11/11/2019

1

“My Doctor told me I needed

an eye exam because…….. Bruce Onofrey, OD, RPh, FAAO

Professor, U. Houston, UEI

Drugs can blind you (the

patient)

• Cataract

• Glaucoma

• Uveitis

• Dry eye

• Macular disease

• Optic neuropathies

• Stroke (ischemic disease)

• Ocular heme-alcohol + tylenol

KNOW THY PATIENT

• Individuals ARE different

• HISTORY, HISTORY HISTORY@@@

• Medical

• Eye

• Allergy

• Medications

• Family

• Social

• Demographics

GET FOCUSED

• WHY ARE YOU HERE?

• Take a thorough HISTORIES

• What are you taking

• What are you using it for

• What are your SX

• Know your protocols

CASE #1:

The latent hyperope/macular

hole/diabetic macular edema

patient

“My doctor told me to get my

vision checked”

• 29 Y/O Asian female presents with CC:

“My vision isn’t right”- “IT’S BLURRY”

• Feels like its getting worse for the last 3

months

• My Doctor told me to have my eyes

checked because of my medications

11/11/2019

2

Medical HX

Doctor #1

• “Lung infection” TX X 6 months

• No other significant HX

• MEDS: rifampin, ethambutol,

clarithromycin

• Allergies: None

• Fm HX: Type II DM-F

• Social HX: NEG

• Fm Oc HX: NEG

The exam

10/2011• Current RX; (+) 0.50 OU

• OD: 20/20-2 OS 20/25-1

• Refrac. +0.75-0.25 X 165 20/20-2

• +0.75-0.25 X 10 20/25 -1

• Pupils: PERRLA (-) APD, IOP 12 OU

• DFE: WNL C/D: 0.3/0.3 OU

• DX: HYPEROPE-told everthing is OK

• Gave new RX

DR. #2

4/2012

• HX and complaint: see Dr. #1: My vision

is getting worse and my doctor told me to

get an eye exam

• Acuity with RX: 20/25-2 OU

• Refraction: (+) 150- 0.50 X 10 20/25

• (+) 150 – 0.25 X 160 20/25

A/P: Hyperope/ made new RX

2 weeks later: Doctor #3• MY new glasses don’t work-they make

me blurrier

• HX: Dr. #3 has records from #2

• BVA: Best with original RX

• OD 20/30

• OS 20/30

• Amsler grid: (central blur OU)

• A/P: “Bilateral macular holes”: “see a

retinal specialist”-no appt made for

patient

2 weeks later: Back to Dr. #1

• Same complaint with HX of other visits

• BVA: OD 20/50

• OS 20/80

• Macular OCT performed

• Result:???

• A/P: Diabetic macular edema

• Consult to a PCP for undiagnosed

diabetes

•

1 week later: PCP report:

• NO DIABETES

• Repeats OCT: ?????

• Refers to RETINA: Appt made-non-

emergent referral

11/11/2019

3

10 days later: Retina evaluation

• BVA: OD 20/200

• OS 20/400

• Color vision: Missed (3) plates

OD and (all) plates OS

• (-) APD

• Temporal pallor of OS disc

• VF’s: Paracentral defects

OU, OS > OD

• A/P………..?

WHAT DO YOU THINK?

• 1. LATENT HYPEROPIA

• 2. AMD

• 3. TOBACCO/ALCOHOL

AMBLYOPIA

• 4. ETHAMAMBUTOL TOXICITY

• 5. BILATERAL MACULAR HOLES

• 6. LOW TENSION GLAUCOMA

• 7. MS/ optic neuritis

WHAT DO YOU DO?

• 1. Lower IOP at least 30%

• 2. Get MS consult

• 3. Advise pulmonologist to DC

ethambutol

• 4. Advise patient to start drinking and

smoking

• 5. Start ARED’s vitamins

• 6. Increase her plus at near and start VT

FIRST: LISTEN TO YOUR

PATIENT

• MY DOCTOR TOLD ME TO

HAVE MY EYES CHECKED

BECAUSE OF THE

MEDICATIONS THAT I AM

USING

• MY VISION IS NOT RIGHT

KNOW YOUR PROTOCOLS

THE BLINDING DRUGS

• HYDROXYCHLOROQUINE

• VIAGRA

• CORTICOSTEROIDS

• AMIODARONE

• TAMOXIFEN

• ETHAMBUTOL

Ethambutol ocular toxicity in TX regiments

for M. avium Complex lung disease

• David Griffith, MD, et al

• UT Health center

• “AGGRESSIVELY MONITOR ALL

ETHAMBUTOL PATIENTS

PARTICULARLY THOSE AT

25MG/KG DOSAGE LEVEL”

• INCIDENCE = 6% AT THAT DAILY

DOSAGE LEVEL

11/11/2019

4

WHAT DO YOU DO?• BVA

• COLOR VISION (D15)

• VF’S: 24-2

• EDUCATE

• NOTE ANY DISTURBANCE OF

VISION

• ADVISE DC OF ETHAMBUTOL

IMMEDIATELY

• CV MOST RELIABLE

PREDICTOR

HEY DOC-EVERYTHING

LOOKS BLUE!

• 71 Y/O male for general exam complains

of occasional color disturbance associated

with “migraine-like” HA

• Occurs X 2 months-”at night”

• No prior HX of vascular HA

• No decrease or loss in vision

• No hx TIA

Viagra-The Good

• Affects nitric oxide receptors and may

affect ocular blood flow-Useful in open

angle glaucoma?

• In a recent study 100 male glaucoma

patients take Viagra for one year

RESULTS??

• At the end of one year they still

have glaucoma

• BUT THEY DON’T CARE!!

• Seriously-Studies of blood flow

effects may help in management

of optic nerve perfusion and

explain Viagra’s side-effects

Viagra-The Bad

• Has produced anterior ischemic

neuropathy

• Has produced pupil-sparing third nerve

palsy

• Associated with ocular vascular events

• Vascular adverse effects increase

dramatically when used with

nitrates@@@@

The mechanism, the protocol

• Local loss of perfusion/hypotensive event

• STOP THE DRUG

• ASSESS THE DAMAGE

• DO A VF

• Monitor for nerve palsies

• Look for multiple neuro deficits

• Bad things get worse

11/11/2019

5

Anti-anginal Agents

• Nitrates

• Coronary artery

dilators

Nitroglycerine can be deadly

• Nitro + the match = Bye Bye@@@@

+

The Breast Cancer Wonder

Drug

• Reduces incidence of breast cancer by up

to 75%

• Originally used in elderly, post-

menopausal women to prevent

recurrence of cancer

• Now in young women for

prophylaxis

• Produces vision loss?

Tamoxifen

Maculopathy@@@@

• Occurs in 6% of patients

within 6 months of low

dose therapy (20mg/D)

• Reversible early, not

reversible later

• White crystalline

macular deposits

• Nobody knows about this

Patient Management• Pre-TX baseline evaluation with

emphasis on macular function and

appearance

• Evaluate every 6 months thereafter or

prn decrease in central acuity

• Also monitor for cataract@@@@

What About Plaquenil?

“Bulls-eye” Maculopathy:

Protocols changing all the time

11/11/2019

6

Old thinking: FUGEDABOUDIT!!!

(Maybe)

• Almost non-existent

• Hydroxychloroquine much safer

than chloroquine if daily dose under

750mg (average dose is 400mg/D)

• Very popular for rheumatoid

arthritis

• Do baseline and check yearly

Hydroxychloroquine, dosage parameters and retinopathy.

Spalton DJ, Verdon Roe GM, Hughes GR

Department of Medical Ophthalmology, St. Thomas' Hospital, London, UK.

In a study designed to determine the presence of retinopathy in patients

taking hydroxychloroquine we compared 82 patients attending a

rheumatology clinic who had taken hydroxychloroquine for over 1 year with

controls. Outcome measurements included fundoscopy, fundus photography

and automated computerized visual fields of the macular area. No patient

was found to have retinopathy. No correlation could be found between

indices of visual field function and total drug usage, average daily dose,

dosage in mg/kg body weight or duration of treatment. Retinopathy is

unlikely to occur at dosages of hydroxychloroquine of less than

6.5 mg/kg body weight with under 10 years of treatment.

Present guidelines for ophthalmic screening of patients on

antimalarial therapy are too rigorous and visual field testing if

not of benefit. Further recommendations are made for ophthalmic

supervision.

Retinal toxicity in long term hydroxychloroquine treatment.

Mavrikakis M, Papazoglou S, Sfikakis PP, Vaiopoulos G, Rougas K

Department of Clinical Therapeutics, 'Alexandra' Hospital, Athens, Greece.

. RESULTS: Among 58 patients receiving hydroxychloroquine for more than

six years, two relatively young women (3.5%), one treated for RA and the

other treated for SLE, developed characteristic hydroxychloroquine related

toxic retinal lesions after cumulative doses of 700 g (6.5 years) and 730 g (8

years) of hydroxychloroquine, respectively. Bilateral visual acuity was 6/6 and

6/7.5, respectively; both patients had normal colour perception. Despite an early diagnosis

and cessation of treatment, permanent visual field paracentral scotomata in both patients,

and persisting lesions in fluorescein angiography in the patient with SLE, were observed at

4.5 and 3 years of follow up, respectively. No other specific cases of hydroxychloroquine

related retinopathy have to date been identified in the remaining 302 patients.

CONCLUSION: Cases of irreversible, hydroxychloroquine related retinopathy in patients

who did not receive overdoses have not been reported previously. The present observations

in two relatively young patients should raise our concern regarding the long term usage of

an increasingly popular medication in rheumatology practice.

UH-OH-THINGS CAN CHANGE VERY QUICKLY NEW GUIDELINES:

KNOW YOUR NO’S

• NO COLOR

• NO PHOTO

• NO AMSLER

• NO WAIT FOR VA LOSS

• VA LOSS STOPS AFTER DRUG

DISCONTINUED - NOOOOOOOOO

NEW GUIDELINES:

KNOW YOUR YES’S

• DOSAGE REDUCED FROM 6.5MG/KG TO 5MG/KG

OR LESS , ACTUAL WEIGHT, NOT IDEAL WEIGHT

• BASELINE EVALUATION

• ANNUAL EXAMS AFTER 5 YEARS UNLESS HIGH

RISK

• CUMULATIVE DOSE CALCULATION

• ASSESS PATIENTS RISK FACTORS

• VF-10-2, Asian patients need extra-macular tests, or Multi-

focal ERG’s/fundus auto fluoresence

• OCT-SPECTRAL DOMAIN-PIL

• COUNCIL PATIENT

• COMMUNICATE WITH PRESCRIBER ON DOSAGE

GUIDELINES

RISK FACTORS

• > 5 YEARS TX

• DOSAGE > 5mg/kg

• RENAL OR HEPATIC DISEASE

• RETINAL DISEASE

• HIGH BMI

• OVER 60

• CUMULATIVE DOSE OF 1000 GMS

• EXAMPLE: 10 YEARS TX AT 400MG/D = CD = 10 X

365 X 0.4GM =

1,460 GMS CD

CHECK EVERY 6 MONTHS AT OLD DOSE OR

YEARLY AT NEW LOWER DOSE

11/11/2019

7

Recommendations on screening for chloroquine

and hydroxychloroquine retinopathy-AAO (2016

revision) Risk Reduction

• At 5mg/kg or less risk of maculopathy at

5 years is 1% and at 10 years 2%-Risk

increases to 20% after 20 years, but only

4% risk of converting if normal at 20

years

• Main Risk is dose and duration-

additional tamoxifen use and renal

disease

• Chloroquine dosage suggested is now

2.3mg/kg or less

GET READY TO SPEND SOME MONEY IF YOU

FOLLOW PLAQUENIL PATIENTS

• Fundus autofluoresence

• Multifocal ERG

• OCT: High resolution spectral domain

THE OCT AND PIL THE CASE OF THE

CLOUDED CORNEA

62y/o female with c/o dcreasing

acuity OD X 2 months

• BVA: 20/40+1 OD, 20/25(-) OS

Let’s do a 30-2

• CV: Acquired deficit OD

• DX: Bilateral NAION?? Does the 30-2

support this DX?

11/11/2019

8

Amiodarone optic neuropathy

• Decreased acuity-not symmetrical-from

minimal to <20/200 insidious onset

• Mimics NAION

• Disc edema/CV defects-variable-/ Variable

unlike NAION hemi-field defect

• Test: Acuity, Ishihara, 30-2 VF, DFE

• What to do: Carefully discussion of altered

therapy/max return of VA after 3 months

Watch for ALL anti-arrhythmic

Agents@@@@• All can produce

reversible

decrease in acuity

• Optic neuritis has

occurred

• Permanent loss of

vision with

amiodarone

Adverse Effects

• Mydriasis

• Blurred VisionNight

Blindness/Decreased Color

Vision

• Optic Neuritis

• Diplopia

• Verticillata

WHAT’S GOING ON HERE:

DIFFERENTIAL DX?

THE LIST

• Hypertension: BRVO/CRVO

• Diabetes

• Toxoplasmosis

• CMV retinitis

• Drug induced

THEN AND NOW: FREE

LOVE AND DRUGS

11/11/2019

9

THE PRICE OF IV DRUG

ABUSE

• HEPATITIS C AND LIVER FAILURE

It’s all about the HX

• Social HX

• HIV (sentinal disorders)

• Drugs

• MANAGEMENT?

• NOTHING?

• MAYBE NOT

• Korean J. Oph.

• April 2012

Incidence of P. Intron Retinopathy -

Watch the literature

• 18-86%: Occurs after 4-12 weeks TX

with P. Intron/ribavirin

• Normally self limiting

• Significant retinopathy is rare, but can be

see in patients with microvascular disease

ie diabetes and hypertension

SAMPLE CASE-THE RED

EYE KID• 10 Y/O PRESENTS WITH ACUTE RED

EYE PAIN

• EYE ACHES X 24 HOURS

• 7/10 PAIN RATING

• NAUSEA/VOMITING X 24 HOURS

• 1ST EPISODE

• OS VS decreasing X 1 wk

• VA 20/20 PLANO OD

• -3.00 SPH 20/60 OS

• MED HX: EPILEPSY

• ER DX: Pink eye/Gentamycin

drops/now worse

TESTS

• PUPILS: 5MM/6MM

+3RX/+1RX (-)

APD

• (+) 2-3 CELL AND

FLARE

• (+) 1-2 CORNEAL

EDEMA

Differential DX?

• 1. Iritis

• 2. Angle closure glaucoma

• 3. “Pink eye”

• 4. Cataract

• 5. Bacterial endo-ophthalmitis

• 6. Need more information

11/11/2019

10

What would you like to know?

• IOP: 16 OD 68 OS

• Shallow chambers OS > > >OD

• NARROW ANGLES: ATROPINE??

• YES

WAIT, THERE’S MORE

WHO KNEW THAT TOPAMAX COULD

PRODUCE VF DEFECTS

MECHANISM

• RETINAL TOXICITY

• GABA ACCUMMULATION

• 125-150MG/D

• 8-12 WEEKS OF TX

• 2 CASES

• MORE INDICATIONS EVERY DAY

More info

Meds: @@@@

• Topamax

• DX: Choridal effusion OS

• Acute myopia/ secondary angle closure glc within 1 month of start of TX

Case #2:

The “atypical, I think we need

a corneal consult”

conjunctivitis case-or “take (2)

drops of this artificial tear and

call me in the morning –if

you’re still alive” case

Visit #1: AT COMMUNITY

CLINIC

5/25• 60 Y/O HF

• CC: “MY EYES ARE RED, I SEE

DOUBLE AND I HAVE HAD DAILY

SEVERE HEADACHES FOR THE

LAST (5) MONTHS

YES, THEY

REALLY ARE

RED

11/11/2019

11

Doctor #1: I think you

have…….

• ATYPICAL CONJUNCTIVITIS

• DIPLOPIA: UNKNOWN

ETIOLOLOGY

• TX: PRED FORTE BID OU

• REFER TO UEI FOR EVALUATION

Visit #2: UEI

6/6

• CC: Referred from community clinic for

red eye X 5 months and diplopia X 1

month

• Using pred forte BID X 2 weeks-no help

• Med HX: Type II DM X 4 yrs and

hypertensive

• Hospitalized 2 months earlier for BP

Visit #2 (cont’d)

• Meds: Olmesartan (BP) and metformin

(DM)

• NKDA

• FM HX: (-)

• Social HX: (-)

• BVA: 20/20 – OD/OS Hyperopic/astig

• BP: 136/77

Visit #2 (cont’d)

• IOP: 17/16

• CF’s and pupils: Normal

• SLE: (+) 4 conjunctival hyperemia OU

• (+) 1-2 chemosis OU

• (-) C or F

• Cornea clear

• EOM’s” Mild? Restriction in (L) gaze

• Lids:Ptosis OS

Visit #2 (cont’d)• HVF-30-2:

• OD Scattered defects, judged unreliable

• OS: Scattered defects, judged reliable

• DR# 2: I THINK YOU HAVE:

• DX: Unspecified conjunctivitis/

• (L) 6th nerve palsy secondary to BP/DM

• PLAN: DC PRED, start artificial tears

• Wear eye patch for diplopia/RTC if

worsens

• Refer to cornea specialist for red eye (3)

weeks

Visit #3 UEI

6/26• Reason for visit: Recheck red eyes

• CC: “HA’s, red eyes and diplopia are

worse”

• SLE: Corkscrew vessels OU

• IOP: 32/24

• EOM: Bilateral 6th N palsy

• CF/Pupils: normal

• DFE: Venous congestionOU

11/11/2019

12

Assessment and Plan (take your pick)

• 1. Really bad conjunctivitis / Restart

Pred forte

• 2. Episcleritis / Restart pred forte

• 3.Scleritis / restart Pred forte

• 4. Angle closure GLC/ Diamox , oral

glycerin, and topical brimonidine STAT

• 5. Immediate referral to corneal

specialist STAT

• 6. Needs MRI/MRA/MRV STAT

Red eye, diplopia, headache, venous

congestion, Increased IOP:

A VERY Atypical conjunctivitis

Patient referred for imaging for suspected

CCF (Carotid cavernous sinus fistula)

BINGO!!

MRI

MRA

ARTERIOGRAM

The anatomy

@@@@@@@

Direct: INTERNAL

CAROTID

Indirect (dural):

EXT. CAROTID or

meningial arteries

Risk factors

• Marriage (head trauma)

• MVA

• Idiopathic

1 month after CCF repair: all

is well

11/11/2019

13

Lessons learned• LISTEN TO YOUR PATIENT

• IT’S BETTER TO BE A HERO THAN A

SCHMUCK !!!!

• Every red eye is not conjunctivitis

• Think of common denominator

Ie what could cause ALL symptoms (SYNDROME)

• Prioritize: LIFE, SIGHT,VISION

• Know the tests to R/O the bad stuff

• Bad referrals can lead to delay in correct DX

and TX

THE CASE OF THE

SWOLLEN NERVE

• 16 y/o female general and CL exam

• severe HA’s X 6-8 weeks-is it her

glasses

• Med HX: Acne

• Asthma

Obesity

Medication HX

• Tetracycline 250mg TID

• Topical Benzoyl peroxide

• Accutane tablets daily

BVA : 20/20

DFE: Bilateral papilledema

NEURO CONSULT?? MRI??

Is she gonna die!!

The Hallucinating Senior Citizen• 72 y/o male -

Visual

disturbance@@@

“Lights look like

covered in snow

with halos”

• Vision getting

blurry X 2

months

• Told by primary

care doc to get

new glasses

Therapeutic Index@@@@

LD 50 Lethal Dose

_______________

ED 50 Effective Dose

Low TI = Dangerous drug

High TI = Safe Drug

Toxic Level

Bilateral uveitis-it’s in the

bones?

• 55 year old female referred by her

internist for red eyes due to her

osteoporosis meds

• Started alendronate (Fosemax) 10 days

earlier, within the last day she developed

a red, painful OD and this AM, the OS

also became involved-

CONJUNCTIVITIS??

11/11/2019

14

The exam

• BVA 20/25 OD 20/40 OS

• Conj: Diffuse bulbar hyperemia OU

• Cornea: KP OD

• IOP: 12/18

• OD: (+) 3 C & F

• OS: (+) C & F

• Pupils (+) 2 RX RD (-) APD

• DFE: NML

Biphosphonates and ocular

inflammation

• Most common with the amino-

biphophonates

• Can produce :

• Uveitis

• Scleritis

• Episcleritis

• Triggers the immune response

• Must TX aggressively and DC drug

The Bespecled Bleeder

• 66 y/o white male

• Bloody OD discovered this AM

• Daily nose bleeds

• bruises on arms X 2 weeks

• His eye doctor says that this is

normal

Subconj. Heme-A DX

of………..

If they like to drink, skip the Tylenol

• Acetaminophen contraindicated in

alcoholics

• Can not exceed 4gm/day in normal adults

• Liver failure produces excessive

bleeding@@@@

Clotting Tests

• APTT: Activated

partial thromboplastin

time-Monitor heparin

and warfarin

• PT: Prothrombin

time-Monitor

Warfarin

• INR: Combination of

both

11/11/2019

15

The EX-flight instructor

• 48 Y/O female with CC of recurrent red

eye OS

• Mild ache

• BVA 20/20 OU

• Sectoral injection OS

• (+) FM HX GLC M and F and GM (M)

• IOP’s: 15 OU

DX: Episcleritis

• TX : FML 0.1% QID X 7 D

• Min. benefit

• IOP: 17/16

• Switch to Pred forte QID, recheck 5D:

• Marked improvement, IOP: 18/18

• Start 5D taper and recheck in 1 week

The 1 week recheck

• Pred forte BID

• 90% resolved

• IOP 29/28

• DC: Pred/ start loteprednol 0.5%

• Rebound of episcleritis (+) phenylephrine

test

• Sent for rheumatoid eval (-)

Refer to OD/MD

• Fellowship at UCSF: Ocular

inflammation for evaluation and TX

• Advised patient was a steroid responder

Hey it’s good to see you again-I

wish you could see me