common eye problems for primary care

1. Common Eye Problemsfor Primary Care MAJ Travis C. Frazier, MD Chief, Ophthalmology Dewitt Health Care Network 1 June 2009

2. Common Eye Problems The Red Eye Diabetes Thyroid Eye Disease Cataracts Age-Related Macular Degeneration Primary Open Angle Glaucoma Refractive error and refractive surgery

3. Red Eye History of Trauma? Is it Acute or Chronic? Pain or no pain? Normal or decreased vision? Usually self-limited Refer if pain, decreased vision or photophobia Or if it persists or worsens despite treatment

4. Red Eye Differential Acute Conjunctivitis Chalazion or Hordeolum Subconjunctival hemorrhage Chronic Allergic conjunctivitis Blepharitis Dry eye

5. Red Eye Differential Painful Red Eye Acute Angle Closure Glaucoma Keratitis Bacterial or Viral Scleritis Uveitis

7. Diabetes Leading cause of blindness in the US Significant morbidity from decreased vision Higher rate of cataract progression Macular edema Vitreous hemorrhage Cranial nerve palsies Dry eye

8. Nonproliferative Disease After 20 years ALL Type 1 DM will have retinopathy 2/3 of those with Type 2

9. Proliferative Disease

10. Diabetic retinopathy Diabetes Control and Complications Trial (DCCT) United Kingdom Prospective Diabetes Study (UKPDS) Landmark studies Showed that tight glycemic control reduced the risk of onset and progression (HbgA1c <7)  Tight BP control also reduced the onset of retinopathy Each reduction of 1 point decreased microvascular complications by 37% RR Each reduction of 1 point decreased microvascular complications by 37% RR

11. Eye Exam Guidelines Type 1 DM Within 3-5 years after onset Not necessary prior to age 10 Type 2 DM Initial exam after diagnosis Yearly follow up unless retinopathy detected Refer any diabetic with decreased vision, eye pain or diplopia Pregnant- if daibetic- should have exam early in pregnancy Increased risk for progression during pregnancyPregnant- if daibetic- should have exam early in pregnancy Increased risk for progression during pregnancy

12. Treatment Macular edema causing reduced vision Laser photocoagulation Proliferative retinopathy Panretinal photocoagulation and/or Vitrectomy Role newer treatments such as intravitreal triamcinolone (Kenalog) and bevacizumab (Avastin) Cataract surgery

13. Thyroid Eye Disease AKA Graves orbitopathy Autoimmune disease affecting the orbital muscles and fat Middle aged W:M 5:1 Bilateral but asymmetric Multiple muscles involved, commonly inferior and medial rectus

14. Thyroid Eye Disease Occurs most commonly in hyperthyroidism, but can be euthyroid or hypo 7.7X more likely in smokers Eye symptoms include: Dry eye/irritation, diplopia and loss of vision

15. Treatment Refer to ophthalmologist if eye disease suspected Correct hyperthyroidism, antithyroid meds, radioactive iodine, surgery Lubrication Periorbital surgery if needed Smoking cessation

16. Cataracts Leading cause of irreversible blindness in the world Cause of 50% decreased vision among patients older than 40.

17. Cataract Progressive clouding of the natural lens Causes include: Increasing age Exposure to UV/radiation Trauma Steroids Secondary to diabetes/ HTN Familial

18. Cataract Symptoms include painless and gradual decreased vision Increased glare, haloes with difficulty driving at night and reading fine print AAO recommends considering surgery when QOL is affected No longer needs to be �ripe�

19. Cataract Surgery Successful with 90% patients seeing better than 20/40 without glasses Complications though rare can occur: Infection, retinal detachment, lens dislocation and macular edema Refer ALL post-surgical patients with decreased vision or eye pain Same day surgery, local anesthesia, requires little recovery Can now correct for astigmatism, presbyopiaSame day surgery, local anesthesia, requires little recovery Can now correct for astigmatism, presbyopia

20. New Developments Decreased surgical time 15 minutes No sutures Quicker recovery and better visual outcomes Newer IOL technology Toric IOL Multifocal IOL Phakic IOL

21. Age Related Macular Degeneration(ARMD) Leading cause of blindness in patients >50 years in the developing world Risk factors: Caucasian Atherosclerosis Smoking Advanced age Family History

22. ARMD Usually asymptomatic early Gradual central blurring of vision and metamorphopsia (straight lines appear curvy) Followed by further loss of central vision

23. Dry ARMD Dry (nonexudative or atrophic) Drusen and macular atrophy Responsible for 90% ARMD but only 10% vision loss

24. Wet ARMD Wet (Exudative or Neovascular) Choroidal neovascularization with leak-prone vessels that lead to bleeding and scarring Loss of central vision within hours or days

25. Treatment Control BP and smoking cessation Wear sunglasses AREDS study Vits with zinc, Vit A, C, E Beneficial only to those with moderate-severe ARMD Lots of new treatments for �wet� ARMD, though with little chance of significant visual recovery VEGF- Lucentis, Avastin, macugen. Monthly injectons costing $2000 each! Number of RMD patients expected to skyrocket VEGF Ab researchVEGF- Lucentis, Avastin, macugen. Monthly injectons costing $2000 each! Number of RMD patients expected to skyrocket VEGF Ab research

26. Primary Open Angle Glaucoma (POAG) Most common cause of irreversible blindness in the world Most common cause of blindness in AA patients >50 years Primary Open Angle Glaucoma is the most common type in the US

27. POAG A characteristic progressive optic neuropathy that causes progressive visual field loss which can lead to blindness if untreated Asymptomatic until late in the disease Early detection in at risk individuals is key

28. POAG Risk Factors Major risk factors include: Increased Intraocular Pressure (IOP) though not necessary for diagnosis >22mmHg considered ocular HTN African American, Latino, Asian (3-4X higher risk) Family History (4-10X risk) Other risk factors include: Diabetes High Myopia Eye Trauma Steroids

29. Screening and Diagnosis Refer to eye specialist Black patients older than 40 years White patients older than 65 Any patient with FH Diagnosis based on appearance of optic nerve and characteristic findings on the visual field exam

30. Treatment Lowering the eye pressure will slow or stop the progression in most patients with glaucoma Options include topical drops, laser trabeculoplasty and surgery Issues with compliance and side effects from drugs, potential blinding complications from surgeryIssues with compliance and side effects from drugs, potential blinding complications from surgery

31. Refractive Surgery Very common elective surgery to reduce dependence on glasses and contacts. Treats myopia, hyperopia and astigmatism Safe and effective, >90% with 20/40 vision or better without glasses. Complications that affect vision occur infrequently <1% Cataract surgery still the most common refractive surgical procedureCataract surgery still the most common refractive surgical procedure

32. PRK Remove the epithelium with a brush or alcohol under local anesthesia Excimer laser ablates and reshapes the corneal surface Vision recovers after the abrasion heals

33. LASIK More commonly performed A corneal flap is created with either a blade or laser The same excimer laser as used in PRK is used to reshape the cornea The flap is replaced Quicker visual recovery, less pain

34. Refractive Surgery Complications Overcorrection or undercorrection Refractive surgery patients typically have increased dry eye symptoms for months to years afterwards LASIK flap complications include dislocation, folds, dehiscence (<1%) Corneal ectasia

35. Eye Protection