Do You See What I See (or Don’t)? Office-based Ophthalmology for

the Primary Care Provider Steve Roberts, MDCM, FRCSC, D. ABO

2017 PEIP Conference DoubleTree Hotel, West Edmonton

Oct. 22, 2017

Faculty/Presenter Disclosure

• Presenter: Steve Roberts

• Relationships that may introduce potential bias and/or conflict of interest:

– Grants/Research Support: N/A

– Speakers Bureau/Honoraria: Steve Roberts has received a speaker fee and expense support from the Alberta College of Family Physicians.

– Consulting Fees: N/A

– Other: N/A

Disclosure of Commercial Support

• This program is presented by the Alberta College of Family Physicians (ACFP) without any commercial or in-kind support. – The ACFP provides a speaker fee and expense support for presenting at the Practical

Evidence for Informed Practice.

How I Arrive at a Diagnosis

• the best answers to questions asked in this specialty typically require lots of gear!

Hallway Consult

• Oh good! Dr. Roberts!

• This happened 2 days ago, I was out with my kids in a field, when….

• ???????????????????????????????????????????????????????????????

Be Realistic

• So it is going to be impossible to independently manage many eye complaints armed with, at best:

But Hopeful

• But you don’t have to feel powerless or that the eye is somehow an impenetrable puzzle

Outline

• Helpful Reminders and Tips

• Dry Eye Disease

• Allergic Conjunctivitis

• Cataract

• Retinal Detachment

Basic facts prior to consultation

• Visual acuity (the vital sign of the eye)

• Nature of symptom

• Duration of symptom (blind eye for 1 day or 10 years)

• Relevant antecedents (eg: recent surgery, trauma, previous similar episode)

• Previous ocular conditions or surgeries

• Does the patient wear glasses or contact lenses (and if so, did they bring them to the office or ER for their exam!)

• Do not fax an urgent referral – please call the office, or page the specialist

General Tips – Visual Acuity

• Please ascertain this prior to consultation. ‘She can see my fingers’ is not very descriptive or accurate. It is likely that ‘she’ can see even more precisely, and this should be communicated.

• Nurses and clinical staff can do this for you. • Patient should be wearing glasses for distance (if

checking at distance), or glasses for near if checking vision on a near chart (paper or smart phone, EHB app).

• Cover left eye, test the right. • Cover right eye, test the left. • Record.

It’s, um, in the iris…

I’ll just sew that up….

There is a proper way…

Poor (No?) Repair Can Be Bad…

Sudden loss of vision – Use Red Reflex

Dry Eye Disease

• Endemic problem, affecting 7.4 – 33.7 % of the population1

• Incidence in Canada may be as high as 25%2

• Particularly worse when the environment does not help at all, such as in Alberta

• Was dismissed for many years, but its importance is becoming better recognized, and therefore, better studied

3 Major Categories

• Aqueous Tear Deficiency

• Evaporative Dry Eye Disease

• Some relative combination of the two

Aqueous Tear Deficiency

That which is due to SJS, or non-SJS entities

Sjögren syndrome – ATD + dry mouth

Evaporative Dry Eye Disease

3 categories

1. Oil deficient

2. Lid related (exposure)

3. Surface changes of conjunctiva

Lid-Related

• Reduced blink rate – primary or secondary to neurological disease (Parkinsons, Alzheimer’s)

• Tumors/previous surgery (sling repair of congenital ptosis)/trauma

• Ectropion

• Nocturnal lagophthalmos

• TAO (proptosis/lid retraction)

3 Major Categories

Symptoms

• Burning • Itching • Foreign body sensation • Stinging • Dryness • Photophobia • Ocular fatigue • Redness • Crusting • Loss of clarity with concentration/sustained visual

focus

Testing

Testing

Therapy for Dry Eye Disease

Replacement Many different formulations and admixtures, with various effects benefits and side-effects • Lubricating drops • Gel-drops • Mineral oil-based drops • Ophthalmic ointments • Preservative-Free Recent Cochrane Review reaffirms that they all in general relieve dry eye disease, but no extrapolations can be made with regards to comparative efficacy of OTC brands4

Restasis

• 0.05% cyclosporine A

• Only medicine to assist with helping patient increase tear production, although this was not seen in patients with tear duct plugs or in those using anti-inflammatory drops

• Clearly improves objective markers of dry eye disease, but is less effective in controlling symptoms5

Hot Compresses Rx

Omega 3 FFA Supplementation

• Improves the quality of the oil secreted

• Patients objectively and subjectively improved with regular supplementation6,7

Blepharitis Management

• Daily lid care

• Tetracycline/doxycycline, for 3 months at a time for rosacea patients with eye symptom flare-up is helpful

• Short-term (10-14 days) topical steroids (fluorometholone, loteprednol, prednisolone)

Blepharitis Management

Blepharitis Managment

Blinking Exercises

• Written exercise instruction handouts

• Smartphone apps

• PC Programs

Environmental

Environmental

Allergic Conjunctivitis

Without Corneal Involvement

• <24 hours = Acute Allergic Conjunctivitis

• One season = Seasonal Allergic Conjunctivitis

• All seasons = Perennial Allergic Conjunctivitis

With Corneal Involvement

• Vernal keratoconjunctivitis (VKC)

• Atopic keratoconjunctivitis (AKC)

Alergic Conjunctivitis - Symptoms

• Itchiness (with eye rubbing Hx)

• Swollen lids

• Swollen conjunctiva

• Hyperemic conjunctiva

• Bilateral presentation

• ‘Ropey’ or watery discharge

Allergic Conjunctivitis

Giant Papillary Conjunctivitis

VKC

AKC

Ideal Treatment

• Prevent/avoid/reduce exposure to offending allergen

Real Treatment8

• OTC antihistamine/vasoconstrictor like tetrahydrozoline, oxymetazoline, etc, eg: Visine, Cleareyes

• H1 receptor antagonist (bepotastine/Bepreve) • Mast-cell stabilizers (olopatadine/Pataday, also a H1

receptor antagonist) • Lower dose/potency steroids (Prednisolone 0.125 %/

Pred Mild, loteprednol 0.2 %/Alrex) • NSAIDS – ketorolac/Acular and ketotifen/Zaditor • Cold compresses, artificial tears to dilute allergy • Allergy specialist referral – immunotherapy, sublingual

immunotherapy (SLIT)

Advice

• Cochrane review from 2015 indicates that for seasonal/perennial allergic conjunctivitis, ALL reported topical antihistamines and mast cell stabilizers improved symptoms vs. placebo, while being safe and well tolerated9

Examples – Opticrom, Pataday, Bepreve

Cataract

• Media opacity of the human lens

• Can be completely insignificant

• Can be life-altering

Mature Cataract

Medical Treatment?

• No medical treatment for cataracts

• A twin study from the UK analysing 1000 female twins, indicated that diets rich in vitamin C were associated with a 20 percent risk reduction for cataract. After 10 years, researchers found that women who reported consuming more vitamin C-rich foods had a 33 percent risk reduction of cataract progression10

Supportive Treatment

• Changes and progression of cataract can be rapid (trauma, penetrating injury, etc.) or slow (nuclear sclerosis getting slowly worse with age)

• This incurs refractive change, and patients require frequent updates to their glasses or contact lenses

• …until vision becomes too poor or there is too much light scatter affecting patient’s ability to see

Nuclear Sclerosis

Phacoemulsification

Complications • one of the most commonly performed, safest medical

procedures in existence

• ‘blurred vision’ is non-specific and is most likely due to a continued need for glasses for optimal vision post-operatively

• IFIS – intraoperative floppy iris syndrome is a problem during surgery in patients on tamsulosin, as well as those on quetiapine and risperidone to a lesser extent

• Study from 2009, from Canada, demonstrated men on tamsulosin had 2.3 times the risk of severe postoperative complications from cataract surgery, including retinal detachment and endophthalmitis11

IFIS

Recommendation

• In patients who are anticipating cataract surgery or are on a cataract surgery waiting list, it is advised to hold off on prescribing an alpha blocker until after the surgery12,13

Retinal Detachment

• Painless loss of vision, which usually starts with a dense visual field loss or darkness, beginning on one side/top/bottom of the visual field, gradually extending centrally

Symptoms

Vitreous Detachment

• Flashes may be present, but there is usually a new or prominent large floater, +/- many new little ones (often signifying RBCs)

• Characterized by a separation of the posterior aspect of the vitreous, and that of the underlying retina

• 74-92 % of the time a ‘clean’ break occurs

• So the other times are what happens when the vitreous gel pulls too strongly on the retina, causing a retinal hole or tear

Retinal Photocoagulation for Tear

Retinal Detachment

Retinal Detachment

RD - Urgency

• If dark curtain and central vision is good – Urgent case

• If Hx of dark curtain and the central vision is poor – 7 days to repair14

References

1. Gayton, JL. Etiology, prevalence, and treatment of dry eye disease. Clinical Ophthalmology. 2009; 3: 405-412.

2. Doughty MJ, Fonn D, Richeter D, et al. A patient questionnaire approach to estimating the prevalence of dry eye symptoms in patients presenting to optometric practices across Canada. Optom Vis Sci. 1997;74:624–631.

3. Viso E, Rodriguez-Ares MT, Abelenda D, Oubina B, Gude F. Prevalence of asymptomatic and symptomatic meibomian gland dysfunction in the general population of Spain. Invest Ophthalmol Vis Sci 2012;53:2601-6

4. Pucker AD, Ng SM, Nichols JJ. Over the counter (OTC) artificial tear drops for dry eye syndrome. Cochrane Database of Systematic Reviews 2016, DOI: 10.1002/14651858.CD009729.pub2.

References

5. Ames P, Galor A. Cyclosporine ophthalmic emulsions for the treatment of dry eye: a review of the clinical evidence. Clin Investig. 2015; 5(3): 267–285.

6. Macsai M. The Role of Omega-3 Dietary Supplementation in Blepharitis and Meibomian Gland Dysfunction. Trans Am Ophthalmol Soc. 2008 Dec; 106: 336–356.

7. Epitropoulos AT, Donnenfeld ED, Shah ZA, et al. Effect of Oral Re-esterified Omega-3 Nutritional Supplementation on Dry Eyes. Cornea. 2016 Sep;35(9):1185-91.

8. Au A, Grigorian AP, Adamopoulou C. (2014, December 17). Allergic Conjunctivitis. Retrieved from: http://eyewiki.aao.org/Allergic_conjunctivitis on Oct. 12, 2017.

9. Castillo M, Scott NW, Mustafa MZ, et al. Topical antihistamines and mast cell stabilisers for treating seasonal and perennial allergic conjunctivitis. Cochrane Database of Systematic Reviews 2015, DOI: 10.1002/14651858.CD009566.pub2.

References

10. Yonova-Doing E, et al. Genetic and Dietary Factors Influencing the Progression of Nuclear Cataract. Ophthalmology. 2016 Jun;123(6):1237-44.

11. Bell CM, Hatch WV, Fischer HD, et al. Association between tamsulosin and serious ophthalmic adverse events in older men following cataract surgery. JAMA. 2009;301:1991–1996.

12. Gani J, Perlis N, Radomski SB. Urologic medications and ophthalmologic side effects: a review. Can Urol Assoc J. 2012 Feb; 6(1): 53–58.

13. Zaman F, Bach C, Junaid I, et al. The Floppy Iris Syndrome – What Urologists and Ophthalmologists Need to Know. Curr Urol. 2012 May; 6(1): 1–7.

14. Ross WH. Visual recovery after macula-off retinal detachment. Eye. (2002) 16, 440–446.