1. 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

2. 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
What would a practicing

4. Normal Anatomy

5. Glaucoma

6. 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

7. Diabetic Retinopathy non-proliferative proliferative

8. Diabetic Retinopathy Management
Prevention: control chronic medical conditions
Treatment
Macular edema: focal laser
Proliferative retinopathy: scatter laser

9. Diabetic Retinopathy NEW: VEGF inhibitors Bevacizumab (Avastin)
Ranibizumab (Lucentis)
Aflibercept (Eylea)
Intravitreal injection

10. Age-Related Macular Degeneration Dry Neovascular (“Wet”)

11. Macular Degeneration: Management
Dry AMD: Prevention
Neovascular AMD
NEW: anti-oxidants
NEW: VEGF inhibitors

12. pre: 20/100 post: 20/50

13. Cataract Prevention: UV protection (but not really…)
Treatment: surgery
NEW: multifocal and accommodating intraocular lenses

14. 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

15. Preventive Ophthalmology

16. Preventive Lifestyle Tips: Not Much New
Dilated eye exams
“Healthy Living”
Protective eyewear: safety, UV-blocking

17. Managing Acute Ocular Problems
The red eye
Ocular trauma
Flashes and floaters
Acute loss of vision

18. The Tool Box

19. 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

21. Cellulitis Pre-septal vs. orbital Pain with eye movements?
Uncertain? CT orbits

23. Conjunctivitis Majority: viral Purulent discharge Other Bacterial
Topical ABX (NOT gent)
Other
allergic
irritant
dry eye
blepharitis

25. Episcleritis/Scleritis
Often sectoral
Episcleritis
Minimal pain
Blanches with neo
Treatment: NSAIDS
Painful? …Scleritis
Refer

27. Sub-Conjunctival Hemorrhage
Treatment: observation only

29. Corneal Abrasion Treatment: ABX ointment and close f/u
If large, refer to ophthalmology
Do not patch

32. 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

34. Corneal Ulcer Contact lens user? Refer
Think: pseudomonas
Refer
Initiate ABX treatment if referral will be delayed
Close follow-up

36. Angle Closure Glaucoma
Start pressure lowering drops and Diamox
Urgent referral
Treatment
peripheral laser iridotomy

38. Uveitis
History of same?
Auto-immune DZ?
Ciliary flush?
Refer

39. Ocular Trauma

40. 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

41. Suspected Penetrating Trauma: “Ruptured Globe”
Protect the eye
NPO
Urgent referral

42. Chemical Injury Defer vision check and detailed history
Copious irritation
Antibiotic ointment
Urgent referral

43. Floaters and Flashes Chronic floaters New floaters Photopsias
Benign vitreous changes
New floaters
Refer
Photopsias
Urgent referral

44. 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

46. 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: a picture to your favorite ophthalmologist!

47. QUESTIONS?

49. 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
What would a practicing

51. Herpetic Keratitis Herpes simplex keratitis Herpes zoster (VZV)
Risk of corneal scarring
Ophtho referral for aggressive Rx
Herpes zoster (VZV)
Acyclovir
Artificial tears
Erythromycin ointment

52. The Assessment Chief complaint Ocular and medical history VISION
Pupil exam
Visual fields: less important
Ocular motility
How does the eye look?