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Systemic Disorders with Ophthalmic Manifestations Common Ophthalmic Disorders in Primary Care
THE EYES HAVE IT
Kate Goldblum, CFNP
NMNPC Annual
Conference April 16, 2016
DISCLOSURES
I have no financial interests relevant to this presentation.
I will not discuss an off-label or investigational use of any commercial product.
THE EXTENT OF MY OPHTHALMOLOGY KNOWLEDGE IS THAT I KNOW OD MEANS RIGHT EYE & OS MEANS LEFT EYE.
A. True B. False
M R . S M I T H H A D H E R P E S Z O S T E R O P H T H A L M I C U S T H AT C O M P L E T E LY & U N E V E N T F U L LY R E S O LV E D 6 W E E K S A G O F O L L O W I N G T R E AT M E N T B Y H I S O P H T H A L M O L O G I S T . H E N O W P R E S E N T S T O Y O U W I T H C / O M I L D I R R I TAT I O N & R E D N E S S I N T H E S A M E E Y E . Y O U . . . .
A. Tell him to use artificial tears. B. Refer him to an ophthalmologist. C. Prescribe a topical antihistamine. D. Have him return in a week if his
symptoms aren’t improving.
! Varicella-zoster virus (chicken pox) ! Virus resides latent in the dorsal root ganglia of
sensory neurons ! Reactivation in adult years ! Any dermatome can be affected
! 50% to 56% - thoracic ! 20% - CNs V, VII, & VIII ! Ophthalmic division of trigeminal nerve (CN V)
! Obeys midline
HERPES ZOSTER ETIOLOGY
! 1 in 3 will develop herpes zoster over lifetime ! 1 million new cases per year ! 25 to 40% will have ocular involvement ! Increasing due to aging population ! Prevention
! Zostavax ! Adults ≥ age 60
HERPES ZOSTER EPIDEMIOLOGY
! Trigeminal nerve involvement ! Vesicles on forehead, side of nose, upper eyelid, & eye ! Post-herpetic neuralgia
! Ocular disease ! Blepharitis ! Conjunctivitis ! Keratitis – epithelial, stromal, neurotropic ! Uveitis, recurrent iritis – at risk for secondary glaucoma,
cataracts, scarring, retinitis ! Scleritis, episcleritis
CLINICAL CHARACTERISTICS OCULAR INVOLVEMENT
CUTANEOUS LESIONS
EPITHELIAL KERATITIS
! May mimic dendritic lesion of herpes simplex ! Stains with fluorescein
STROMAL KERATITIS
! Subepithelial infiltrates
! Located in anterior stroma below areas of previous epithelial keratitis
SEQUELAE
! Occurrence or reoccurrence of symptoms possible months later
T e a c h i n g M o m e n t
W H AT P ERC EN T OF PAT IEN T S W IT H D IA B ET ES H A D A N A N N UA L EY E EX A M IN 2 01 2 AC C ORDING TO NM H EALT H CARE TAKES ON D IAB ET ES ?
A. 25.6% B. 55.3% C. 75.8% D. 95.2%
DIABETES MELLITUS EPIDEMIOLOGY
! Normal or minimal NPDR ! Mild NPDR ! Moderate NPDR ! Severe NPDR ! Non-high-risk PDR ! High-risk PDR
Follow-Up & Treatment Based on Degree of Retinopathy
D I A B E T I C R E T I N O P A T H Y
CLINICAL CHARACTERISTICS OCULAR INVOLVEMENT
! Mild non-proliferative diabetic retinopathy (NPDR) ! Microaneurysms
! Moderate NPDR ! More than just microaneurysms ! Less than severe
CLINICAL CHARACTERISTICS OCULAR INVOLVEMENT
! Severe NPDR ! Any of following (4-2-1 rule) & no signs of proliferation
! Severe intraretinal hemorrhages & microaneurysms in each of FOUR quadrants
! Definite venous beading in TWO or more quadrants of venous beading
! Moderate IRMA* in ONE or more quadrants
*intraretinal microvascular abnormalities
CLINICAL CHARACTERISTICS OCULAR INVOLVEMENT
! Proliferative diabetic retinopathy (PDR) ! Abnormal blood vessels on optic disc, retina, iris, angle
structures (neovascularization) ! Vitreous/pre-retinal hemorrhage ! Associated with severe vision loss
! Clinically significant macular edema (CSME) ! Retinal thickening at or within 500 µm of central macula, &/or ! Hard exudates at or within 500 µm of macula if associated with
thickening of the adjacent retina &/or ! Zone(s) of retinal thickening one disc area in size, any part of
which is within 1 disc diameter of macula
EPIDEMIOLOGY OF OCULAR INVOLVEMENT 2005-2008
! Adults with diabetes ≥ 40 years of age ! 4.2 million (28.5%) had diabetic retinopathy ! 655,000 (4.4%) had advanced diabetic
retinopathy
BACKGROUND DIABETIC RETINOPATHY
TREATED DIABETIC RETINOPATHY
Insurance Model 2008 2009 2010 2011 2012 2012 Nat’l Avg
Commercial HMO 47.5 44.8 49.0 45.5 46.3 56.8
Commercial PPO 27.6 42.5 36.8 40.6 42.1 48.8
Medicaid HMO 53.3 55.4 52.7 51.4 51.2 53.2
Medicare HMO 69.7 69.6 66.0 67.5 70.9 66.8
Medicare PPO -- 62.0 62.1 62.5 65.9 64.6
Average Rate 49.5 54.9 53.3 53.5 55.3 --
NM HEALTH CARE TAKES ON DIABETES NM RATES FOR EYE EXAM 2008-2012
Report of Diabetes Eye Examination on ___________________
To: _________________________________________ Clinic/Office ____________________________________ Primary Care Provider Phone ______________________________________ Fax _____________________________________________
Patient Name ____________________________________________________ DOB ______________________
Visual Acuity __________ OD __________OS Intraocular Pressure __________ OD __________OS
Retinal Examination Findings
No retinopathy or history of retinopathy; recommend re-examination in one year.
Needs no laser now, but should return in _____ months because of risk of developing diabetic
macular edema (DME) or high risk proliferative diabetic retinopathy (PDR).
DME requiring focal laser photocoagulation.
High risk PDR or iris neovascularization requiring panretinal photocoagulation.
Tractional retinal detachment or vitreous hemorrhage requiring vitrectomy.
Other Ocular Conditions
Cataracts, not interfering with activities of daily living or functional abilities.
Cataracts, interfering with activities of daily living or functional abilities.
Glaucoma, controlled. Glaucoma, suboptimally controlled.
Ocular hypertension. Vitreous floaters.
Pseudophakia. Other ________________________________________________
Treatment Plan
Refer to retinal specialist Follow up in _____ weeks/months
Fluorescein angiogram OD OS
Panretinal laser photocoagulation OD OS
Focal laser photocoagulation OD OS
Vitrectomy OD OS
Cataract surgery OD OS
Other ____________________________________________________________________________________ _________________________________________________________________ Date _____________________
Acme Eye Center
123 Central Street • Anytown, NM 12121 Phone: (505) 333-2222 • Fax: (505) 333-4444
! Toxoplasma gondii parasitic infection ! Foodborne
! Undercooked meats (especially pork, lamb, venison) ! Failure to wash hands after handling raw meat ! Contamination of fresh food with utensils used on meat
! Animal to human (zoonotic) ! Cats infected by eating infected rodents, birds ! Shed microscopic oocysts in feces up to 3 weeks
TOXOPLASMOSIS ETIOLOGY
! Congenital ! Newly infected during pregnancy ! Ocular & nervous system consequences for unborn
child can be severe ! Rare causes
! Organ transplant ! Blood transfusion ! Laboratory workers – accidental inoculation
TOXOPLASMOSIS ETIOLOGY
! At least 14% of population infected by age 40 ! 1,000,000 + infected each year ! Most common retinal infection in US – about 2%
of all those infected have ocular involvement ! 20,000 develop ocular lesions each year ! Symptomatic retinitis in 0.2% to 0.7% of those
infected (2000–7500/year; midpoint ~5000) ! New lesions may develop over years after
infection so incidence may be higher
TOXOPLASMOSIS EPIDEMIOLOGY
CLINICAL CHARACTERISTICS OCULAR INVOLVEMENT
! Asymptomatic in most immunocompetent patients ! Eye pain, photophobia, epiphora, blurred vision ! Eye disease may reactivate months to years later
! Further damage to retina ! Progressive loss of vision if central retinal structures
involved ! Can lead to blindness
CLINICAL CHARACTERISTICS OCULAR INVOLVEMENT
! Ocular symptoms vary with age ! Young children - " VA, strabismus, nystagmus, leucocoria ! Teens & adults - " VA, floaters, photophobia, pain,
hyperemia ! Retinochoroiditis – typically in posterior pole ! Active lesions – grey-white retinal necrosis surrounded
by choroiditis, vasculitis, vitreitis, hemorrhages ! Anterior uveitis – mutton-fat keratic precipitates, cell &
flare, iris nodules, synechiae
RETINAL LESION
RETINAL LESIONS
DIAGNOSTIC CONSIDERATIONS HISTORY OF PRESENT ILLNESS
! Complaints of fever, myalgia, fatigue, headache, rash, sore throat
! Exposure to cat feces, undercooked meats ! Active ocular disease – blurred VA, floaters,
metamorphopsia
DIAGNOSTIC CONSIDERATIONS OCULAR EXAMINATION
! Decreased VA ! Congenital disease
! Strabismus ! Microphthalmia ! Cataract ! Optic atrophy ! Nystagmus ! Retinal detachment
! Retinal exam – old retinochoroidal scars
! Treatment dependent on several factors ! Acquired disease in
immunocompetent often requires no Rx
! Minimal inflammation, peripheral ocular lesions, VA minimally affected – lean toward no Rx
! No studies show extent Rx alters course of disease
! Immunocompromised patients ! Various antibiotic regimens
(sufadiazine, pyrimethamine, clindamycin, azithromycin, TMP/SMX, e.g.)
Treatment
OCULAR TOXO
HYPERTENSION OCULAR INVOLVEMENT
H y p e r t e n s i v e r e t i n o p a t h y c a n p r e d i c t l o n g - t e r m r i s k
o f s t r o k e .
CLINICAL CHARACTERISTICS OCULAR INVOLVEMENT
! Retinal fundus findings ! Retinal hemorrhages (blot & flame shaped) ! Microaneurysms ! Soft exudates ! Hard exudates ! Macular edema ! Intraretinal microvascular abnormalities (IRMA) ! Venous beading, ! New vessels at disc or elsewhere ! Vitreous hemorrhage ! Disc swelling ! Arteriolar narrowing
HYPERTENSIVE RETINOPATHY
HOLLENHORST PLAQUES
CENTRAL RETINAL ARTERY OCCLUSION
HYPERTENSIVE RETINOPATHY
Silver Wiring
Silver Wiring
Exudates
Cotton Wool Spot
Treatment
HTN RETINOPATHY
G o o d B P C o n t r o l
! Inflammation of the conjunctiva ! Allergic – seasonal, atopic, giant papillary conjunctivitis (GPC) ! Mechanical, irritative, or toxic – medication induced, exposure
to toxic chemicals ! Viral ! Bacterial
CONJUNCTIVITIS DEFINITION
! Frequent cause of patient self-referral for eye care ! Rarely causes permanent vision loss but economic impact is
significant
CONJUNCTIVITIS EPIDEMIOLOGY
! Bulbar & tarsal components ! Very vascular ! Pathophysiology dependent on cause
CONJUNCTIVITIS ANATOMY & PATHOPHYSIOLOGY
! Discharge ! Irritation &/or pain ! Redness ! Itching ! Decreased vision
CONJUNCTIVITIS CLINICAL PRESENTATION
! Allergic ! Itching ! Watery or stringy discharge ! Chemosis
CONJUNCTIVITIS CLINICAL PRESENTATION
! Viral (adenovirus) ! Watery discharge ! Unilateral or bilateral (sequentially bilateral) ! Preauricular adenopathy ! Petechial & subconjunctival hemorrhage
CLINICAL PRESENTATION
CONJUNCTIVITIS # ALLERGIC
CONJUNCTIVITIS # BACTERIAL
! Topical antihistamines ± vasoconstrictor ! Pheniramine + naphazoline/Naphcon A ! Rebound congestion with vasoconstrictors
! ALLERGIC
CONJUNCTIVITIS MEDICAL MANAGEMENT
! H1-receptor antagonists ! Azelastine/Optivar (mast cell action) ! Emedastine/Emadine ! Ketotifen/Zaditor (mast cell action) ! Levocabastine/Livostin ! Olopatadine/Patanol & Pataday (mast cell action)
! ALLERGIC
CONJUNCTIVITIS MEDICAL MANAGEMENT
! Topical steroid (mildest potency/frequency) ! Fluorometholone/FML ! Loteprednol etabonate/Alrex
! Topical non-steroidal anti-inflammatory ! ketoralac/Acular approved for use in allergic conjunctivitis
! ALLERGIC
CONJUNCTIVITIS MEDICAL MANAGEMENT
! Mast call inhibitors ! Cromolyn/Crolom ! Lodoxamide tromethamine/Alomide ! Nedocromil sodium/Alocril ! Pemirolast potassium/Alamast
! ALLERGIC
CONJUNCTIVITIS MEDICAL MANAGEMENT
! Usually self-limiting ! Symptomatic relief
! Artificial tears, cold compresses ! Topical antihistamines ! Topical steroids (increases length of contagious period)
! VIRAL
CONJUNCTIVITIS MEDICAL MANAGEMENT
! Mild presentation ! Self-limiting ! Earlier clinical response with topical antibacterial therapy ! Antibiotic choice based on cost & convenience ! 5 to 7 days of treatment adequate
! BACTERIAL
CONJUNCTIVITIS MEDICAL MANAGEMENT
! Severe or complicated presentation ! Copius discharge ! Pain & inflammation ! MRSA increasing in frequency
! Antibiotic choice based on culture ! Neisseria gonorrhoeae & Chlamydia trachomatis require
systemic antibiotics
! BACTERIAL
CONJUNCTIVITIS MEDICAL MANAGEMENT
! Axithromycin/AzaSite ! Besifloxacin/Besivance ! Ciprofloxacin/Ciloxan ! Gatifloxacin/Zymaxid ! Moxifloxacin/Vigamox ! Ofloxacin/Ocuflox
! BACTERIAL
CONJUNCTIVITIS MEDICAL MANAGEMENT
! Socioeconomic issues ! Good figures not available ! Missed work &/or school ! Example – adenovirus conjunctivitis outbreak in nursing home
with 41 affected cost $29,527 ! With savings from rapid test for viral conjunctivitis, cost savings
in US estimated at $430 million
CONJUNCTIVITIS $$$$$
BLEPHARITIS DEFINITION & CLASSIFICATION
! Chronic inflammation of lid margins ! Anterior
! Eyelid skin ! Base of lashes ! Lash follicles
! Posterior ! Meibomian glands ! Gland orifices
BLEPHARITIS SUBCLASSIFICATION
! Staphylococcal ! Seborrheic ! MGD (meibomian gland dysfunction)
! Common condition but data lacking ! Mean age 50 ! With staph blepharitis – 80% women (eye makeup?) ! Irritation, erythema, edema of lid margin
BLEPHARITIS EPIDEMILOGY & CLINICAL FEATURES
! Dry eye ! Reported in 50% of patients with staph blepharitis ! Conversely, of patients with dry eye, up to 75% have staph blepharitis
or conjunctivitis
! Rosacea ! Use of isotretinoin – usually resolves with discontinuation ! Contact-lens-associated giant papillary conjunctivitis (GPC)
BLEPHARITIS ASSOCIATIONS
! Ocular irritation ! Eyelid features
! Irritation ! Erythema ! Edema ! Eyelash “collarettes”
BLEPHARITIS CLINICAL CHARACTERISTICS
! Eyelid hygiene ! Lid scrubs ! Warm soaks ! Massage in MGD
! Topical antibiotic in staph blepharitis ! Bacitracin ! Erythromycin ! Patients often prefer drops
BLEPHARITIS TREATMENT
! Loss of vision ! Pain ! Erythema – severe &/or chronic ! Orbital involvement ! Recurrent episodes ! Lack of treatment response
BLEPHARITIS INDICATIONS FOR REFERRAL
M a l i g n a n c y ?
! Disorders of tear film due to reduced tear production or excessive tear evaporation
! Associated with ocular discomfort &/or visual symptoms & possible ocular surface disease
DRY EYE DEFINITION
! Information limited by lack of uniform definition & inability of of any single diagnostic test or set of tests to confirm or rule out the disorder
! Recognized as a common condition ! 1 million – 4.3 million aged 65 to 84 in the US
DRY EYE EPIDEMIOLOGY
! Risk factors ! Older age & female gender ! Low dietary intake of omega-3 fatty acids ! Antihistamines ! LASIK & refractive excimer laser surgery ! Many other factors with less certain effect
DRY EYE EPIDEMIOLOGY
! Lacrimal & meibomian glands form integrated unit to maintain tear film
! Inadequate tear production by lacrimal gland ! Increased tear evaporation due to meibomian gland
secretory dysfunction
DRY EYE ANATOMY & PATHOPHYSIOLOGY
Large lacrimal gland
Conjunctivaa
Meibomian glands
Mucous layer Watery layer Oily later
Tear film
! Complaints of irritation, tearing, burning, stinging, dry or foreign body sensation
! Mild itching, photophobia, blurry vision, contact lens intolerance, redness, eye fatigue
! Symptoms may be worse later in the day ! Exacerbation by wind, air travel, low humidity
DRY EYE CLINICAL PRESENTATION
! Ocular surface dye staining ! Tear breakup time ! Schirmer test (aqueous tear production) ! Tear osmolarity
! NO single test adequate to confirm diagnosis
DRY EYE OPHTHALMIC DIAGNOSTICS
! Testing for systemic disorders ! Sjögren syndrome ! Thyroid eye disease ! Sarcoidosis ! Cictricial pemphigoid
DRY EYE DIAGNOSTICS
! Treat causative factors (e.g., thyroid disease, Sjögren syndrome)
! Tear replacement ! Ophthalmic anti-inflammatory agents (cyclosporine/Restasis) ! Omega-3 fatty acids – nutritional supplement ! Eyelid therapy – lid hygiene, warm compresses ! Environmental modifications
DRY EYE MEDICAL MANAGEMENT
! Punctal occlusion ! Plugs ! Permanent occlusion
! Tarsorrhaphy ! Ectropian repair, other lid surgeries to improve
malposition
DRY EYE SURGICAL MANAGEMENT
! Primary angle-closure glaucoma ! Ocular emergency – can result in vision loss ! Narrow anterior chamber (AC) angle predisposes to angle
closure
ACUTE GLAUCOMA
ANTERIOR SEGMENT
Ciliary body
Iris
Anterior chamber Lens Cornea Bulbar
conjunctiva
! Refer emergently
ACUTE GLAUCOMA
! Periorbital – preseptal cellulitis ! Orbital – septal cellulitis
CELLULITIS PERIORBITAL & ORBITAL
! Periorbital redness, tederness ! Must rule out orbital involvement, sepsis
PRESEPTAL CELLULITIS
PRESEPTAL (PERIORBITAL) CELLULITIS
SEPTAL (ORBITAL) CELLULITIS
! Often secondary to sinusitis ! Proptosis ! Ophthalmoplegia ! Decreased ocular mobiltiy ! Fever ! Life-threatening ! Require hospitalization, IV antibiotics
ORBITAL CELLULITIS
! Often secondary to sinusitis ! Proptosis ! Ophthalmoplegia ! Decreased ocular mobility ! Fever ! Life-threatening ! Referral for hospitalization, IV antibiotics
! Esotropia – convergent misalignment of the visual axes (eye turns in) ! Infantile (3 to 6 months) ! Acquired (accommodative, non-accommodative)
STRABISMUS DEFINITION
! Exotropia – divergent misalignment of the visual axes (eye turns out) ! Infantile – presents before 6 months of age; constant ! Intermittent – usually seen before age 3 ! Convergence insufficiency – typically have intermittent
exotropia at near
STRABISMUS DEFINITION
! Esotropia – about 1% ! Exotropia – about 1% ! Associated with prematurity, maternal substance abuse
& smoking, family history, other factors ! Higher risk of amblyopia – about 50% of children with
strabismus develop amblyopia
STRABISMUS EPIDEMIOLOGY
! Children with strabismus ! Reduced binocular vision ! Social interactions impaired ! Perceived negatively
STRABISMUS EPIDEMIOLOGY
STRABISMUS # ANATOMY Superior oblique
Inferior oblique Inferior rectus
Medial rectus
Lateral rectus
Superior rectus
Levator palpebrae superioris
! Abnormality of poorly understood neuromuscular control of eye movement
! Less commonly, a problem with the actual eye muscle ! Paralytic strabismus (CN III, CN IV & CN VI)
STRABISMUS PATHPHYSIOLOGY
Muscle CN Primary Secondary Tertiary
MR III Adduction – –
SR III Elevation Intorsion Adduction
IR III Depression Extorsion Adduction
IO III Extorsion Elevation Abduction
SO IV Intorsion Depression Abduction
LR VI Abduction – –
! Parents don’t always notice the deviation ! Deviation may be intermittent or constant ! Amblyopia frequently present – must assume it is ! Adult patients with strabismus or hx of strabismus may
have children with strabismus ! Vision training is NOT indicated
STRABISMUS CLINICAL PRESENTATION
THE EXTENT OF MY OPHTHALMOLOGY KNOWLEDGE IS THAT I KNOW OD MEANS RIGHT EYE & OS MEANS LEFT EYE.
A. True B. False
M R . S M I T H H A D H E R P E S Z O S T E R O P H T H A L M I C U S T H AT C O M P L E T E LY & U N E V E N T F U L LY R E S O LV E D 6 W E E K S A G O F O L L O W I N G T R E AT M E N T B Y H I S O P H T H A L M O L O G I S T . H E N O W P R E S E N T S T O Y O U W I T H C / O M I L D I R R I TAT I O N & R E D N E S S I N T H E S A M E E Y E . Y O U . . . .
A. Tell him to use artificial tears. B. Refer him to an ophthalmologist. C. Prescribe a topical antihistamine. D. Have him return in a week if his
symptoms aren’t improving.
W H AT P ERC EN T OF PAT IEN T S W IT H D IA B ET ES H A D A N A N N UA L EY E EX A M IN 2 01 2 AC C ORDING TO NM H EALT H CARE TAKES ON D IAB ET ES ?
A. 25.6% B. 55.3% C. 75.8% D. 95.2%
PERIORBITAL CELLULITIS IS MORE CONCERNING THAN ORBITAL CELLULITIS.
A. True B. False
STRABISMUS RARELY CAUSES AMBLYOPIA.
A. True B. False