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Interactive Grand Rounds

Interactive Grand Rounds. Blair Lonsberry, MS, OD, MEd., FAAO Diplomate, American Board of Optometry Clinic Director and Professor Pacific University College of Optometry blonsberry@pacificu.edu. Disclosures and Special Request. Paid consultant for:

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Interactive Grand Rounds

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  1. Interactive Grand Rounds Blair Lonsberry, MS, OD, MEd., FAAO Diplomate, American Board of Optometry Clinic Director and Professor Pacific University College of Optometry blonsberry@pacificu.edu

  2. Disclosures and Special Request Paid consultant for: • Alcon Pharmaceuticals, Bausch and Lomb, Carl Zeiss Meditec, NiCox, Sucampo Special Request: Interactive remotes don’t work on your TV, so please don’t take them home!  Commitment to change: - write down three things that you “learned” from this presentation that you can incorporate into your practice to improve patient care

  3. Case 1

  4. Case History • 38 black male, complaining that the vision in his right eye is blurry. • Got the current Rx 3 weeks previously, and started out good but in last couple of days OD vision has become blurry • Medical Hx: no current health concerns and no medications

  5. Entrance Skills • Va’s: OD: 6/7.5 (20/25), OS: 6/6 (20/20) • Pupils: PERRL • CVF: full to finger count • EOM’s: FROM • Amsler: central metamorphopsia OD • HVF: 10-2 (see VF)

  6. Which of the following OCT’s goes with this patient? 1 2 3 4

  7. Case 2

  8. Case • 55 yr white female complains of fluctuating vision • Worse at near • Spends 8-10 hours/day on the computer • Medical Hx: • Hypertension for 10 years • Joint pain • Medications: • HCTZ for HTN • Celebrex for her joint pain

  9. Exam Data • VA (corrected): • 6/7.5 (20/25) OD, OS • PERRL • EOM’s: FROM • CVF: FTFC • SLE: • TBUT 5 sec OD, OS • Positive NaFl staining and Lissamine green staining of conj and cornea • Decreased tear prism

  10. Additional Testing/Questions • Schirmer: < 5 mm of wetting in 5 minutes OD, OS • RF and ANA: normal for patients age • SS-A: 2.0 (normal < 1.0), SS-B: 1.9 (normal <1.0) • Additional symptoms reported: • Patient experiences dry mouth and taking Salagen • Diagnosis: Sjogren’s Syndrome

  11. Differential Diagnosis of Dry Eye

  12. Signs and Symptoms of Dry Eye Signs: Ocular Surface Damage Corneal Staining (Fluorescein and/or Rose Bengal) Conjunctival Staining (Lissamine Green ) Decreased Tear Quantity Schirmer Score Phenol Red Thread Test Tear Meniscus Height Decreased Tear Quality Tear Break Up Time (TBUT) Tear Osmolarity Symptoms: Grittiness Burning Irritation Stringy discharge Blurring of vision Ocular Surface Disease Index (OSDI)

  13. Treatment • We initiated: • Omega-3 supplements (3-4 grams per day) • Recommended warm compresses and lid washes qhs • Testosterone cream 3% applied to upper lid bid • Patient had significant improvement in symptoms with the use of the topical testosterone cream. • However, she was still symptomatic at the end of the day and she still had significant staining on her cornea and conjunctiva • Initiated FML tid for 1 month, restasis bid after 2 weeks • 2 months later patient reported further improvement in her symptoms • No conjunctival staining was noted and only slight SPK • Schirmer values improved to OD: 9 mm, OS: 10 mm

  14. Transdermal Testosterone Cream • Recent studies suggest that androgen deficiency may be the main cause of the meibomian gland dysfunction, tear-film instability and evaporative dry eye seen in Sjogren patients • Transdermal testosterone promotes increased tear production and meibomian gland secretion, thereby reducing dry eye symptoms (Dr. Charles Connor). • arGentis and Allergan have conducted trials to see if topical androgens are effective in treating dry eye

  15. SJOGREN’S SYNDROME: OLD/NEW CLASSIFICATION • Old: • 1o Sjogrens: occurs when sicca complex manifests by itself • no systemic disease present • 2o Sjogrens: occurs in association with collagen vascular disease such as • RA and SLE • significant ocular/systemic manifestations • New: • The diagnosis of SS should be given to all who fulfill the new criteria while also diagnosing any concurrent organ-specific or multiorgan autoimmune diseases, without distinguishing as primary or secondary.

  16. Diagnosis: New Criteria • Sjogren’s International Collaborative Clinical Alliance (SICCA) was funded by the National Institutes of Health to develop new classification criteria for SS • New diagnostic criteria requires at least 2 of the following 3: • 1) positive serum anti-SSA and/or anti-SSB or (positive rheumatoid factor and antinuclear antibody titer >1:320), • 2) ocular staining score >3, or • 3) presence of focal lymphocytic sialadenitis with a focus score >1 focus/4 mm2 in labial salivary gland biopsy samples

  17. Ocular Surface Score (OSS) • The ocular surface score (OSS) is the sum of: • 0-6 score for fluorescein staining of the cornea and • 0-3 score for lissamine green staining of both the nasal and temporal bulbar conjunctiva, • yielding a total score ranging from 0-12.

  18. Antibodies to SS-A and SS-B • Sjogren’s syndrome A and B • Typically tested by ELISA and immunoblot • Associated Conditions: • Uncommon in the normal population and in patients with rheumatic diseases other than Sjogren’s syndrome and SLE • Present in 75% of patients with “primart” Sjogren’s but only 10-15% of patients with RA and secondary Sjogren’s syndrome

  19. Antibodies to SS-A and SS-B • Indications: • Should be measured in patients with a clinical suspicion of Sjogren’s or SLE • Interpretation: • Presence of AB’s is a strong argument for the diagnosis of Sjogren’s Syndrome in a patient with sicca syndrome

  20. Dry Eye and Lid Disease? • It is estimated that 67-75% of patients who have dry eye have some form of lid disease • it is often the most overlooked cause for dry eye symptoms • Important to address the lids in any treatment plans for patients with dry eye

  21. Quickie

  22. CHRPE vs Nevus

  23. Nevi Trivia • 31% of choroidal nevi show slight enlargement over time without the transformation to a melanoma (Ophthalmology 2011) • The prevalence of choroidalnevi in the white U.S. population ranges from 4.6% to 7.9% • If it is assumed that all choroidal melanomas arise from preexisting nevi, then the published data suggest a low rate (1/8845) of malignant transformation of a choroidal nevus in the U.S. white population. (Ophthalmology 2005) • Choroidalmelanoma risk for metastasis, ranging from 16% to 53% (at 5 years of follow-up) depending on the size of the tumor at the time of diagnosis. (Arch Ophthalmol 1992)

  24. Nevi Trivia • Studies suggest that the presence of orange pigment is significantly correlated with the risk of subsequent growth • when orange pigment is difficult to clinically discern (especially with the natural coloration of the fundus and in amelanotic nevi), FAF offers the best currently available method to enhance its visibility. (Optometry 2009) • Aggressive surveillance for survivors of ocular melanoma appears to carry a relatively high risk of secondary cancers from the radiation exposure, particularly for young women. (JAMA Ophthalmology 2013).

  25. TFSOM—“To Find Small Ocular Melanoma” Thickness: lesions >2mmFluid: any subretinal fluid (suggestive of serous retinal detachment)Symptoms: photopsia, vision lossOrange pigment overlying the lesionMargin touching optic nerve head • None of these factors = 3% risk of a nevus converting to melanoma in five years.One of these factors = 8% risk of conversion in five years. Two or more factors = 50% risk of conversion in five years. For any changes noted during the course of follow-up, refer the patient to a retinal practice or an ocular oncology service.

  26. Case • 65 yr old white male • Notices spot in vision in his left eye • Diabetes for 15 years • Vision:6/6 (20/20) and 6/12 (20/40) • Dilated exam: • Large lesion noted in left eye (not noted in exam 6 months previously • See photo

  27. Astrocytic Hamartoma Amelanotic Melanoma Ocular Tumors Retinoblastoma Metastatic Choroidal Tumor

  28. Choroidal Melanoma Metastases • 80 to 90% of metastases from uveal melanoma occurred in the liver, less common sites being the skin and lung. • Gragoudas ES, Seddon JM, Egan KM, et al. Long-term results of proton beam irradiated uveal melanomas. Ophthalmology. 1987;94:349–53.

  29. Case 3

  30. Case • 23 WM • Eye pain OD • Severe, started 2 days ago • Photophobia and redness • POHx: • Had similar problem and was given drops and felt better • PMHx: • Told to get back into shape and to reduce stress • Meds: • Ibuprofen for lower back pain

  31. Assessment • VA: • 6/6 (20/20)-, • 6/6 (20/20)+ • Entrance skills unremarkable • SLE: • OD: • 2+ injection, • 2+ cell, • Mild flare, • Fine deposits • IOP: 18, 14 mm HG • DFE: unremarkable

  32. Uveitis • Uveitis frequently is nonspecific but can be associated with: • systemic disease, • occur following trauma, or • be the result of a primary ocular disorder such as: • Fuchs's heterochromic iridocyclitis or • glaucomatocyclitic crisis (ie, Possner-Schlossman syndrome)

  33. Helpful Mnemonic • Mnemonic for acute forms of non-granulomatous uveitis: BLAIR G • B: Behcet’s disease • L: Lyme disease • A: Ankylosing spondilitis • I: Irritable bowel syndrome (Crohn’s) • R: Reactive arthritis • G: Glaucomatocyclitic crisis

  34. Uveitis: Clinical Features • The clinical features of anterior uveitis are readily recognizable • complaints of: • photophobia, • pain, • blurred or variable vision • A change in the blood-aqueous barrier results in the liberation of protein and cellular matter into the anterior chamber and the vitreous.

  35. Uveitis: Clinical Findings • Clinical findings of: • circumlimbal hyperemia, • cells and flare in the aqueous and anterior vitreous, and • keratic and trabecular precipitates

  36. Uveitis: Treatment • “Classical treatment”: • Pred forte: every 1-2 hours, ensure taper • Pred forte: prednisolone acetate formulation which allows penetration through cornea to anterior chamber • Newer treatment option: • Durezol

  37. Treatment Options • Durezol: • Difluprednate • only difluorinated steroid • Steroid emulsion • BAK free • Increased “potency” so dosing needs to be less than “classical treatment” with Pred Forte • rough recommendation is 1/2 dosing of Pred Forte

  38. Cycloplegics • Common cycloplegic agents include: • cyclopentolate 1-2% tid for mild-to-moderate, • homatropine 5% BID • scopolamine 0.25% • atropine 1% bid-tid for moderate-to-severe inflammation • most common is the use of Homatropine 5% bid • be careful using atropine as there is potential for severe systemic side effects • also makes the iris essentially immobile

  39. Cycloplegics • Cycloplegia: • used for reduction of pain, • break/prevent the formation of posterior synechiae • also functions in the reduction of inflammation

  40. Treatment • Topical administration is most common though periocular injections and systemic meds are useful for posterior uveitis and difficult cases • Dosing is dependent upon severity of the inflammation • typically you want to hit the uveitis hard and fast! • E.g 1 gtt q 2hrs until the inflammation is gone! • If you have a minimal anterior chamber reaction then steroid may not be necessary at all

  41. Treatment • NOTE: it is crucial to taper your steroid treatment! • You will have a rebound inflammation if you simply remove your patient from their steroids… • The taper will be dependent upon how long you have had them on the steroid to get rid of the inflammation! • Typically, a slow taper is better in order to prevent rebound inflammation • If the patient has been on the steroid for less than a week a faster taper can be considered.

  42. Treatment • NSAIDs: • do not play an important role in the treatment of an acute uveitis

  43. Treatment: Additional Therapies • Immunosuppressive agents (cytotoxic) • reserved for sight-threatening uveitis that have not responded to conventional treatment • e.g. cyclophosphamide • Antimetabolites (e.g. methotrexate) have been found useful in JIA related iridocyclitis and scleromalacia • Cyclosporin has a very specific effect on the immune system and has been found useful in posterior and intermediate uveitis

  44. Follow-up • Every 1-7 days in acute phase depending upon severity and every 1-6 months when stable. • On each f/u visit the AC reaction and IOP should be evaluated • DFE should be performed for flare-ups, when VA affected, or every 3-6 months.

  45. Follow Up • If AC reaction improving, then steroid drops can be slowly tapered. • cycloplegia can also be tapered as the AC reaction improves. • slow taper recommended for chronic granulomatous uveitis.

  46. Case 4

  47. Case • 65 year old Caucasian patient presents with sudden onset loss/blurring of vision in the right eye • PMHx: HTN for 15 years, takes “water pill” • VA’s: 6/18 (20/60) OD, 6/7.5 (20/25) OS • Pupils: PERRL –APD • CVF: Inferior defect right eye, no defects noted in the left eye

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