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Chronic Visual Loss

Chronic Visual Loss. UBC Ophthalmology Club 2012. Approach. History, physical, tests Patient population tends to be the elderly, but 2% of adults in the US over age 40 have vision <20/40 ( Congdon et al. 2004. Arch Ophthalmol 122(4):477-85.) Prevalence increases with age

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Chronic Visual Loss

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  1. Chronic Visual Loss UBC Ophthalmology Club 2012

  2. Approach • History, physical, tests • Patient population tends to be the elderly, but 2% of adults in the US over age 40 have vision <20/40 (Congdon et al. 2004. Arch Ophthalmol 122(4):477-85.) • Prevalence increases with age • Early detection may lead to early intervention and preservation of vision • Primary care is the first screen, know when to refer

  3. Case 1 • 55M comes to GP for routine physical • Has HTN, currently on thiazide • Denies visual loss, eye pain, headaches • Sister was taking an eye drop but not sure what that’s for • Exam: • OD 20/30 OS 20/30 (both 20/25 2 years ago) • Pupils equal reactive • No RAPD • EOM full • Confrontational VF grossly intact

  4. Case 1 • Management: • A. This pt needs urgent treatment to lower his IOP • B. Refer pt to ophthalmologist 1-2 weeks • C. Reassess pt in 3 months • D. Increase his thiazide dose and consider adding a second antihypertensive Photo courtesy Dr. Fred Mikelberg

  5. Transillumination defect. (Kuo & Noecker, AAO 2009) Pseudoexfoliation. (Shaw, AAO 2003)

  6. Primary Open Angle Glaucoma • Progressive optic neuropathy of unknown etiology with persistent VF defect • Risk factors incl. elevated IOP, family hx, race, age, myopia • Sx incl. gradual loss of peripheral visual field • Further tests: • VF testing of this pt reveals nasal step defect • IOP: OD 29mmHg, OS 23mmHg • Retina tomography shows moderate thinning of nerve fibre layer • AAO recommends refer pt when: • disc:cup >0.5 or one cup significantly larger than the other • IOP > 21mmHg or >5mmHg difference between the eyes • Sx of acute glaucoma

  7. Common Rx for glaucoma • The only pharmacological target is lowering IOP • Alpha agonists(↑drain, ↓aq): clonidine, brimonidine • Beta blocker (↓aq): timolol • CA inhibitor (↓aq): acetazolamide (Diamox) • Prostaglandin analog (↑drain): latanoprost (Xalatan) • SE of PG analog- iris color change and longer eye lashes

  8. Case 2 • 70M c/o decreasing vision in both eyes over last 6 months to GP • This is particularly bothersome as he is having more trouble reading and watching TV • No eye conditions in the past • Hx significant for obesity and 50 pkyr smoking, quit 5 years ago • Family history unremarkable

  9. Case 2 • OD 20/80, OS 20/100 • (last 2 years decreased) • Pupils equal reactive • EOM full • CVF intact • IOP within normal limits • Fundoscopy: • Amsler grid: (Khanifar et al. Retinal Physician, 2007)

  10. What do you tell this patient? • A. he has missed the window for effective intervention • B. he needs immediate antioxidant and zinc supplement • C. his children are at increased risk of this disease • D. his condition probably won’t cause complete blindness

  11. Age Related Macular Degeneration • 2 forms: atrophic (dry) and exudative (wet) • Leading cause of blindness in adults >75 yr, mostly from exudative form • Multifactorial disease, see characteristic drusen • Early diagnosis enables detection of exudative form, which can be effectively treated with anti-VEGF agents • Screening in primary care: • Visual distortions, especially in central vision • Presence of drusen in macula, retinal pigment breakdown • Refer to ophthalmologist for full evaluation

  12. Wet AMD Monthly injection, $1600 per shot

  13. Case 3 • 68F comes to GP with c/o decreased vision in her L eye • She denies double vision or glares, in fact she said she can read better with her L eye than her R eye now; she wants to know if her reading glasses are still necessary • No eye disease or trauma • No family hx of eye diseases • Meds include prednisone 20 mg daily for last 2 months for RA flare

  14. Case 3 • OD 20/30, OS 20/50 • Pupils equal reactive no RAPD • EOM full • Confrontational VF full • Fundus visualized, unremarkable (Espandar, AAO 2009)

  15. Management • What’s your course of action? • A. Inform pt that her cataract is the result of her prednisone use • B. This pt needs to see an ophthalmologist STAT because of risk of irreversible visual loss • C. This pt’s presbyopia is improving so she should be followed up in 6 months at your office • D. Referral to ophthalmologist for evaluation and treatment options

  16. Cataract • Etiology: opacified lens • Most commonly associated with increasing age, but also congenital, DM, steroid use, trauma, radiation • Pt complain of painless gradual unilateral vision decrease • “Second sight” refers to myopic shift as cataract increases power of lens; this is temporary • Referral to ophthalmologist when decrease in vision becomes symptomatic and/or interfere with function • Cataract removal+IOL implant is one of the most frequently-performed and successful procedures in all of surgery

  17. Other types of cataracts Cortical cataract Posterior subcapsular cataract Implantable IOL

  18. Case 4 • 63M with 17 yr hx of Type 2 DM comes to GP to c/o decrease in vision in both eyes • Denies pain, distortions, double vision • Hb A1c 7.5% despite being on metformin and gliclazide • Also has dyslipidemia, on atorvastatin • No previous eye complaints

  19. Case 4 • OD 20/40, OS 20/60 • Pupils equal reactive, red reflex present • EOM full VF intact • AC deep and quiet • Fundoscopy: (AAO, 2012)

  20. Diagnosis • What is the cause of this pt’s decreased vision? • A. Non-proliferative diabetic retinopathy • B. Age related macular degeneration • C. Proliferative diabetic retinopathy • D. Branch retinal vein occlusion

  21. Diabetic retinopathy • Microvascular complication of DM • Most common cause of vision loss in adults 25-74 yr • In NPDR, vision loss arise from macular edema • In PDR, vision loss can be rapid, secondary to scarring and vitreous hemorrhage • Ophthalmologist referral when: • Newly diagnosed DM patient • Eye exam every 1-2 years after • Patient who develop rapid vision change • Glycemic control is the cornerstone of systemic management. DR is managed with laser and anti-VEGF

  22. PDR Proliferative disease, characterized by formation of new and fragile vessels that form a tangle on the disc and elsewhere. Pan-retinal photocoagulation uses laser to destroy ischemic retina in order to prevent neovascularization and preserve the macula.

  23. Summary • 4 most common causes of chronic visual loss and their features: • Open angle glaucoma- insidious, treat IOP • Age related macular degeneration- distortions, most common • Cataract- often unilateral, good result with surgery • Diabetic retinopathy- check in all DM pt, bilateral visual loss • All are either reversible or can be managed well (slow/stop vision loss) if detected early • Therefore, primary care’s role is vital in screening of chronic eye diseases

  24. Questions? • Edited by: Steven Schendel, PGY-4 • Reviewed by: Drs. Fred Mikelberg, David Maberley, Francis Law • Contact: • R Tom Liu • rztom.liu@gmail.com

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