Eye Care for Health Care Providers

Len Oshinskie, O.D.
Chief, Optometry Section
Newington VA Medical Center
 Laser-assisted Cataract surgery
 Age-related macular degeneration
 Diabetic Macular Edema
 Glaucoma and Medications
 Red eye
 Dry eye
 Practical advice
Common Causes of Blindness
and Visual Impairment
 Age-related macular
 Diabetic retinopathy
 Glaucoma
 Cataract
Femtosecond laser
 Approved by FDA for several steps in cataract surgery
in 2009-2010
 Uses laser energy at 1053 nm that is precise to 3
microns( lens capsule is 2-28 microns thick)
 Ultra short pulse does not damage surrounding tissue
(10-15 of a sec)
laser assisted
cataract surgery
Advantages to laser assisted
cataract surgery
 Incisions more reproducible than bladed incisions
 Less risk for capsular rupture
 More precise opening so IOL can be more accurately
 Less energy from phaco probe for at risk pts, less
 Perhaps less risk of infection
Disadvantages of laser assisted
cataract surgery
 Takes longer
 Requires expensive equipment
 Capsulorhexis not always complete
 Not paid for by Medicare
 Pts have higher expectations
Age-related macular degeneration
 Leading cause of blindness over age 65
 Drusen and pigment atrophy and clumping
 exudative changes(heme, lipid, small central
retinal detachments)
 sudden distortion of vision, new unilateral
blur, scotoma, difficulty reading
Macular Degeneration Types
 Atrophic (dry) AMD 80-90%
 Neovascular(wet) AMD 10-20%
 500 mg vit C
 400 IU vit E
 15 mg betacarotene
 80 mg zinc
 2 mg copper
 Over 5 yr followup reduced risk of progression to
advanced AMD by 25 % if pt had certain macula
findings(larger drusen)
AREDS 2 results May 2013
JAMA 2013: 309(19):2005-2015
 Placebo controlled clinical trial(AREDS 1 was placebo)
 Multiple arms: lutein 10 mg/zeathanthin 2 mg,
DHA(350 mg) and EPA(650 mg), both, AREDS 1
 AREDS 1 formula with lutein/zeaxanthin(removing
betacarotene) slightly reduced risk of developing
advanced AMD
 Adding DHA and EPA did not reduce risk
Risks with AREDS 2
 Large dose of vit E(prostate and heart failure)
 Coumadin users
Genetics and AMD
 One study to suggest genetic testing maybe important
before prescribing AREDS supplement
Exudative (Wet) AMD
Early exudative AMD
ocular coherence tomography
Br J Ophthal 1997; 81:154-162
 A significantly increased expression of VEGF
(p=0.00001) and TGF-β (p=0.019) was found in the
retinal pigment epithelium (RPE) of maculae with
AMD compared with control maculae.
Anti-VEGF medications
 Macugen(Pegaptanib) 2004
 Avastin(bevacizumab) 2005 but not FDA approved
 Lucentis(ranibizumab) 2006
 Eylea(aflibercept) 2011
Intravitreal injection
Studies on Treatment of Wet AMD
(ETDRS visual acuity chart)
Visual Acuity with Eylea
Ocular side effects
 Cataract
 Inflammation
 Retinal detachment
 endophthalmitis
 Intravitreal injection
 Approved for treatment of vitreo-retinal adhesions
 Side effects-transient vision decrease and
Aspirin use in pts with wet
 Conflicting reports
 Recent studies suggest an increased risk, but not
 If risks for CV complications,
suggest continuing ASA
Trends in Treating Diabetic
Mechanism of Diabetic Macular
 Hyperglycemiathickened endothelial
cellsIschemia  increased VEGF, loss of pericytes
 Macular edema :
increased permeability
increased hydrostatic pressure
dilating blood vessels, pericytes disrupted
Inflammatory component
Treatment of Diabetic Macular
 Anti-VEGF treatment
 Corticosteroids
 Laser
Anti-VEGF treatment of DME
 Lucentis more effective than sham or laser in
decreasing thickness and improving vision
 Lucentis as adjunct to laser more effective than laser
alone in decreasing thickness and improving vision
 Eylea showed improved vision compared to laser
 Lucentis approved by FDA for Tx of DME
What to tell your patients about
intravitreal injections
 Does not hurt as much as you think
 Very safe (2.1% have ocular complications)
 Multiple injections needed
 Very effective in preventing vision loss
 It usually take several weeks for vision to
 Post op: expect mild soreness, irritation, floaters,
subconj heme
 Report any sudden vision changes or pain stat
 There may be small risk for CVA
Marijuana and glaucoma
AAO June 2014 recommendations:
Only lowers IOP 3-4 hours
Not as effective as available medications
Potential for abuse
Potential for lung damage
Lowers BP (less perfusion)
Topical THC drops tried but not effective(not water soluble
 effects of Marinol on glaucoma are not impressive
 No standardization of dose with various forms of
marijuana plants
 Not legal in federal system
Plaquenil Monitoring
 Visual field
 OCT and FAF
 Focal ERG
 Angle closure glaucoma
 Visual field defects
Tear film composition
 Lipid, aqueous, mucin
Tear film components
 Lipid-Meibomian glands
 aqueous-lacrimal gland
 Mucin-goblet cells
 Ideal tear film
 has uniform thickness
 maintains corneal coverage between blinks
 limited debris
Dry eye
 Multifactorial disease of tears and ocular surface
 Discomfort, vision changes and tear film instability
 Decreased tear production, increased osmolarity and
inflammation of ocular surface
Dry Eye Cascade
Clin Ophthalmol. 2009; 3: 405–412
Guidelines from the 2007 International Dry Eye
Dry Eye Disease
Stevenson et al in
Arch Ophthalmology
Dry Eye Symptoms
 Dryness
 Irritation/burning(“hurt”)
 Foreign body sensation(“sand in my eyes”)
 Watering
 Intermittent blurred vision
 Itching
Differential Diagnosis Pt with
Symptoms of Dry Eye
 Blepharitis
 Rosacea
 Exposure keratitis (TAO, CN 7 palsy,ectropion )
Risk factors for Dry Eye
Stevenson et al. Arch Ophthalmology 2012;130:90-100
 Increased age
 Female >males
 Hormonal inbalance
 Autoimmune disease
 Vitamin deficiency
 Medications
 Environmental stress
 Contact lens use
 Ophthalmic surgery(LASIK)
Contributors to Dry Eye
 Air flow(AC, fans etc)
 Humidity
 Smoke
 Alcohol
 Antihistamines
 Diuretics
 Blink rate(reading and computer)
Evaluation of the Dry Eye Patient
 History
 Tear Breakup time-quality
 Schirmer-quantity
 Corneal staining(fluorescein or lissamine green)
 Tear wedge-quantity
 Osmolarity
Break up Time
Corneal staining
Tear Wedge
Lid Position
 Proptosis
 Lagophthalmus
 Ectropion
 Parkinson’s
 CN VII palsy
 Partial blinker
 Sleep apnea
 Artificial tears-preserved and non-preserved
 Restasis(topical cyclosporin A)
 Topical corticosteroids
 Omega 3/Fish Oil
 Qhs ointment
 Tetracyclines
 Punctal plugs
 tarsorrhaphy
Using Artificial tears
 Avoid OTC “gets the red out” drops
 Use drops that say lubricant or artificial tears
 Must use 4 times a day
 Don’t touch tip of bottle to eye or lids
 Systane Balance
 Refresh Optive Advanced
 FreshKote(by Rx only)
 Give ointment at night ?
Punctal plugs
My patient has glaucoma, is it
safe to prescribe them_____?
 antihistamines
 tricyclic antidepressants
 Parkinson's disease
 anti-cholinergics such as atropine
 anti-spasmolytics
 anti-psychotic medications
Glaucoma Classification
• Primary, chronic or idiopathic
type(open angle)
secondary forms: pseudoexfoliation,
pigmentary, uveitic, steroid induced,
traumatic, post-op, others)
low-tension or normal-tension type
developmental type
angle-closure type
Narrow angle and dilated pupil
Meds to avoid if pt has
narrow angles
 Antihistamines and decongestants: Pseudoephedrine,
diphenhydramine , hydroxyzine, and clemastine
 Asthma medicines: Albuterol, metaproterenol sulfate,
isoetharine, and theophylline
 Motion sickness medicines: Scopolamine and
 Tricyclic antidepressants, such as amitriptyline,
nortriptyline , doxepin, clomipramine amoxapine,
chlordiazepoxide and amitriptyline ), trimipramine
and imipramine.
Risk factors for acute angle-closure
 Age 55-70
 Hyperopia
 females
 Asians
Signs/Symptoms of Acute Angle
Closure Glaucoma
 Pain
 hazy/blurred vision
 haloes around lights
 frontal HA
 nausea/vomiting
 Fixed pupil
 Steamy cornea
 Red eye
Glaucoma Medications
 Prostaglandin analogs(Xalatan, Lumigan,
Travatan Z, Zioptan, latanoprost)
 beta-blockers( Ocupress, Betagan, Betoptic S,
Betimol, Istalol, timolol)
 alpha agonist(Alphagan P, brimonidine)
 CAI(Trusopt, Azopt, dorzolamide)
 Combo meds(Cosopt, Combigan, Simbrinza)
 miotics(pilocarpine)
 Oral carbonic anhydrase inhibitors(Diamox)
Differential Diagnosis of the Red
 Infectious(bacterial, viral, fungal)
 Inflammatory(uveitis, episcleritis,scleritis)
 Increased IOP
 Allergic
 Mechanical(lid, FB, contact lens)
 Dry eye
 Toxic
Differential Diagnosis of the Red
 Systemic disorders/dermatologic disease
 thryroid disease
 Chlamydia
 rosacea
 atopic dermatitis
 subconjunctival hemorrhage
When to refer the red eye
 History important for deciding when to refer
 Refer if associated with :
 Blur
 Pain
 Hx of narrow angles
 Pupil unresponsive to light
 Hx of Herpes keratitis or zoster, light sensitivity
 Contact lens wearer
 Chemical injury involving alkaline
Clinical exam
 Stain the cornea with fluorescein
 examine lids(entropion, bleparitis)
 pupil(ACG, uveitis)
 cul-de-sacs for FB
Older Ophthalmic antibiotics
 Erythromycin
 Sulfacetamide
 gentamicin
 neomycin/polymyxin
Current trends
 Fluoroquinolones(Vigamox/Moxema, Zymaxid,
Quixin/Iquix, Besivance)
 Tobradex(beware steroids)
 Polytrim(trimethoprim/polymyxin B)
 Polysporin ointment
When to refer the red eye
 Vision changes
 Pain
 Redness getting worse
 History of narrow angles
 Light sensitivity
 Fixed pupil or steamy cornea
 Previous bouts of uveitis or Herpes simplex keratitis
Urgent Eye/Visual Symptoms
• eye pain(keratitis, uveitis, ACG)
• photophobia(keratitis, uveitis)
• numerous floaters(retinitis, RD, VH)
• sudden onset distortion or blur(AMD)
• sudden unilateral vision loss(CRAO/CRVO,
• red eye with blur(ACG, keratitis, posterior
• Fixed pupil with pain or diplopia
Topical Steroids
 Increases IOP in 10-15%
 allow proliferation of destructive
organisms(HSK, Pseudomonas)
 cataracts
 duty to warn
 limit refills
 Try Lotemax

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