Eyecare Review— For Primary Care Practitioners

1. Eyecare Review—For Primary Care Practitioners

2. Primary Care Practitioners • See variety of eye problems • Discuss treatment options • Facilitate referrals • Positioned to explain optometry's role as primary eye care providers

3. Outline • Anatomy • Optics • Turned Eyes • Lazy Eye • External Conditions • Internal Conditions • Diabetic Retinopathy

4. ANATOMY

5. Basic Anatomy Choroid Sclera Retina Cornea Fovea Pupil Lens Optic Nerve Iris Ciliary Body

6. Lids • Lashes—protection from foreign material • Glands—lubricate anterior surface • Meibomian glands • Glands of Zeis • Glands of Moll

7. Conjunctiva • Thin, transparent, vascular layer lining • Backs of eyelids • Fornices • Anterior sclera

8. Sclera • Tough outer shell • Composed of collagen bundles • Protects from penetration

9. Cornea • Composed of regularly oriented collagen fibers • 5 layers

10. Anterior Chamber • Space between cornea and iris • Filled with aqueous humor produced by ciliary body

11. Iris • Iris gives eye color • 2 muscles: • Dilator—opens • Sphincter—constricts

12. Pupil • Allows light to enter • Enables view to back of eye and eye health evaluation

13. Lens • Located behind iris • Focuses light on retina • Allows for accommodation • Normally transparent • Where cataracts form

14. Ciliary Body • Primary functions • Pulls on lens for accommodation • Epithelium secretes aqueous fluid that fills anterior chamber

15. Red Reflex • Light reflection off retina • Useful for assessing media clarity • Affected by any opacity of cornea, lens, vitreous • White reflex = leukocoriaRefer immediately!

16. Vitreous Humor • Gel-like fluid that fills back cavity • Serves as support structure for blood vessels while eye formed—before birth • After birth, just ‘hangs out’ in there • Where floaters are located

17. Fundus • Interior surface of eye • Includes • Optic nerve • Retina • Vasculature

18. Optic Nerve Head • Collection of nerve fibers and blood vessels from retina • Transfers info to brain’s visual cortex • Slightly yellow-pink when healthy • White ‘full moon’ appearance can mean trouble!

19. Optic Nerve Head • Cup is natural depression in center of nerve • Cup size varies between people • Very large cup, or change in appearance over time, can indicate glaucoma Optic Disc Physiologic Cup Optic Nerve

20. Macula • Dense collection of cone photoreceptors • Fine detail and color vision • Macular degeneration affects this area

21. Retinal Vessels • Include arteries and veins • Only place in body where you can directly visualize blood vessels • Excellent indicators of systemic diseases • HTN • Diabetes • High cholesterol • Carotid disease

22. Peripheral Retina • Can only be evaluated with dilated pupil • Important to evaluate periodically to fully assess eye health

23. OPTICS

24. Optics Review • Myopia • Hyperopia • Astigmatism • Presbyopia

25. Myopia • Nearsightedness • See well up close but blurry in distance • Eye is too long • Light focuses in front of retina

26. Hyperopia • Farsightedness • See well in distance • Eye is too short • Focus point is behind retina

27. Hyperopia • Blurry image on retina • Lens focuses to compensate • Hyperopes often asymptomatic much their of lives • Can cause headaches or eyestrain with extended reading • These problems can get worse after age 40

28. Astigmatism • Surface of cornea isirregular or misshapen • Light focuses at various points causing distorted vision • Often combined with nearsightedness and farsightedness

29. Presbyopia • Normal, age-related change • Near vision becomes difficult • Mid-40s lens becomes less elastic and losesability to change focus • Time for bifocals…

30. MISALIGNED EYES

31. Eye misalignment One or both turn in, out, up or down Caused by muscle imbalance 3 Kinds of Strabismus Esotropia Exotropia Hypertropia Turned Eyes - Strabismus

32. 1. Esotropia • Eye turns in towards nose

33. 3 Types of Esotropia • Infantile (congenital) • Develops in first 3 months of life • Surgery usually recommended—along with vision therapy and glasses • Accommodative • Usually noted around age 2 • Child typically farsighted • Focusing to make images clear can cause eyes to turn inward • Treated with glasses but vision therapy may also be needed

34. 3 Types of Esotropia • Partially Accommodative • Combination of • accommodative dysfunction and • muscle imbalance • Glasses and vision therapy won’t completely correct eye turn • Surgery may be required for best binocularity

35. If you see Esotropia • Refer to pediatric optometrist or ophthalmologist • Sooner the better for best chance of good vision

36. 2. Exotropia • Eye turns outward • Congenital—present at birth • Surgery usually needed to re-align • Many exotropias are intermittent • May occur when patient is tired or not paying attention • Concentration can force eyes to re-align • Vision therapy and/or glasses can help

37. 2. Exotropia • When intermittent • Brain sometimes receives info from both eyes (binocular) • Less chance of amblyopia • However, important to be seen by eyecare provider when deviation noted

38. 3. Hypertropia • One eye vertically misaligned • Usually from paresis of an extra-ocular muscle • Typically much more subtle for patient to describe and provider to diagnose

39. 2 Types • Congenital • Most common type • Patients can compensate for years by tilting head • Can be discovered by looking at childhood photos

40. 2 Types • Acquired • Trauma—Extra-ocular muscle ‘trapped’ by orbital fracture • Vascular infarct—Systemic diseases that affect blood supply to nerves can cause temporary nerve palsy • Diabetes and HTN most common • Palsies tend to resolve over weeks or months • Neurological—In rare cases a tumor or aneurysm can cause symptoms

41. LAZY EYE

42. Lazy Eye - Amblyopia • Decreased vision uncorrectable by glasses or contacts—not due to eye disease • For some reason, brain doesn’t fully acknowledge images seen

43. 3 Types of Amblyopia Strabismic Anisometropic Stimulus deprivation Lazy Eye - Amblyopia

44. 1. Strabismic Amblyopia • One eye deviates from other and sends conflicting info to brain • Brain doesn’t like to see double—so “turns off” info from deviated eye • Results in under developed visual cortex for that eye • Can usually be reversed or decreased if treated during first 9 years • Need to visit eyecare provider ASAP to determine cause

45. Treatment • If caught early, treatment can teach brain how to see better • Vision therapy/patching • Glasses • Surgical re-alignment • Early vision screenings are critical!

46. 2. Anisometropic Amblyopia • Anisometropia—significant difference in Rx between eyes • Commonly one eye more farsighted • Farsighted eye works hard to see clearly—and sometimes gives up • Brain relies on info from other eye

47. 2. Anisometropic Amblyopia • If not caught, one eye won’t learn to see as well as other • Vision therapy and glasses are both beneficial • Sooner the better

48. 3. Deprivational Amblyopia • Any opacity in visual pathway can be devastating to developing visual system • Congenital cataracts • Corneal opacities • Ptosis (droopy eyelid) • Other media opacities

49. EXTERNALCONDITIONS

50. Blepharitis Hordeolum—stye Preseptal cellulitis Orbital cellulitis Pterygium Corneal ulcer Conjunctivitis Viral “pink eye” Adenovirus Bacterial Allergic Hyperacute Chlamydial Common External Ocular Conditions