primary care, oc dx, pharm
TRANSCRIPT
Primary Care, Oc Dx, Pharm
Deepak Gupta, OD, FAAO
No financial disclosures
Anterior Blepharitis
Inflammation of the outside of the eyelids
Signs and symptoms include:
– Morning crusting of lids
– Collarettes - scales that encircle lash
– Loss of lashes
– Lid margin redness
Posterior Blepharitis
Inflammation of the inside of the eyelids
Signs and symptoms include:– Dilated & plugged meibomian gland orifices
with “toothpaste” like material– Thickened lid margin– Filmy vision with foam in tear film
Treatment Goals
Reduce Inflammation
Increase patient comfort
Decrease the Bacterial Load/Improve LidHygiene
Blepharitis:Short term management
Warm Compresses
Zylet or Tobradex– Tobramycin is great for any Staph component
– Steroid helps with redness, irritation
Side effects of Corticosteroids
Increased IOP
Cataracts
Decreased healing or re-emergence of certainviral, herpetic, and fungal infections
Most potent steroid
Difluprednate (Durezol)
Safest steroid
Loteprednol (Lotemax and Alrex)
Steroids and IOP spikes
Impacts 4 – 6% of the population
Usually takes over 2-4 weeks to get IOP spike
Steroids and IOP spikes
Mechanism: Inhibition of phagocytosis
Steroids and cataracts
If prescribing rarely for a given patient, not a bigdeal
If prescribing periodically, then educate thepatient on the risk and document this conversation
What about the risk of HSK?
You can never be 100% sure it’s not HSK
Document negative findings i.e. (no dendrites, no corneal staining)
See patient for follow up; educate patient to comeback ASAP if gets worse
If patient has herpetic infection
RX = Zirgan
ADV: Better dosing schedule than Viroptic
Also, more selective mechanism of action
Blepharitis:Long term management
THE KEY IS LYD HYGIENE
Patient education
Warm compresses
Lid Scrubs
Baby shampoo
My Approach
Have the patient use warm wash cloth in theshower every AM
Express glands in the shower, if needed
Call me ASAP for flare-ups
Corneal Foreign Body
Diagnostic Criteria:
– History related to accident
– Slit Lamp examination
Slit Lamp Exam - Abrasions
– See how close abrasion is to visual axis
– Check to see how deep the abrasion is
Management
Topical Antibiotics at least QID until resolution
Consider an antibiotic ointment at bedtime
Cycloplegic agent
Consider bandage CL
Topical
Topical NSAIDs
Key point to educate your patient on: Not usingtoo much!
MAX Dose of Acetaminophen
Two 325 mg tablets
Commonly used control substances
– Codeine Tylenol #3 (APAP 300 mg + Codeine 30 mg)
– Hydrocodone Lortab, 5, 7.5 (APAP 500 mg + Hydrocodone 2.5, 5, 7.5 mg) Vicodin (APAP 500 mg + Hydrocodone 5 mg)
Vicodin ES (APAP 500 mg + Hydrocodone 7.5 mg)
– Oxycodone
Percocet (APAP 326 mg + Oxycodone 5 mg)
Percodan (ASA 325 mg + Oxycodone 4.5 mg)
Tylox (APAP 500 mg + Oxycodone 5 mg)
Controlled Substances
– Schedule I: High abuse potential (heroin, marijuana, LSD)
– Schedule II: High abuse potential with severe dependence liability(narcotics, amphetamines
– Schedule III: Moderate dependence liability (certain narcotics,nonbarbiturate sedatives, etc)
– Schedule IV: Less abuse potential than S3; limited dependence lability(nonnarcotic analgesics, antianxiety agents, etc)
– Schedule V: Limited abuse potential (small amounts of narcotics inantitussives or antidiarrheals)
FDA Pregnancy CategoriesA - Controlled studies demonstrate no risk
B - No evidence in risk in humans. Either animal studies show risk and humansdo not OR if no human studies, animal studies negative
C - Risk cannot be ruled out. Human studies lacking but animal studies arepositive for fetal risk or lacking
D - Positive Evidence of riskInvestigational or post-marketing data show risk to fetus. If needed in life-
threatening situation or serious situation or serious disease, drug may beacceptable
X –Contraindicated in pregnancyFetal risk clearly outweighs any benefit to patient
For central abrasions
Or, you and instill loading dose of topicalantibiotics and then Rx both the antibiotic andtopical steroid
Document to the patient the potential for loss ofBCVA even if everything goes 100% as planned
My protocol for central abrasions
Instill antibiotic drop q 5 min for 30 min while patient isstill in office
Then I send patient home with: Hourly topical antibiotics TID topical steroid Cycloplegic agent Antibiotic ung QHS Oral OTC pain medications RTO 24 hours follow up
Patient may have RCE
What are risk factors for RCE?
Manage with Muro 128– Drops during the day
– Ointment at bedtime
Epithelial Debridement
Loosely adherent epithelium is debrided using a surgical sponge,spatula, or surgical blade
Anterior Stromal Puncture
Numerous small punctures through the epithelium andBowman’s layer into the anterior stroma.
Excimer Laser Phototherapeutic Keratectomy
The objective of PTK is simply to remove enough of thesuperficial Bowman layer to permit formation of a new basementmembrane with adhesion structures
The ablated anterior corneal stromal surface appears to be highlysupportive of stable reepithelialization
Doxycycline
DRUG CLASS: Systemic tetracylines
– MMP is upregulated in epithelial specimens of pts with recurrenterosion
– MMPs alter the epithelial basement membrane during wound healing
Doxycycline
Systemic tetracylines and topical steriods to reduce matrixmetalloproteinase (MMP) activity
– MMP is upregulated in epithelial specimens of pts with recurrenterosion
– MMPs alter the epithelial basement membrane during wound healing
Cataract surgery and keratoconus
Wound position a little more critical
Post op refraction more variable
Things to avoid: Toric and Multifocal IOL
ACG – classic signs
Increased IOP
VA hazy
Pt has headache and/or nausea
Mid fixed pupil
Steamy cornea
How do we rule out ACG on this patient?
SLE: Angles appear open
? Gonioscopy – probably not on this eye
IOP 23
Pupils: NL
If it was ACG what would you do on thispatient?
Lower IOP
Add Alphagan in office
?Add two tablets Diamox 250 - why not Diamox500 sequels?
Send to ER/Glaucoma Specialist?
Acute hydrops
Acute corneal hydrops is caused by the acutedisruption of Descemet's membrane in the settingof corneal ectasia.
Hydrops denotes the abnormal accumulation offluid
Management
Most cases of acute corneal hydropsspontaneously resolve over 2-4 months
Do we Rx anything?
Acute hydrops
Hypertonic sodium chloride to reduce epithelial edema
Cycloplegic for patient comfort.
Topical steroids to help reduce the inflammation and subsequentneovascularization that can accompany these episodes.
A large diameter bandage contact lens can be placed for comfort.
What about Corneal Cross-linking?
Uses Riboflavin as photosensitizer toincrease bonds between collagen fibers
Oral vs Topical
Can generally get better penetration intosuperficial ocular tissues with topical route
Only need orals for those tissues with poor ocularpenetration
If you have a topographer Initial Diagnosis
If you don’t a have topographer…
Refraction
Retinoscopy
Slit Lamp Findings
Corneal Pachmetry
Quick GP refraction
Refraction
Large changes in cylinder
Shifts in axis
BCVA not 20/20
Retinoscopy findings for keratoconus
Scissors motion
Keratometry findings for keratoconus
Distorted mires
Oval mires
Non superimposable central rings
Pachmetry findings for keratoconus
Normal cornea 540 Microns but that is centralcornea
You want thinnest point of cornea
Slit Lamp Findings Quick GP VA Check
Put in a drop of anesthetic
Apply GP roughly equivalent to BC
Do VA and OR
When does a keratoconus patient needsurgery
Risk of perforating
Scarring preventing adequate vision
???? Progression of disease ????
How often does the cornea perforate?
Almost never
Scarring of cornea
Mostly due to CL abuse and/or improperly fit lens
As scarring progresses, CL refit can often stop theprocess. Patients only need surgery if you waittoo long to refit them
When does a keratoconus patient NOTneed surgery
GP Intolerance
Poorly fitting contact lenses
???? Progression of disease ????
GP Intolerance/Poor fit
The percentage of patients who are truly GPintolerant is WAY over-rated
The vast majority of them have not been properlyfit or prepared for the process
Ways to avoid GP intolerance
New shoe analogy
Wait for vision to be bad enough to motivate thepatient to work through the discomfort
Astigmatism after PKP
The vast majority of patients are left with residualastigmatism
Refraction may be difficult or imprecise in these patients
Glasses may not work to correct this astigmatism. GPare often needed to fully restore vision
Complications
Delayed corneal reepithelization
Infection
Corneal endothelium cell damage – in thin corneas
Keratouveitis
Severe corneal haze
Is a patient better of getting refitmultiple times or surgery?
Which is less risky?
Progression is usually a finite time period
3 most common conditionswe send to retinal specialist
Retinal detachment
Diabetic retinopathy
Macular degeneration
How do we monitor patients with dryAMD
Amsler Grid is an easy screening test for monitoring AMD
Visual field 10-2 Fundus Photography
OCT UV Protection
Vitamins Stop Smoking
Dietary Changes Increase exercise
Genetic testing
Can we do these ourselves?
Absolutely !!!
So why do you need to send out?
Lucentis
Used for wet AMD, macular edema due to CRVOor diabetic macular edema
Typical protocol: once a month for at least 3months, then “every couple of months” dependingon clinical situation
When does a glaucoma patient needsurgery?
Selective Laser Trabeculoplasty Selective Laser Trabeculoplasty
Uses a “cold” laser
No thermal damage to tissues
Efficacy of SLT
90% successful after 3 years
Many still at target IOP at 5 years
SLT
Not best choice for adjunctive or alternativetherapy
Best use: Truly non compliant patients
Conventional Surgery OptionsTrabeculectomy
Conventional Surgery Options
Conventional Surgery Options
Tube Shunts
Stents and Microstents
Conventional Surgery Options
Cyclodestructive Procedures
Most common reasons why patients haveLASIK
Discomfort from CL wear
They are tired of having to deal with taking CL inand out every day
They want to be able to see during the night
By offering your patient a fitting with aCONTINUOUS WEAR CONTACT LENS
You will either solve the patient’s problem
OR
You will reinforce his or her decision to haveLASIK
When do we send a patient forcataract surgery?
When do you send a patient for cataractsurgery?
No magic number – it is based on a patient’s visual needs
Before you send them…
Talk to them about IOL optons – spherical, toric,bifocal
Talk to them about post op goal for refractiveerror
Talk to them about costs
Common Surgeries
Pterygium
PKP
Intacs
Corneal Crosslinking
SLT
Trab & Tube Shunts
Cataract Surgery
RD surgeries
Lid Surgeries
Refractive Surgery Procedures