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Volpe Healthy Transitions ‘13 Nicholas J. Volpe, MD Tarry Professor and Chairman Department of Ophthalmology Feinberg School of Medicine Northwestern University.

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Presentation on theme: "Volpe Healthy Transitions ‘13 Nicholas J. Volpe, MD Tarry Professor and Chairman Department of Ophthalmology Feinberg School of Medicine Northwestern University."— Presentation transcript:

1 Volpe Healthy Transitions ‘13 Nicholas J. Volpe, MD Tarry Professor and Chairman Department of Ophthalmology Feinberg School of Medicine Northwestern University The Aging Eye: How to Keep Your Sight For Life

2 Volpe Healthy Transitions ‘13 Strategies to Preserve Your Vision Choose your parents well and stop aging!!! OR Don’t Smoke Wear Glasses that are UV protective –Safety glasses for high risk activities Pay Attention to Nutrition and Vitamins Don’t Ignore Symptoms Get Regular Eye Examinations Prevention is our most potent tool in the quest to reduce disease (and healthcare costs)

3 Volpe Healthy Transitions ‘13 Major Causes of Chronic Visual Loss Preventable and Treatable Cataracts Glaucoma Macular degeneration Diabetic retinopathy Other Issues –Dry eye –Presbyopia near vision blurring

4 Volpe Healthy Transitions ‘13 Protective Eye Ware Avoid fireworks! Always if you have poor vision in one eye High risk activities –Racquet sports –Sawing –Drilling –Sawing –Working overhead –Any high speed tool –firearms

5 Volpe Healthy Transitions ‘13 Stop Smoking Clearly a risk factor for cataracts –3X the risk Clearly a risk factor for macular degeneration and its response to treatment

6 Volpe Healthy Transitions ‘13 Nutrition Healthy tear film Macular degeneration Fruits and Green Leafy Vegetables –Carotenoid pigments (lutein) accumulate in macula and prevent light damage Omega fatty acids Lutein and Zeaxanthin –Studied in AREDS 2 Vitamins A,C, E

7 Volpe Healthy Transitions ‘13 Regular Check Ups Many diseases can be detected Every 2-3 years from age Every 1-2 years after age 65 More frequently with diabetes or family history of glaucoma or macula degeneration Young adults, in the absence of symptoms, do not require routine examinations

8 Volpe Healthy Transitions ‘13 Cataracts Expected if ≥ 60 years old 50% years old 70% > 75 years old Most common cause of decreased vision Symptoms –Loss of acuity –Difficulty with colors –Glare at night –Trouble reading small print Age Steroids (PSC) Trauma Inflammation Diabetes Other drugs

9 Volpe Healthy Transitions ‘13 Subcapsular cataract AnteriorPosterior

10 Volpe Healthy Transitions ‘13 Nuclear cataract Exaggeration of normal nuclear ageing change Causes increasing myopia Increasing nuclear opacification Initially yellow then brown Progression

11 Volpe Healthy Transitions ‘13 Classification according to maturity Immature Mature HypermatureMorgagnian

12 Volpe Healthy Transitions ‘13 Drugs Chlorpromazine Long-acting miotics Other drugs Amiodarone Busulphan - initially posterior subcapsular Systemic or topical steroids - central, anterior capsular granules

13 Volpe Healthy Transitions ‘13 Cataract Surgery Outpatient Very successful > 95% Almost all with intraocular lenses Most common surgical procedure in U.S. >1.4 million/year Most successful surgical intervention Complications uncommon sight threatening IOL technology continues to evolve for astigmatic correction and presbyopia Newest modality is femtosecond laser

14 Volpe Healthy Transitions ‘13 Cataract Prevention Smoking cessation –Reduces Vitamin C in the eye –Vitamin C levels are high in the eye and this helps remove prooxidants Fruits and vegetables –5 fold decrease at 3-4 servings per day Regular alcohol consumption increases risk of cataract Steroids and inflammatory conditions are risks for cataracts Obesity and radiation

15 Volpe Healthy Transitions ‘13 Ultraviolet Light Cataracts and Macular Degeneration –Cataracts much more prevalent in equatorial climate –AMD more common in light eyes Same rules as sun tan lotions –if you might tan or burn you should be wearing sunglasses 10-30% transmission of light Wide brimmed hat Also water, sand and snow Polarized not necessary but will cut glare Don’t assume expensive is UVA and B protective Test lens quality and fit to ensure successful use

16 Volpe Healthy Transitions ‘13 Age- Related Macular Degeneration Age-related macular degeneration (AMD) is the most common cause of severe, irreversible vision loss in older Americans and Europeans. (AMD Alliance International 2008; Ferris et al. 1984; National Society to Prevent Blindness 1980). Worldwide, AMD disease affects million people. Etiology is complex and poorly understood –Free-radical mediated damage to the photoreceptors and the RPE may disrupt the transport of metabolites from photoreceptors to choroidal capilaries –Angiogenesis is a feature of neovascular AMD –AMD may be associated with a systemic vascular disorder –Genetic and environmental factors –Variation in the complement factor H gene

17 Volpe Healthy Transitions ‘13 Free radicals and antioxidants in CNV photoreceptors and RPE damage light free radical production damage blocked by antioxidants

18 Volpe Healthy Transitions ‘13 AMD Risk Factors Gender ♀ > ♂ Race/Ethnicity Smoking Family History Atherosclerosis Hypertension Symptoms early = None, mild distortion late = acute loss of vision

19 Volpe Healthy Transitions ‘13 Atrophic AMD Initially drusen and non-specific RPE changes Late RPE (geographic) atrophy Progression

20 Volpe Healthy Transitions ‘13 Atrophic AMD Hyperfluorescence from RPE window defect Low-vision aids if appropriate ManagementFluorescein angiogram

21 Volpe Healthy Transitions ‘13 Pathophysiology: Penetration of Bruch’s Membrane schematic New blood vessels penetrate Bruch’s membrane fundus photograph

22 Volpe Healthy Transitions ‘13 Choroidal Neovascularization (CNV) Metamorphopsia is initial symptom Many lesions are not visible clinically Suspicious clinical signs Gray-yellow subretinal lesion with fluid Subretinal blood or lipid Less common than atrophic AMD but more serious

23 Volpe Healthy Transitions ‘13 Current Status of Therapies for CNV Antiangiogenic therapy Lucentis, Avastin, Macugen –CATT trial (Avastin vs Lucentis) Photodynamic therapy with verteporfin Steroids Thermal Laser

24 Volpe Healthy Transitions ‘13 Treatment w/Anti VEGF

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26 Treatment for Dry AMD -Age-related Eye Disease Study (AREDS) –role of antioxidants vitamin E, 400 IU vitamin C, 500 mg beta carotene, 15 mg (approximately 25,000 IU Vitamin A) zinc 80 mg as zinc oxide copper, 2 mg, as cupric oxide –Copper should be taken with zinc, because high-dose zinc is associated with copper deficiency.

27 Volpe Healthy Transitions ‘13 Established Age Related Macular Degeneration Use Amsler Grid to monitor central vision AREDS-Occuvite Preservision B carotene vs. Lutein and Zeaxanthin (AREDS 2) Vitamin C Vitamin E Zinc Oxide (?necessary and ? Stomach upset) Copper NB: No beta carotene for smokers and others at risk for lung cancer Others??? Lutein Eyes, PhoVision, Perspective, Ocu- force

28 Volpe Healthy Transitions ‘13 AREDS Results Recommendations Evaluation: Persons over 55 years old receive a dilated eye exam to assess risk of advanced AMD. Contraindications to Treatment: Smokers and ex-smokers should not use beta carotene, because previous studies have suggested an association with lung cancer and beta carotene in smokers. There were no benefits from treatment shown in the AREDS for patients with no AMD (Category 1) and early AMD (Category 2).

29 Volpe Healthy Transitions ‘13 AREDS 2 Adding omega 3’s did not help Taking away B Carotene did not hurt and lutein and zexanthine may have been a bit more protective Reducing zinc dose did not hurt and less side effects No prevention of cataracts

30 Volpe Healthy Transitions ‘13 Diabetic Retinopathy most common cause of most common cause of new blindness among adults yo new blindness among adults yo Blindness in working adults Blindness in working adults affects over 5.3 million Americans age >18 (2.5% of this population) affects over 5.3 million Americans age >18 (2.5% of this population) Prevention- worse in HTN, obesity, renal failure, hyperlipidema, smoking, anemia, pregnancy and POOR glycemic control Prevention- worse in HTN, obesity, renal failure, hyperlipidema, smoking, anemia, pregnancy and POOR glycemic control

31 Volpe Healthy Transitions ‘13 Clinical Findings in NPDR Microaneurysms Earliest clinical sign of diabetic retinopathy Appear as small red dots in the superficial retinal layers Rupture produces blot/flame hemorrhages

32 Volpe Healthy Transitions ‘13 Macular Edema (CSME) Leading cause of visual impairment in patients with diabetes

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34 Macular Edema Treatments ETDRS – focal laser surgery for CSME reduces the incidence of moderate visual loss (doubling of visual angle or roughly a 2-line visual loss) from 30% to 15% over a 3-year period Steroids -peri-ocular -intraocular Anti-VEGF agents

35 Volpe Healthy Transitions ‘13 Ischemic diab etic maculopathy Macula appears relatively normal Capillary non-perfusion on FA Poor visual acuity Treatment not appropriate

36 Volpe Healthy Transitions ‘13 PDR Proliferation of new blood vessels due to ischemia NVD Disc NVE Elsewhere NVI Iris NVA Angle

37 Volpe Healthy Transitions ‘13 PDR - cont. Treatment Options Pan-retinal photocoagulation Peripheral Retinal Cryotherapy Vitrectomy Anti-VEGF

38 Volpe Healthy Transitions ‘13 Retinopathy Screening Type 1 diabetes - screen within 3-5 years of diagnosis after age 10 1 Type 2 diabetes - screen at time of diagnosis 1 Pregnancy - women with preexisting diabetes should be screened prior to conception and during first trimester 1 Follow-up depends on severity of disease

39 Volpe Healthy Transitions ‘13 Diabetic Eye Care Like glaucoma, you will NOT HAVE SYMPTOMS UNTIL IT IS TOO LATE! % treatable with early detection Regular eye exams at 6 or 12 month interval depending on what MD sees Bleeding, swelling and growth of blood vessels Diabetes control (Hemoglobin A1c) is the most important way to reduce your risk High blood pressure is a risk Diet and exercise

40 Volpe Healthy Transitions ‘13 Glaucoma Optic nerve 1.2 million nerve fibers Ganglion cells in retina exit to brain as optic nerve

41 Volpe Healthy Transitions ‘13 Definition of Glaucoma A group of optic neuropathies in which retinal ganglion cells die by apoptosis with resultant optic disc cupping and characteristic visual field deficits –Optic neuropathy –Retinal ganglion cell apoptosis –Optic disc cupping or excavation –Loss of visual function -IOP is too high for the nerve??? Most common cause blindness: African-Americans COMPLETE/TOTAL BLINDNESS

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44 Glaucoma Loss of visual field Site of visual field loss corresponds to area of damage on optic disc, e.g., “cupping”

45 Volpe Healthy Transitions ‘13 Classification of the Glaucomas Open-angle glaucomas (90%) Angle-closure glaucomas (10%) Primary glaucomas Secondary glaucomas RISK FACTORS IOP  21 mm Hg Family history Risk is increased by x2 if parent has POAG Risk is increased x4 if sibling has POAG African American C:D ratio > 0.5 Asymmetric cupping Myopia Diabetes Age > 75 years

46 Volpe Healthy Transitions ‘13 Angle Closure Glaucoma Acute pain, redness, tearing Associated with dilation of pupil Natural (e.g., movie theater) Pharmacologic Nausea & vomiting often in ER with “acute abdomen” Risk factor of narrow angle can be detected on screening exam (esp hyperope) and prophylactic iridotomy is preventative of attack in 100%

47 Volpe Healthy Transitions ‘13 Acute angle-closure glaucoma Severe corneal edema Complete angle closure Dilated, unreactive, vertically oval pupil Shallow anterior chamber Ciliary injection Signs Medical rx to lower IOP, followed by laser (Yag) iridotomy

48 Volpe Healthy Transitions ‘13 Primary Open-Angle Glaucoma The most prevalent type of glaucoma in the United States Elevated intraocular pressure is not part of the diagnostic criteria –25% of patients with primary open-angle glaucoma in the US have normal intraocular pressure Asymptomatic –Some loss of visual field –Most common type –Familial, bilateral –“Sneak thief of sight”

49 Volpe Healthy Transitions ‘13 Primary Open-Angle Glaucoma Evidence that IOP reduction is beneficial Collaborative Normal-Tension Glaucoma Study (CNTGS) Advanced Glaucoma Intervention Study (AGIS) Early Manifest Glaucoma Study (EMGT) –25% IOP reduction RoP 62% to 45% at a median of 6 years. Ocular Hypertension Treatment Study (OHTS)

50 Volpe Healthy Transitions ‘13 Treatment for POAG Lower the IOP Medical therapy Prostaglandin, B- blockers,Sypathomimetic s, Carbonic-anyhrase inhibitors Laser surgery (ALT, SLT) Incisional surgery (Trab, shunt)

51 Volpe Healthy Transitions ‘13 Incisional Surgey Most glaucoma specialists use an anti-fibrosis agent for every case in the year 2003 Limit episcleral fibrocellular proliferation Mitomycin C (MMC) anti- tumor antibiotic 0.2 to 0.5 mg/mL for 1 to 5 minutes 5-Fluorouracil (5-FU) antimetabolite 50 mg/mL for 5 minutes

52 Volpe Healthy Transitions ‘13 Tube Shunts

53 Volpe Healthy Transitions ‘13 Eye Strain Myth?? Often dry eye Maybe the muscles around the eye Worse with misalignment issues Cant do any harm Take breaks often and focus at distance A few extra blinks Lubricate before long drives, plane trips, windy or smoke filled environments Careful not to dismiss Headaches as “eye strain” Seek care if not responsive to behavioral strategies

54 Volpe Healthy Transitions ‘13 Summary Diabetic Retinopathy Prevention, treatment Cataract –Surgical treatment continues to improve Glaucoma –Silent blindness, family history –Medical and surgical rx ARMD –New age of available prevention strategies and treatments exudative variety

55 Volpe Healthy Transitions ‘13 Strategies to Preserve Your Vision Choose your parents well and stop aging!!! OR Don’t Smoke Wear Glasses that are UV protective –Safety glasses for high risk activities Pay Attention to Nutrition and Vitamins Don’t Ignore Symptoms Get Regular Eye Examinations Prevention is our most potent tool in the quest to reduce disease (and healthcare costs)


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