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From Carrots to Keratitis: An Eye Update for Non-Ophthalmologists . Objects in mirror are closer than they appear. Rachel Bishop, MD, MPH CDR, USPHS Chief, Consult Service, National Eye Institute, NIH. Objectives. Update: what’s new for t he “Big 4”? Glaucoma Diabetic eye disease - PowerPoint PPT Presentation
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From Carrots to Keratitis: An Eye Update for Non-Ophthalmologists
Rachel Bishop, MD, MPHCDR, USPHS
Chief, Consult Service, National Eye Institute, NIH
Objects in mirror are closer than they appear.
Objectives
• Update: what’s new for the “Big 4”?– Glaucoma– Diabetic eye disease– Macular degeneration– Cataract
• A few words on preventive ophthalmology
• Managing acute eye problems
Normal Anatomy
Glaucoma
Glaucoma Management: What’s new? Not much.• Prevention: none• Treatments– Medical: pressure lowering drops– Laser to the trabecular meshwork– Surgery: shunt
• Good news: most patients maintain vision
Diabetic Retinopathy
non-proliferative proliferative
Diabetic Retinopathy Management
• Prevention: control chronic medical conditions
• Treatment– Macular edema:
focal laser
– Proliferative retinopathy: scatter laser
8
Diabetic Retinopathy
9
• NEW: VEGF inhibitors– Bevacizumab (Avastin)– Ranibizumab (Lucentis)– Aflibercept (Eylea)
• Intravitreal injection
Age-Related Macular Degeneration
Dry Neovascular (“Wet”)
Macular Degeneration: Management
Dry AMD: Prevention– NEW: anti-oxidants
Neovascular AMD– NEW: VEGF inhibitors
pre: 20/100 post: 20/50
Cataract • Prevention: UV protection (but not really…) • Treatment: surgery• NEW: multifocal and accommodating
intraocular lenses
Refractive Error
• Half of Americans– myopia, hyperopia, astigmatism– excludes presbyopia
• 11 million Americans have impaired vision (<20/40) due to uncorrected refractive error
• Accounts for 80% of vision impairment
Preventive Ophthalmology
Preventive Lifestyle Tips: Not Much New
• Dilated eye exams
• “Healthy Living”
• Protective eyewear: safety, UV-blocking
Managing Acute Ocular Problems• The red eye• Ocular trauma• Flashes and
floaters• Acute loss of vision
The Tool Box
DDx: The Red Eye• Cellulitis• Conjunctivitis • Episcleritis and scleritis• Subconjunctival hemorrhage• Corneal abrasion • Corneal or conjunctival foreign body• Corneal ulcer• Keratitis• Angle closure glaucoma• Uveitis
Cellulitis• Pre-septal vs. orbital• Pain with eye
movements?• Uncertain? CT orbits
Conjunctivitis
• Majority: viral
• Purulent discharge– Bacterial– Topical ABX (NOT gent)
• Other– allergic– irritant– dry eye– blepharitis
Episcleritis/Scleritis
• Often sectoral• Episcleritis– Minimal pain– Blanches with neo– Treatment: NSAIDS
• Painful? …Scleritis– Refer
Sub-Conjunctival Hemorrhage
Treatment: observation only
Corneal Abrasion
• Treatment: ABX ointment and close f/u• If large, refer to ophthalmology• Do not patch
Corneal or Conjunctival Foreign Body
• Remove with Q-tip or small clean instrument
• Topical ABX and f/u until healed
• Refer if rust or deep penetration
Corneal Ulcer
• Contact lens user?– Think: pseudomonas
• Refer • Initiate ABX
treatment if referral will be delayed
• Close follow-up
Angle Closure Glaucoma
• Start pressure lowering drops and Diamox • Urgent referral• Treatment– peripheral laser iridotomy
Uveitis
• History of same?• Auto-immune DZ?• Ciliary flush?• Refer
Ocular Trauma
Blunt Ocular Trauma• Assess vision
(if possible)• Refer if…– Floaters and/or flashes– Change in vision– Eye too swollen to
examine– Blood in eye– Suspected blow-out FX
Suspected Penetrating Trauma: “Ruptured Globe”
• Protect the eye • NPO• Urgent referral
Chemical Injury• Defer vision check and
detailed history• Copious irritation• Antibiotic ointment• Urgent referral
Floaters and Flashes
• Chronic floaters– Benign vitreous changes
• New floaters– Refer
• Photopsias– Urgent referral
Acute Loss of Vision
• Refer urgently to ophthalmology
• Differential diagnosis is extensive– Acute angle closure glaucoma– Retinal vascular disease– Vitreous or retinal hemorrhage– Retinal detachment– Optic neuropathy– Optic neuritis– CNS disease
Concluding Pearls• Most vision impairment is correctable or
avoidable• Dilated eye exams necessary for detection of
eye disease • Urgent referral if significant change in vision or
trauma • If in doubt: email a picture to your favorite
ophthalmologist!
QUESTIONS?
Objectives
• Update: what’s new for the “Big 4”?– Glaucoma: 2.2million – Diabetic eye disease: 5.3 million – Macular degeneration: 1.8 million– Cataract: 20 million
• A few words on preventive ophthalmology
• Managing acute eye problems
Herpetic Keratitis
• Herpes simplex keratitis– Risk of corneal scarring– Ophtho referral for
aggressive Rx• Herpes zoster (VZV)– Acyclovir– Artificial tears– Erythromycin ointment
The Assessment• Chief complaint • Ocular and medical history• VISION• Pupil exam• Visual fields: less important• Ocular motility • How does the eye look?