2016 the eyes have it...clinical characteristics ocular involvement ! proliferative diabetic...

Systemic Disorders with Ophthalmic Manifestations Common Ophthalmic Disorders in Primary Care

THE EYES HAVE IT

Kate Goldblum, CFNP

NMNPC Annual

Conference April 16, 2016

DISCLOSURES

I have no financial interests relevant to this presentation.

I will not discuss an off-label or investigational use of any commercial product.

THE EXTENT OF MY OPHTHALMOLOGY KNOWLEDGE IS THAT I KNOW OD MEANS RIGHT EYE & OS MEANS LEFT EYE.

A.  True B.  False

M R . S M I T H H A D H E R P E S Z O S T E R O P H T H A L M I C U S T H AT C O M P L E T E LY & U N E V E N T F U L LY R E S O LV E D 6 W E E K S A G O F O L L O W I N G T R E AT M E N T B Y H I S O P H T H A L M O L O G I S T . H E N O W P R E S E N T S T O Y O U W I T H C / O M I L D I R R I TAT I O N & R E D N E S S I N T H E S A M E E Y E . Y O U . . . .

A.  Tell him to use artificial tears. B.  Refer him to an ophthalmologist. C.  Prescribe a topical antihistamine. D.  Have him return in a week if his

symptoms aren’t improving.

! Varicella-zoster virus (chicken pox) ! Virus resides latent in the dorsal root ganglia of

sensory neurons ! Reactivation in adult years ! Any dermatome can be affected

! 50% to 56% - thoracic ! 20% - CNs V, VII, & VIII ! Ophthalmic division of trigeminal nerve (CN V)

! Obeys midline

HERPES ZOSTER ETIOLOGY

! 1 in 3 will develop herpes zoster over lifetime ! 1 million new cases per year ! 25 to 40% will have ocular involvement ! Increasing due to aging population ! Prevention

! Zostavax ! Adults ≥ age 60

HERPES ZOSTER EPIDEMIOLOGY

! Trigeminal nerve involvement ! Vesicles on forehead, side of nose, upper eyelid, & eye ! Post-herpetic neuralgia

! Ocular disease ! Blepharitis ! Conjunctivitis ! Keratitis – epithelial, stromal, neurotropic ! Uveitis, recurrent iritis – at risk for secondary glaucoma,

cataracts, scarring, retinitis ! Scleritis, episcleritis

CLINICAL CHARACTERISTICS OCULAR INVOLVEMENT

CUTANEOUS LESIONS

EPITHELIAL KERATITIS

! May mimic dendritic lesion of herpes simplex ! Stains with fluorescein

STROMAL KERATITIS

! Subepithelial infiltrates

! Located in anterior stroma below areas of previous epithelial keratitis

SEQUELAE

! Occurrence or reoccurrence of symptoms possible months later

T e a c h i n g M o m e n t

W H AT P ERC EN T OF PAT IEN T S W IT H D IA B ET ES H A D A N A N N UA L EY E EX A M IN 2 01 2 AC C ORDING TO NM H EALT H CARE TAKES ON D IAB ET ES ?

A.  25.6% B.  55.3% C.  75.8% D.  95.2%

DIABETES MELLITUS EPIDEMIOLOGY

! Normal or minimal NPDR ! Mild NPDR ! Moderate NPDR ! Severe NPDR ! Non-high-risk PDR ! High-risk PDR

Follow-Up & Treatment Based on Degree of Retinopathy

D I A B E T I C R E T I N O P A T H Y


! Mild non-proliferative diabetic retinopathy (NPDR) ! Microaneurysms

! Moderate NPDR ! More than just microaneurysms ! Less than severe


! Severe NPDR ! Any of following (4-2-1 rule) & no signs of proliferation

! Severe intraretinal hemorrhages & microaneurysms in each of FOUR quadrants

! Definite venous beading in TWO or more quadrants of venous beading

! Moderate IRMA* in ONE or more quadrants

*intraretinal microvascular abnormalities


! Proliferative diabetic retinopathy (PDR) ! Abnormal blood vessels on optic disc, retina, iris, angle

structures (neovascularization) ! Vitreous/pre-retinal hemorrhage ! Associated with severe vision loss

! Clinically significant macular edema (CSME) ! Retinal thickening at or within 500 µm of central macula, &/or ! Hard exudates at or within 500 µm of macula if associated with

thickening of the adjacent retina &/or ! Zone(s) of retinal thickening one disc area in size, any part of

which is within 1 disc diameter of macula

EPIDEMIOLOGY OF OCULAR INVOLVEMENT 2005-2008

! Adults with diabetes ≥ 40 years of age ! 4.2 million (28.5%) had diabetic retinopathy ! 655,000 (4.4%) had advanced diabetic

retinopathy

BACKGROUND DIABETIC RETINOPATHY

TREATED DIABETIC RETINOPATHY

Insurance Model 2008 2009 2010 2011 2012 2012 Nat’l Avg

Commercial HMO 47.5 44.8 49.0 45.5 46.3 56.8

Commercial PPO 27.6 42.5 36.8 40.6 42.1 48.8

Medicaid HMO 53.3 55.4 52.7 51.4 51.2 53.2

Medicare HMO 69.7 69.6 66.0 67.5 70.9 66.8

Medicare PPO -- 62.0 62.1 62.5 65.9 64.6

Average Rate 49.5 54.9 53.3 53.5 55.3 --

NM HEALTH CARE TAKES ON DIABETES NM RATES FOR EYE EXAM 2008-2012

Report of Diabetes Eye Examination on ___________________

To: _________________________________________ Clinic/Office ____________________________________ Primary Care Provider Phone ______________________________________ Fax _____________________________________________

Patient Name ____________________________________________________ DOB ______________________

Visual Acuity __________ OD __________OS Intraocular Pressure __________ OD __________OS

Retinal Examination Findings

No retinopathy or history of retinopathy; recommend re-examination in one year.

Needs no laser now, but should return in _____ months because of risk of developing diabetic

macular edema (DME) or high risk proliferative diabetic retinopathy (PDR).

DME requiring focal laser photocoagulation.

High risk PDR or iris neovascularization requiring panretinal photocoagulation.

Tractional retinal detachment or vitreous hemorrhage requiring vitrectomy.

Other Ocular Conditions

Cataracts, not interfering with activities of daily living or functional abilities.

Cataracts, interfering with activities of daily living or functional abilities.

Glaucoma, controlled. Glaucoma, suboptimally controlled.

Ocular hypertension. Vitreous floaters.

Pseudophakia. Other ________________________________________________

Treatment Plan

Refer to retinal specialist Follow up in _____ weeks/months

Fluorescein angiogram OD OS

Panretinal laser photocoagulation OD OS

Focal laser photocoagulation OD OS

Vitrectomy OD OS

Cataract surgery OD OS

Other ____________________________________________________________________________________ _________________________________________________________________ Date _____________________

Acme Eye Center

123 Central Street • Anytown, NM 12121 Phone: (505) 333-2222 • Fax: (505) 333-4444

! Toxoplasma gondii parasitic infection ! Foodborne

! Undercooked meats (especially pork, lamb, venison) ! Failure to wash hands after handling raw meat ! Contamination of fresh food with utensils used on meat

! Animal to human (zoonotic) ! Cats infected by eating infected rodents, birds ! Shed microscopic oocysts in feces up to 3 weeks

TOXOPLASMOSIS ETIOLOGY

! Congenital ! Newly infected during pregnancy ! Ocular & nervous system consequences for unborn

child can be severe ! Rare causes

! Organ transplant ! Blood transfusion ! Laboratory workers – accidental inoculation

TOXOPLASMOSIS ETIOLOGY

! At least 14% of population infected by age 40 ! 1,000,000 + infected each year ! Most common retinal infection in US – about 2%

of all those infected have ocular involvement ! 20,000 develop ocular lesions each year ! Symptomatic retinitis in 0.2% to 0.7% of those

infected (2000–7500/year; midpoint ~5000) ! New lesions may develop over years after

infection so incidence may be higher

TOXOPLASMOSIS EPIDEMIOLOGY


! Asymptomatic in most immunocompetent patients ! Eye pain, photophobia, epiphora, blurred vision ! Eye disease may reactivate months to years later

! Further damage to retina ! Progressive loss of vision if central retinal structures

involved ! Can lead to blindness


! Ocular symptoms vary with age ! Young children - " VA, strabismus, nystagmus, leucocoria ! Teens & adults - " VA, floaters, photophobia, pain,

hyperemia ! Retinochoroiditis – typically in posterior pole ! Active lesions – grey-white retinal necrosis surrounded

by choroiditis, vasculitis, vitreitis, hemorrhages ! Anterior uveitis – mutton-fat keratic precipitates, cell &

flare, iris nodules, synechiae

RETINAL LESION

RETINAL LESIONS

DIAGNOSTIC CONSIDERATIONS HISTORY OF PRESENT ILLNESS

! Complaints of fever, myalgia, fatigue, headache, rash, sore throat

! Exposure to cat feces, undercooked meats ! Active ocular disease – blurred VA, floaters,

metamorphopsia

DIAGNOSTIC CONSIDERATIONS OCULAR EXAMINATION

! Decreased VA ! Congenital disease

! Strabismus ! Microphthalmia ! Cataract ! Optic atrophy ! Nystagmus ! Retinal detachment

! Retinal exam – old retinochoroidal scars

! Treatment dependent on several factors ! Acquired disease in

immunocompetent often requires no Rx

! Minimal inflammation, peripheral ocular lesions, VA minimally affected – lean toward no Rx

! No studies show extent Rx alters course of disease

! Immunocompromised patients ! Various antibiotic regimens

(sufadiazine, pyrimethamine, clindamycin, azithromycin, TMP/SMX, e.g.)

Treatment

OCULAR TOXO

HYPERTENSION OCULAR INVOLVEMENT

H y p e r t e n s i v e r e t i n o p a t h y c a n p r e d i c t l o n g - t e r m r i s k

o f s t r o k e .


! Retinal fundus findings !  Retinal hemorrhages (blot & flame shaped) ! Microaneurysms !  Soft exudates !  Hard exudates ! Macular edema !  Intraretinal microvascular abnormalities (IRMA) !  Venous beading, !  New vessels at disc or elsewhere !  Vitreous hemorrhage !  Disc swelling !  Arteriolar narrowing

HYPERTENSIVE RETINOPATHY

HOLLENHORST PLAQUES

CENTRAL RETINAL ARTERY OCCLUSION

HYPERTENSIVE RETINOPATHY

Silver Wiring

Silver Wiring

Exudates

Cotton Wool Spot

Treatment

HTN RETINOPATHY

G o o d B P C o n t r o l

!  Inflammation of the conjunctiva !  Allergic – seasonal, atopic, giant papillary conjunctivitis (GPC) ! Mechanical, irritative, or toxic – medication induced, exposure

to toxic chemicals !  Viral !  Bacterial

CONJUNCTIVITIS DEFINITION

!  Frequent cause of patient self-referral for eye care !  Rarely causes permanent vision loss but economic impact is

significant

CONJUNCTIVITIS EPIDEMIOLOGY

!  Bulbar & tarsal components !  Very vascular !  Pathophysiology dependent on cause

CONJUNCTIVITIS ANATOMY & PATHOPHYSIOLOGY

!  Discharge !  Irritation &/or pain !  Redness !  Itching !  Decreased vision

CONJUNCTIVITIS CLINICAL PRESENTATION

!  Allergic !  Itching ! Watery or stringy discharge !  Chemosis

CONJUNCTIVITIS CLINICAL PRESENTATION

!  Viral (adenovirus) ! Watery discharge !  Unilateral or bilateral (sequentially bilateral) !  Preauricular adenopathy !  Petechial & subconjunctival hemorrhage

CLINICAL PRESENTATION

CONJUNCTIVITIS # ALLERGIC

CONJUNCTIVITIS # BACTERIAL

!  Topical antihistamines ± vasoconstrictor !  Pheniramine + naphazoline/Naphcon A !  Rebound congestion with vasoconstrictors

! ALLERGIC

CONJUNCTIVITIS MEDICAL MANAGEMENT

!  H1-receptor antagonists !  Azelastine/Optivar (mast cell action) !  Emedastine/Emadine !  Ketotifen/Zaditor (mast cell action) !  Levocabastine/Livostin !  Olopatadine/Patanol & Pataday (mast cell action)

! ALLERGIC


!  Topical steroid (mildest potency/frequency) !  Fluorometholone/FML !  Loteprednol etabonate/Alrex

!  Topical non-steroidal anti-inflammatory !  ketoralac/Acular approved for use in allergic conjunctivitis

! ALLERGIC


! Mast call inhibitors !  Cromolyn/Crolom !  Lodoxamide tromethamine/Alomide !  Nedocromil sodium/Alocril !  Pemirolast potassium/Alamast

! ALLERGIC


!  Usually self-limiting !  Symptomatic relief

!  Artificial tears, cold compresses !  Topical antihistamines !  Topical steroids (increases length of contagious period)

! VIRAL


! Mild presentation !  Self-limiting !  Earlier clinical response with topical antibacterial therapy !  Antibiotic choice based on cost & convenience !  5 to 7 days of treatment adequate

! BACTERIAL


!  Severe or complicated presentation !  Copius discharge !  Pain & inflammation ! MRSA increasing in frequency

!  Antibiotic choice based on culture !  Neisseria gonorrhoeae & Chlamydia trachomatis require

systemic antibiotics

! BACTERIAL


!  Axithromycin/AzaSite !  Besifloxacin/Besivance !  Ciprofloxacin/Ciloxan !  Gatifloxacin/Zymaxid ! Moxifloxacin/Vigamox !  Ofloxacin/Ocuflox

! BACTERIAL


!  Socioeconomic issues !  Good figures not available ! Missed work &/or school !  Example – adenovirus conjunctivitis outbreak in nursing home

with 41 affected cost $29,527 ! With savings from rapid test for viral conjunctivitis, cost savings

in US estimated at $430 million

CONJUNCTIVITIS $$$$$

BLEPHARITIS DEFINITION & CLASSIFICATION

! Chronic inflammation of lid margins ! Anterior

! Eyelid skin ! Base of lashes ! Lash follicles

! Posterior ! Meibomian glands ! Gland orifices

BLEPHARITIS SUBCLASSIFICATION

! Staphylococcal ! Seborrheic ! MGD (meibomian gland dysfunction)

!  Common condition but data lacking ! Mean age 50 ! With staph blepharitis – 80% women (eye makeup?) !  Irritation, erythema, edema of lid margin

BLEPHARITIS EPIDEMILOGY & CLINICAL FEATURES

!  Dry eye !  Reported in 50% of patients with staph blepharitis !  Conversely, of patients with dry eye, up to 75% have staph blepharitis

or conjunctivitis

!  Rosacea !  Use of isotretinoin – usually resolves with discontinuation !  Contact-lens-associated giant papillary conjunctivitis (GPC)

BLEPHARITIS ASSOCIATIONS

!  Ocular irritation !  Eyelid features

!  Irritation !  Erythema !  Edema !  Eyelash “collarettes”

BLEPHARITIS CLINICAL CHARACTERISTICS

!  Eyelid hygiene !  Lid scrubs ! Warm soaks ! Massage in MGD

!  Topical antibiotic in staph blepharitis !  Bacitracin !  Erythromycin !  Patients often prefer drops

BLEPHARITIS TREATMENT

!  Loss of vision !  Pain !  Erythema – severe &/or chronic !  Orbital involvement !  Recurrent episodes !  Lack of treatment response

BLEPHARITIS INDICATIONS FOR REFERRAL

M a l i g n a n c y ?

!  Disorders of tear film due to reduced tear production or excessive tear evaporation

!  Associated with ocular discomfort &/or visual symptoms & possible ocular surface disease

DRY EYE DEFINITION

!  Information limited by lack of uniform definition & inability of of any single diagnostic test or set of tests to confirm or rule out the disorder

!  Recognized as a common condition !  1 million – 4.3 million aged 65 to 84 in the US

DRY EYE EPIDEMIOLOGY

!  Risk factors !  Older age & female gender !  Low dietary intake of omega-3 fatty acids !  Antihistamines !  LASIK & refractive excimer laser surgery ! Many other factors with less certain effect

DRY EYE EPIDEMIOLOGY

!  Lacrimal & meibomian glands form integrated unit to maintain tear film

!  Inadequate tear production by lacrimal gland !  Increased tear evaporation due to meibomian gland

secretory dysfunction

DRY EYE ANATOMY & PATHOPHYSIOLOGY

Large lacrimal gland

Conjunctivaa

Meibomian glands

Mucous layer Watery layer Oily later

Tear film

!  Complaints of irritation, tearing, burning, stinging, dry or foreign body sensation

! Mild itching, photophobia, blurry vision, contact lens intolerance, redness, eye fatigue

!  Symptoms may be worse later in the day !  Exacerbation by wind, air travel, low humidity

DRY EYE CLINICAL PRESENTATION

!  Ocular surface dye staining !  Tear breakup time !  Schirmer test (aqueous tear production) !  Tear osmolarity

!  NO single test adequate to confirm diagnosis

DRY EYE OPHTHALMIC DIAGNOSTICS

!  Testing for systemic disorders !  Sjögren syndrome !  Thyroid eye disease !  Sarcoidosis !  Cictricial pemphigoid

DRY EYE DIAGNOSTICS

!  Treat causative factors (e.g., thyroid disease, Sjögren syndrome)

!  Tear replacement !  Ophthalmic anti-inflammatory agents (cyclosporine/Restasis) !  Omega-3 fatty acids – nutritional supplement !  Eyelid therapy – lid hygiene, warm compresses !  Environmental modifications

DRY EYE MEDICAL MANAGEMENT

!  Punctal occlusion !  Plugs !  Permanent occlusion

!  Tarsorrhaphy !  Ectropian repair, other lid surgeries to improve

malposition

DRY EYE SURGICAL MANAGEMENT

!  Primary angle-closure glaucoma !  Ocular emergency – can result in vision loss !  Narrow anterior chamber (AC) angle predisposes to angle

closure

ACUTE GLAUCOMA

ANTERIOR SEGMENT

Ciliary body

Iris

Anterior chamber Lens Cornea Bulbar

conjunctiva

!  Refer emergently

ACUTE GLAUCOMA

!  Periorbital – preseptal cellulitis !  Orbital – septal cellulitis

CELLULITIS PERIORBITAL & ORBITAL

!  Periorbital redness, tederness ! Must rule out orbital involvement, sepsis

PRESEPTAL CELLULITIS

PRESEPTAL (PERIORBITAL) CELLULITIS

SEPTAL (ORBITAL) CELLULITIS

!  Often secondary to sinusitis !  Proptosis !  Ophthalmoplegia !  Decreased ocular mobiltiy !  Fever !  Life-threatening !  Require hospitalization, IV antibiotics

ORBITAL CELLULITIS

!  Often secondary to sinusitis !  Proptosis !  Ophthalmoplegia !  Decreased ocular mobility !  Fever !  Life-threatening !  Referral for hospitalization, IV antibiotics

!  Esotropia – convergent misalignment of the visual axes (eye turns in) !  Infantile (3 to 6 months) !  Acquired (accommodative, non-accommodative)

STRABISMUS DEFINITION

!  Exotropia – divergent misalignment of the visual axes (eye turns out) !  Infantile – presents before 6 months of age; constant !  Intermittent – usually seen before age 3 !  Convergence insufficiency – typically have intermittent

exotropia at near

STRABISMUS DEFINITION

!  Esotropia – about 1% !  Exotropia – about 1% !  Associated with prematurity, maternal substance abuse

& smoking, family history, other factors !  Higher risk of amblyopia – about 50% of children with

strabismus develop amblyopia

STRABISMUS EPIDEMIOLOGY

!  Children with strabismus !  Reduced binocular vision !  Social interactions impaired !  Perceived negatively

STRABISMUS EPIDEMIOLOGY

STRABISMUS # ANATOMY Superior oblique

Inferior oblique Inferior rectus

Medial rectus

Lateral rectus

Superior rectus

Levator palpebrae superioris

!  Abnormality of poorly understood neuromuscular control of eye movement

!  Less commonly, a problem with the actual eye muscle !  Paralytic strabismus (CN III, CN IV & CN VI)

STRABISMUS PATHPHYSIOLOGY

Muscle CN Primary Secondary Tertiary

MR III Adduction – –

SR III Elevation Intorsion Adduction

IR III Depression Extorsion Adduction

IO III Extorsion Elevation Abduction

SO IV Intorsion Depression Abduction

LR VI Abduction – –

!  Parents don’t always notice the deviation !  Deviation may be intermittent or constant !  Amblyopia frequently present – must assume it is !  Adult patients with strabismus or hx of strabismus may

have children with strabismus !  Vision training is NOT indicated

STRABISMUS CLINICAL PRESENTATION

THE EXTENT OF MY OPHTHALMOLOGY KNOWLEDGE IS THAT I KNOW OD MEANS RIGHT EYE & OS MEANS LEFT EYE.


M R . S M I T H H A D H E R P E S Z O S T E R O P H T H A L M I C U S T H AT C O M P L E T E LY & U N E V E N T F U L LY R E S O LV E D 6 W E E K S A G O F O L L O W I N G T R E AT M E N T B Y H I S O P H T H A L M O L O G I S T . H E N O W P R E S E N T S T O Y O U W I T H C / O M I L D I R R I TAT I O N & R E D N E S S I N T H E S A M E E Y E . Y O U . . . .

A.  Tell him to use artificial tears. B.  Refer him to an ophthalmologist. C.  Prescribe a topical antihistamine. D.  Have him return in a week if his

symptoms aren’t improving.

W H AT P ERC EN T OF PAT IEN T S W IT H D IA B ET ES H A D A N A N N UA L EY E EX A M IN 2 01 2 AC C ORDING TO NM H EALT H CARE TAKES ON D IAB ET ES ?

A.  25.6% B.  55.3% C.  75.8% D.  95.2%

PERIORBITAL CELLULITIS IS MORE CONCERNING THAN ORBITAL CELLULITIS.


STRABISMUS RARELY CAUSES AMBLYOPIA.


2016 the eyes have it...clinical characteristics ocular involvement ! proliferative diabetic...

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