Ophthalmology for the Primary Care

Provider Padmini Kaushal, M.D.

Financial Disclosures

• None

Acknowledgements

The many patients that I have been able to take care of over the years.

My primary Care Colleagues

Program Chair, Richard Riemer, DO

2017-2018 OPSC Education Committee

A little about me …

Outline

• Review Ocular Anatomy • Basic Ocular Vital Signs • Miscellaneous Things

• Ophthalmology abbreviations

• Color of Eye Drops

• The Red eye

• Diagnosis not to miss • Headaches: IIH and GCA

• Glaucoma

Components of an Eye Exam

• Va with glasses (preferably) at Distance or

with a near card with each eye occluded

• Eye Pressure

• Pupils

• EOMs (Extraocular movement)

• CVF (Confrontational Visual Field)

• Pen Light exam

Components of an Eye Exam

• Va with glasses (preferably) at Distance or

with a near card with each eye occluded

• Eye Pressure

• Pupils

• EOMs (Extraocular movement)

• CVF (Confrontational Visual Field)

• Pen Light exam

Visual Acuity

• NORMAL VA

• Conjunctivitis

• SCH

• Preseptal Cellulitis

• DECREASED VA

• Trauma

• Keratitis

• Iritis

• Angle Closure glaucoma

• Orbital Cellulitis

Pupils

• PERRLA • The pupil is an opening located in the center of the iris that

allows light to enter the retina • Its function is to control the amount of light entering the eye

and it is under the influence of the autonomic nervous system • The normal size is 3-4 mm • Should be located centrally and should be round

Pupils

• DILATED

• Trauma

• Third Nerve Palsy

• Adies’ Tonic Pupil

• Acute Glaucoma

• Drugs

• CONSTRICTED

• Iritis

• Horner’s

• Drugs

Pupils

• Assesses the integrity of the pupillary light reflex pathway. • Dim the light and ask the patient to fixate at a distant target. Do not

stand in front of them as their pupils will accommodate to focus on you.

Pupils

• Step 1: Direct : shine light into the right eye, look for pupillary constriction in the same eye. Repeat with the left eye

• Step 2:Consensual: Shine the light in one eye and look for constriction in the other light. Repeat with the other eye

• Normal: there should be a brisk, simultaneous equal response of both pupils in response to the light shone in one eye or the other eye

• Step 3: check for an APD

APD

• The ‘swinging light test’ is used to detect a relative afferent pupil defect (RAPD)

• Detect differences between the two eyes in how they respond to a light shone in one eye at a time.

• The test can be very useful for detecting unilateral or asymmetrical disease of the retina or optic nerve (but only optic nerve disease that occurs in front of the optic chiasm).

APD

• If it dilates when light is shone on it, then this means that the light reflex is weaker than the consensual reflex (produced by withdrawing light from the unaffected eye)

Diagnosis not to miss

EOMs

• Have the patient look in the six cardinal positions of gaze. • Test with both eyes open to assess versions • Repeat monocularly to test ductions

Diagnosis not to miss

Down and out

CVF

• Simple test • Examiner and the patient are separated by about 60 cm • Ask the patient to cover up Left eye and look at the examiners nose.

• Gross assessment “ Do you see my whole face/nose and mouth”

• When the patient covers up his Ask the patient to cover up Left eye and look at the examiners nose.

• Gross assessment “ Do you see my whole face/nose and mouth” • Test all 4 quadrants • Repeat with the Right eye

Case

• “Doc, I can’t see out of my left eye”

• Va 20/20 both eyes • Pupils 4->3 ou, no apd

Ophthalmology Lingo

What do all of these abbreviations mean?

Ophthalmology English

APD Afferent pupillary defect

ARMD Age related macular degeneration

BDR Background Diabetic Retinopathy

BRAO Branch Retinal Artery Occlusion

BRVO Branch Retinal Vein Occlusion

cc With correction

CSDME or CSME Clinically Significant (Diabetic) Macular Edema

CF Counting Fingers

DES Dry Eye Syndrome

DR Diabetic Retinopathy

MA Microaneursyms

MH Macular Hole

OD (ocular dexter) Right e ye

OS Oculus sinister) Left eye

OU (Oculus uterque) Both eyes

sc Without correction

Ta Tonometry Applanation

What eye drops are you taking?

Anatomy of the Eye

Ectropion

• Ectropion

Blepharitis

Blepharitis

• Refers to any inflammation of the eyelid

• In general refers to a “mixed” blepharitis • With flakes and oily secretions on lid edges

• Caused by a combination of factors • Hypersensitivity to staphylococcal infection of the lids

• Glandular hypersecretion

• Treat with warm, moist towel compresses and dilute baby shampoo scrub

Masquerader

Dacryocystitis

Inspection of the Conjunctiva

• Localized Congestion

• SCH

• Scleritis/Episcleritis

• Perilimbal Injection

• Iritis

• Acute Glaucoma

Causes of SCH

• Traumatic

• Non-Traumatic

• Conjunctivitis

• Iritis

• Cellulitis

Conjunctivitis

• Inflammation of the eye surface

• Vascular dilation, cellular infiltration, and exudation

• Acute vs. Chronic

Conjunctivitis • Infectious

• Bacterial • Viral

• Noninfectious • Persistent irritation (dry eye) • Allergic • Toxic (irritants: smoke, dust) • Secondary (Stevens-Johnson)

Historical Clues

• Itching

• Unilateral vs. Bilateral

• Pain, photophobia, blurred vision

• Recent URI

• Prescription, OTC medications, contact lenses

• Discharge

Conjunctivitis, American Family Physician, 2/15/1998; http://aafp.org/afp/980215ap/morrow.html

Bacterial Conjunctivitis

• Dx based on clinical picture • History of burning, irritation, tearing • Usually unilateral • Hyperemia • Purulent discharge • Mild eyelid edema • Eyelids sticking on awakening • Cultures unnecessary unless very rapid progression

Bacterial Conjunctivitis

• Erythromycin • Bacitracin-polymyxin B ointment (Polysporin) • Aminoglycosides: gentamicin (Garamycin), tobramycin (Tobrex) and

neomycin • Tetracycline and chloramphenicol (Chloromycetin) • Fluroquinolones available for eyes!

EKC

• Manifests as a flu like syndrome

• Frequetnly begins as a unilateral condition but in 70% of cases will become Bilatearl within the first week of symptoms as a result of hand to eye transmission.

• Typically self-limiting – lasts 2-3 wks and pts are contagious for 10-14 days

• Fever, malaise, myalgias

• Red eye, eyelid edema, excessive tearing, irriation, FBS, and light sensitivity

Diagnosis

• Typically based on clinical presentation

• 62-75% of cases of infectious etiology are adenovirus

• Diagnosis can be confirmed with a commercially available detection device.

• It has an 88% sensitivity and 91% specificity

Treatment

Why are antibiotics prescribed

• School policies that require treatment

• A lack of patient education about the potential harmful side effects

• Unclear infection cause (bacteria vs. viral vs. allergic)

• Patient expectation to leave with a prescription

Prevention

• Handwashing • Medical equipment sanitation • Triage pts with EKC with universal isolation precautions • CDC Guidelines recommend 60 to 80% ethyl alcohol as an effective

virucidai agent for adenovirus

Strategies to prevent spread

• ID patients with complaints that suggest adenoviral infection

• See them in designated isolation rooms

• Use proper hand washing technique

• Employ single use devices

• Avoid corticosteroids

• Educate patients about infectivity window and the risk of transmission

What about Corticosteroids

• In the past they were prescribed to alleviate severe symptomatic inflammation.

• Animal studies showed that steroids reduce inflammation in the acute phase.

• However, their use increased viral replication and titers and prolonged mean duration from 10 to 14 days.

Povidone-Iodine

• Off label use

• Betadine

• In vitro strudes have shown povidone-Iodine is able to rapidly inactiviate adenovirus within in 1minute of exposure

• Small clinical studies have shown that >2% solution can reduce duration of infectivitiy

Corneal Abrasion

• Do they have a prior history of a cornea abrasion?

• Do they wear contact lenses ?

• Did they sleep w their contact lenses ?

• Has there been any exposure to organic matter

• Herpes zoster

• Corneal Dendrite

• Do not use steroid drops!

Corneal Abrasion

Corneal Ulcer

Herpes Keratitis

• Herpes simplex • Herpes zoster • Corneal Dendrite • Do not use steroid drops! • Aggressive treatment with antivirals, may need debridement • Refer to ophthalmologist

Herpes Keratitis

Herpes Keratitis

Allergic Conjunctivitis

Allergic Conjunctivitis

• Seasonal, itching, associated nasal symptoms.

• Treat with cool compresses. systemic antihistamines, local antihistamines or mast cell stabilizers, local NSAIDs. If severe, brief course of topical steroid drops.

Questions?

Overview

• Uveitis in general • Episcleritis

• Scleritis

• Anterior Uveitis

• Other interesting cases from Fellowship

Uveitis

• NOT a single disease • Separate diseases each with its own features, course and prognosis

• Inflammation of one or all parts of the uveal tract • Iris • Ciliary body • Choroid

? Systemic Disease

• MOST uveitides are eye-limited

Etiology/Uveitis Workup

• Look for an infection (changes management) OR • Systemic disease (affects health)

• Not shot gun labs

1. Episcleritis • Simple • Nodular

2. Anterior scleritis • Non-necrotizing diffuse • Non-necrotizing nodular • Necrotizing with inflammation • Necrotizing without inflammation (scleromalacia perforans )

3. Posterior scleritis

Episcleritis and Scleritis

Applied anatomy of vascular coats Scleritis

• Maximal congestion of deep vascular plexus • Slight congestion of episcleral vessels

• Maximal congestion of episcleral vessels

Episcleritis Normal

• Radial superficial episcleral vessels • Deep vascular plexus adjacent to sclera

Simple episcleritis • Common, benign, self-limiting but frequently recurrent • Typically affects young adults

Treatment

• Seldom associated with a systemic disorder

Simple sectorial Simple diffuse

• Lubrication

Simple episcleritis

• Typically affects young adults

Treatment

• Seldom associated with a systemic disorder

Simple sectorial Simple diffuse

• Lubrication

Before and After

Nodular episcleritis • Less common than simple episcleritis • May take longer to resolve • Treatment - similar to simple episcleritis

Localized nodule which can be moved over sclera Deep scleral part of slit-beam not displaced

Epidemiology

• Exact prevalence and incidence are unknown • Typically affects young adults • More common in women

Etiology

• Idiopathic (70%) • Rheumatoid arthritis

• 1: 200 develop scleritis

• Other Collagen Vascular Diseases

Diffuse anterior non-necrotizing scleritis • Widespread scleral and episcleral injection •Does not progress to necrosis

• Oral steroids if unresponsive

Treatment • Oral NSAIDs

Scleritis

• Scleral inflammation with maximal congestion in the deep vascular plexus

• Symptoms/Signs: • Pain (often severe boring)

• Significant ocular tenderness to movement and palpation

• Watering and photophobia

• Appearance bluish-red

Scleritis

• Etiology

• usually immune rather than infectious (but must always consider)

• 30-60% associated systemic disease- connective tissue disease • most commonly associated with rheumatoid arthritis

• Treatment • underlying condition • NSAIDs • corticosteroids • immunosuppression

Nodular anterior non-necrotizing scleritis

Scleral nodule cannot be moved over underlying tissue

More serious than diffuse scleritis

On cursory examination resembles nodular episcleritis

Treatment - similar to diffuse non-necrotizing scleritis

Anterior necrotizing scleritis with inflammation

Progression

• Painful and most severe type • Complications - uveitis, keratitis, cataract and glaucoma

Treatment • Oral steroids • Immunosuppressive agent • Combined intravenous steroids and IMT if unresponsive

Scleral necrosis and visibility of uvea

Spread and coalescence of necrosis

Avascular patches

• Asymptomatic and untreatable • Associated with rheumatoid arthritis

Progressive scleral thinning with exposure of underlying uvea

Anterior necrotizing scleritis with inflammation (scleromalacia perforans)

Questions ?

Anterior Uveitis

Anterior uveitis (aka Iritis) • Symptoms/Signs

• Pain (ache) • Photophobia • Perilimbal conjunctival injection • Blurred vision • Pupil miotic / poorly reactive

• Slit-lamp examination:

• flare (protein) in AC • cells in AC • Keratic precipitates (WBC) on the

back of the cornea • Hypopyon

Anterior uveitis • Repeated attacks

• Investigations CXR, lumbar XR, autoimmune serology, HLA B27 Bilateral cases or severe cases

• Treatment

• Mydriatic / cycloplegics to break synechiae, comfort

• Topical steroids, depending on severity, initally can be ½ hourly

• May need sub conjunctival steroid if severe

Anterior uveitis

• Idiopathic (70%) • Associated with systemic

disease: • Sarcoid • Ankylosing spondylitis • Inflammatory bowel disease • Reiter’s syndrome • Psoriatic arthritis • Juvenile Chronic arthritis

• Infection • Bacteria- TB, syphyllis, leprosy • Viral: HSV, HZV, HIV • Fungal • Infestation

• Ocular entities: • Post-trauma • Lens-induced • Post-op • Retinoblastoma, lymphoma

Anterior Segment Findings

Management- at least initially

• Cycloplegic agent • Topical steroids • IOP drops if elevated IOP

Common Associated condition

• AS, Reactive arthritis – Acute, anterior, ususally unilateral, non-granulomatous • Inflammatory Bowel Disease- Typically unilateral and NG. • JIA- Chronic anterior, unilateral or bilateral • Sarcoid, TB- Chronic, anterior, posterior, panuveitis, granulomatous • Syphillis- “The great imitator” • Lyme- Variable non-specific • MS- Chronic, bilateral, AU or IU. NG • HSV and B=VZV

Complications of uveitis

Posterior synechiae - 30% Cataract -20%

Glaucoma due to PAS - 15% Band keratopathy - 10%

Uveitic CME

Questions

Headache

• Young

• Older

Headaches

• 26 yo female who presented with a 3 month history of HA. Reported her vision was been blacking out . • Daily HA •

• Pain hadn't resolved w NSAIDS • Recent increase in her weight • Meds: OCPs

Headaches

• Weight/ BMI

• Recent increase in weight

• Any new medications

Mnemonic

• HOT Glucose and Minerals

• HyperVit A

• OCPs

• Tetracyclines

• Glucocorticoids or withdrawal

• Amniodarone

• Mineralocorticoid withdrawal

Management

• Goals of therapy • Weight loss • Diamox

Case

• 64 yo Caucasian female w a few week history of fatigue and then this week with a new onset left sided HA. Didn’t improve with Tylenol. Yesterday, had blurry vision transiently and then it resolved

Risk Factors for GCA

• Increasing age • Women affected more often than men • More common among people of Nordic or Northern European

background, others residing in Northern latitudes • Current smoking or history of smoking • Possible risk factor: varicella zoster virus

What are the characteristic clinical features of GCA?

• Common features related to vascular injury (30%-80%)

• Headache

• Scalp tenderness

• Jaw claudication

• Less common features related to vascular injury (<20%)

• Ocular symptoms, blindness

• Painful dysphagia, respiratory symptoms

• Limb claudication

• Absent or asymmetrical pulses

• Infrequent features related to vascular injury (<5%) • Ischemia of the central nervous system

• Tongue claudication

• Aortic regurgitation, myocardial infarction

• Peripheral neuropathy

• Deafness

• Tissue gangrene

• Common features related to systemic inflammation (40%-100%) • Intense acute-phase response

• Anemia (normocytic, normochromic)

• Polymyalgia rheumatica

• Wasting syndrome

On Physical Examination ….

• Careful head and neck examination • Erythema, tenderness, nodularity, thickening of temporal

artery, decreased pulse (vs. unaffected temporal artery)

• Eye examination • Visual acuity and visual fields

• Optic disc and retinal vessels

• Assess pulse and blood pressure in all 4 extremities

• Listen for bruits over thoracic and abdominal aorta

• Listen for aortic regurgitation

Differential diagnoses

• Differential diagnosis of GCA

• Common or migraine headache

• Atherosclerosis of large vessels

• Takayasu arteritis

• Headache and temporal artery involvement due to other forms of vasculitis

Laboratory testing?

• Marked elevations in ESR and CRP: common

• Hypochromic or normochromic or normocytic anemia and thrombocytosis: common

• Liver function test abnormalities: sometimes

Pathology Slide

Warning signs that should prompt Urgent Referral

patients older than 55-60 years with:

New onset, localized unilateral headache

Ischemic symptoms in cervico-cranial and upper extremity vascular territories

Muscle stiffness of the neck, shoulder, pelvic girdle

Physical exam: tenderness, swelling, and erythema over temporal artery; flow abnormalities of large vessels

Lab: ESR or CRP elevated in most patients

Temporal artery biopsy: gold standard for diagnosis

Questions?

Glaucoma

Types of Glaucoma

• Primary open-angle glaucoma • This is the most common type of glaucoma • Gradual onset, insidious • End organ damage: optic nerve • This type of glaucoma is painless and causes no vision changes at first • Some people can have optic nerves that are sensitive to normal eye

pressure. This means their risk of getting glaucoma is higher than normal • Screening?

Angle-closure glaucoma ( “closed-angle” or “narrow-angle glaucoma”)

• The iris is apposed to the drainage angle of the eye The iris can end up blocking the drainage angle.

• When the drainage angle gets completely blocked, eye pressure rises very quickly. This is called an acute attack. It is a true eye emergency.

Symptoms

• Here are the signs of an acute angle-closure glaucoma attack: • vision is suddenly blurry • Severe eye pain • headache • nausea • Rainbow-colored rings or halos around lights • Angle-closure glaucoma can cause blindness if not treated right away.

Warning Signs

• Decreased vision

• Ptosis

• Dilated pupil

• Extra-ocular movements aren’t full

• Pain (sometimes)

Reassurance

• Still present when they occlude either eye

Thank you! Please feel free to contact me at pkaushal@wheatoneye.com