NO pupil block; NO iris bombé!
Dysgeusia (taste perversion)
Parasthesias (numbness & tingling)

Fatigue
Difficulty with concentration,
attention and memory

Weight loss


Results in lens thickening; this, in addition to the forward rotation of
the lens-iris diaphragm induces a myopic shift
Lens thickening generally does not contribute to angle closure
Other Manifestations


Congestion of ciliary body allows lens zonules to go slack


Swelling/congestion and forward rotation of the ciliary body
Ciliochoroidal effusion with forward shifting of lens-iris diaphragm
Induces extreme anterior chamber shallowing and angle-closure

Mechanism: works by relaxing smooth muscle at the
distal portion of the urethra
Primary: signs and symptoms of benign prostatic
hyperplasia (BPH)
 Off label: urinary retention in women and those with
multiple sclerosis; facilitated passage of kidney stones


Typical dosage: 0.4 mg once daily
Alan G. Kabat, OD, FAAO
7
Pill Problems
Ocular Complications

IFIS - Intra-operative Floppy Iris Syndrome
IFIS

Clinical manifestations:




Management:



Other Manifestations
Poor preoperative dilation
Iris billowing and prolapse
Progressive intraoperative miosis
Identify patients at risk and
discontinue medication if possible
Use of stronger dilating agents,
e.g. epinephrine and/or atropine
Use of Malyugin or Morcher ring
Sulfa Allergy

Pustular, erythematous skin eruptions with urticaria


Can affect any part of the body
May progress to Stevens-Johnson syndrome in
severe cases
Other Manifestations





Fever, chills, body aches, or flu symptoms
Light headedness, dizziness, weakness, drowsiness
Headache
Nausea, diarrhea
Runny nose

Trade: Viagra

Similar medications: tadalafil (Cialis), vardenafil (Levitra,
Staxyn)

Drug class: phosphodiesterase enzyme inhibitor (PDEI)

Indication(s):

Originally studied as an anti-angina medication!
Primary: treatment of erectile dysfunction
Secondary: symptoms of benign prostatic hyperplasia
 Off-label: pulmonary hypertension, Raynaud's phenomenon
(Revatio)




Diminished ejaculate
Decreased sex drive, which leads us to…
Alan G. Kabat, OD, FAAO

Typical dosage: 50 mg (not to exceed 100 mg)
8
Pill Problems
Ocular Manifestations

Mechanism of action (warning: GRAPHIC)

Cyanopsia (“blue vision”)
By affecting PDE6 in the retina, sildenafil can lead to
altered color vision perception (usually a blue or green
“tinge” to vision).
 4 out of 5 men without vascular risk factors reported
this problem after taking sildenafil.

Ocular Manifestations

Tarantini A, Faraoni A, Menchini F, Lanzetta P. Bilateral simultaneous
nonarteritic anterior ischemic optic neuropathy after ingestion
of sildenafil for erectile dysfunction. Case Report Med. 2012.
Nonarteritic anterior ischemic optic neuropathy
Other Manifestations
Headache
 Stuffy nose
 Facial flushing




60-year-old diabetic man
c/o sudden decrease of vision OU, 16 hours after his 3rd
consecutive 50 mg daily sildenafil ingestion.
“In patients with a predisposing diabetic condition,
sildenafil intake can cause changes in NO balance altering
the normal vascular autoregulation so that the ocular
circulation may not be able to compensate for a drop in
systemic blood pressure. ”
Alan G. Kabat, OD, FAAO

And of course…
9
Pill Problems
Ocular Manifestations


Trade: Plaquenil, numerous generic
Drug class: aminoquinoline




anti-malarial drug
DMARD
treatment of malaria
treatment of discoid and systemic lupus erythematosus,
and rheumatoid arthritis
Typical dosage: 400-800 mg/day (malaria)
200-400 mg/day (lupus & RA)
Ocular Manifestations

Corneal deposits
Indication(s):



“Bulls-eye” maculopathy
Dosso A, Rungger-Brändle E. In vivo confocal microscopy in hydroxychloroquine-induced keratopathy. Graefes Arch Clin Exp
Ophthalmol. 2007;245(2):318-20.
Ocular Manifestations

“Bulls-eye” maculopathy
Anderson C, Blaha GR, Marx JL. Humphrey visual field findings in
hydroxychloroquine toxicity. Eye (Lond) 2011 December; 25(12): 1535-45.




Alan G. Kabat, OD, FAAO
66 visual fields from patients
with HCQ retinal toxicity.
HVF changes preceded
fundus changes in 60% of
patients.
Abnormalities were more
obvious on pattern deviation
than the gray scale.
Authors recommend white
stimulus 10-2 fields (vs. redstimulus), as per AAO
guidelines.
10
Pill Problems
OCT: The New Standard
Rodriguez-Padilla JA, Hedges TR 3rd, Monson B, et al. High-speed ultra-high-resolution optical
coherence tomography findings in hydroxychloroquine retinopathy. Arch Ophthalmol. 2007
Jun;125(6):775-80.

Chen E, Brown DM, Benz MS, et al. Spectral domain optical coherence tomography as an
effective screening test for hydroxychloroquine retinopathy (the "flying saucer" sign).Clin
Ophthalmol. 2010 Oct 21;4:1151-8.

ERG: The Emerging Standard
OCT: The New Standard


Chen JJ, Tarantola, RM, Kay CN, Mahajan VB. Hydroxychloroquine (Plaquenil)
Toxicity and Recommendations for Screening. EyeRounds.org. August 30, 2011.
Available from: http://EyeRounds.org/cases/139IplaquenilItoxicity.htm.
Focal thinning and loss of parafoveal PIL (photoreceptor integrity line)
Risk factors for maculopathy

Maintenance dose greater than 6.5 mg/kg/d

Normal mfERG




mfERG in
HCQ toxicity


120 lb. woman: >400 mg/d
200 lb. man: >600 mg/d
Duration of treatment: >10 years
Evidence of renal insufficiency or hepatic disease
Obesity
Advanced age
Presence of macular degeneration or dystrophy
Other Manifestations
Vertigo, tinnitus, headache
 Skin rashes and dermatitis
 GI disturbances
 Muscle weakness



Trade: Fosamax, numerous generic
Drug class: aminobiphosphonate



anti-resorptive agent (strengthens bones)
similar drugs include Actonel, Boniva
Indication(s):
Primary: treatment or prevention of
osteoporosis, treatment of Paget’s disease
 Off label: Metastatic bone cancer, hypercalcemia,
vitamin D overdose


Alan G. Kabat, OD, FAAO
Typical dosage: 5-10 mg/day (osteoporosis)
40 mg/day (Paget’s disease) X 6 months
11
Pill Problems
Ocular Manifestations

Non-specific conjunctivitis and/or keratitis
Ocular Manifestations

Episcleritis, scleritis, anterior uveitis
McKague M, Jorgenson D, Buxton KA. Ocular side effects of bisphosphonates: A case
report and literature review. Can Fam Physician. 2010 Oct;56(10):1015-7
Other Manifestations





Nausea, dyspepsia, acid regurgitation
Abdominal pain, constipation, diarrhea
Musculoskeletal pain
Hypocalcemia
Osteonecrosis of the jaw

Trade: Cogentin (discontinued in US); numerous generics
Drug class: anti-parkinsonian medication

Indication(s):




Possesses both anticholinergic and antihistaminic effects
As an adjunct in the therapy of all forms of parkinsonism
For control of medication-induced movement disorders due
to antipsychotic agents, e.g.


Parkinsonian Tremor
Typical dosage: 1-2 mg/day
Ocular Manifestations

Anticholinergic effects (think atropine!):


Mydriasis
Cycloplegia



Alan G. Kabat, OD, FAAO
Chlorpromazine (Thorazine), haloperidol (Haldol), risperidone
(Risperdal), olanzapine (Zyprexa), quetiapine (Seroquel)
Impaired accommodation
Transient refractive shift
Dry eyes
12
Pill Problems
Ocular Manifestations

Esotropia / diplopia

Proposed mechanism: The ratio of convergence to accommodation
may increase with anticholinergics due to partial block of
accommodation. To see a near target in the setting of blocked
accommodation, children would increase accommodative effort,
resulting in increased convergence. Too much convergence may
cause esotropia.
Other Manifestations

MORE anticholinergic effects
PERIPHERAL
Dry mouth
Hot, dry skin
Tachycardia
Constipation
Urinary retention
CENTRAL
Sedation
Confusion
Delirium
Slowed cognitive function
Oh SY, Shin BS, Lee YH, Lee AY, Kim JS. Benztropine-induced Esotropia and Mydriasis. J Neuroophthalmol. 2007 Dec;27(4):312-3.
Risk of falls
CONCLUSIONS:



Optometric PHYSICIANS must realize that the eye is
impacted by numerous systemic diseases and drugs.
A working knowledge of pharmacology and
common drugs is essential (especially when dealing
with an adult or geriatric population).
Even if you don’t (or can’t) prescribe them, you have
the responsibility to recognize the potential ocular
impact of commonly prescribed medications.
Questions?
Email me at: [email protected]
Alan G. Kabat, OD, FAAO
13