Presentation on theme: "UBC Ophthalmology Club 2012"— Presentation transcript:
1 UBC Ophthalmology Club 2012 Chronic Visual LossObjective:Introduce 4 common conditions causing chronic vision loss and describe cardinal features of eachHighlight the preventability/treatability of eachEmphasize the role of primary care in screening and referral of patientsUBC Ophthalmology Club2012
2 Approach History, physical, tests Patient population tends to be the elderly, but 2% of adults in the US over age 40 have vision <20/40 (Congdon et al Arch Ophthalmol 122(4): )Prevalence increases with ageEarly detection may lead to early intervention and preservation of visionPrimary care is the first screen, know when to refer
3 Case 1 Exam: 55M comes to GP for routine physical OD 20/30 OS 20/30 (both 20/25 2 years ago)Pupils equal reactiveNo RAPDEOM fullConfrontational VF grossly intact55M comes to GP for routine physicalHas HTN, currently on thiazideDenies visual loss, eye pain, headachesSister was taking an eye drop but not sure what that’s forWould it be common or uncommon to detect a VF defect in confrontational field testing? If detected what’s the shape of the defect typically?Glaucoma usually affect inferior disc leading to superior field, which pt usually don’t notice
4 Case 1 Management: A. This pt needs urgent treatment to lower his IOP B. Refer pt to ophthalmologist 1-2 weeksC. Reassess pt in 3 monthsD. Increase his thiazide dose and consider adding a second antihypertensiveAns: BDiscuss dx, confirm it first with audience, then present with management optionsPhoto courtesy Dr. Fred Mikelberg
6 Primary Open Angle Glaucoma Progressive optic neuropathy of unknown etiology with persistent VF defectRisk factors incl. elevated IOP, family hx, race, age, myopiaSx incl. gradual loss of peripheral visual fieldFurther tests:VF testing of this pt reveals nasal step defectIOP: OD 29mmHg, OS 23mmHgRetina tomography shows moderate thinning of nerve fibre layerAAO recommends refer pt when:disc:cup >0.5 or one cup significantly larger than the otherIOP > 21mmHg or >5mmHg difference between the eyesSx of acute glaucomaNote: there are many causes of secondary glaucoma. Look for signs eg. rubeosis, pseudoexfoliation, transillumination defects, shallow ACMay or may not have IOPAfrican american, high myop high risk groupPt usually not going to c/o sx, use Fhx to screenTx:
7 Common Rx for glaucoma The only pharmacological target is lowering IOP Alpha agonists(↑drain, ↓aq): clonidine, brimonidineBeta blocker (↓aq): timololCA inhibitor (↓aq): acetazolamide (Diamox)Prostaglandin analog (↑drain): latanoprost (Xalatan)SE of PG analog- iris color change and longer eye lashes
8 Case 2 70M c/o decreasing vision in both eyes over last 6 months to GP This is particularly bothersome as he is having more trouble reading and watching TVNo eye conditions in the pastHx significant for obesity and 50 pkyr smoking, quit 5 years agoFamily history unremarkableMay or may not have fhx
9 Case 2 OD 20/80, OS 20/100 (last 2 years decreased) Pupils equal reactiveEOM fullCVF intactIOP within normal limitsFundoscopy:Amsler grid:(Khanifar et al. Retinal Physician, 2007)
10 What do you tell this patient? A. he has missed the window for effective interventionB. he needs immediate antioxidant and zinc supplementC. his children are at increased risk of this diseaseD. his condition probably won’t cause complete blindnessAns: DPt may develop wet amd resulting in rapid loss of central vision over days, must treat immediately. 40% will return to baseline.1/10 with dry can develop into wet
11 Age Related Macular Degeneration 2 forms: atrophic (dry) and exudative (wet)Leading cause of blindness in adults >75 yr, mostly from exudative formMultifactorial disease, see characteristic drusenEarly diagnosis enables detection of exudative form, which can be effectively treated with anti-VEGF agentsScreening in primary care:Visual distortions, especially in central visionPresence of drusen in macula, retinal pigment breakdownRefer to ophthalmologist for full evaluation
12 Wet AMD Monthly injection, $1600 per shot Risk of wet includes large confluent drusen (>125um), pigmentary abnormalities. Smoking and white race are also associated with higher risk (AREDS).Monthly injection, $1600 per shot
13 Case 3 68F comes to GP with c/o decreased vision in her L eye She denies double vision or glares, in fact she said she can read better with her L eye than her R eye now; she wants to know if her reading glasses are still necessaryNo eye disease or traumaNo family hx of eye diseasesMeds include prednisone 20 mg daily for last 2 months for RA flare
14 Case 3 OD 20/30, OS 20/50 Pupils equal reactive no RAPD EOM full Confrontational VF fullFundus visualized, unremarkableQuestion what is the dx? cataract(Espandar, AAO 2009)
15 Management What’s your course of action? A. Inform pt that her cataract is the result of her prednisone useB. This pt needs to see an ophthalmologist STAT because of risk of irreversible visual lossC. This pt’s presbyopia is improving so she should be followed up in 6 months at your officeD. Referral to ophthalmologist for evaluation and treatment optionsSystemic prednisone usually cause Posterior Subcapsular cataracts. These are mainly opacification of the posterior capsule due to epithelial cells migration. They tend to cause significant vision loss with lots of glare symptoms. Posterior subcapsular cataracts tend to obscure the posterior pole quite early onNuclear sclerosis cataracts are mainly due to aging and they are the typical lens changes we see when the lens turn a yellow to dark brown colour. They cause the lens central density to increase and cause a myopic shift and as you correctly stated, induces myopia and patients often reads better (though losing distance vision)Most cataracts do not need STAT referral as they tend to be slowly progressing. But if they cause other problems such as phacomorphic glaucoma or phacolytic glaucoma/uveitis, then they have to seen quite urgently
16 Cataract Etiology: opacified lens Most commonly associated with increasing age, but also congenital, DM, steroid use, trauma, radiationPt complain of painless gradual unilateral vision decrease“Second sight” refers to myopic shift as cataract increases power of lens; this is temporaryReferral to ophthalmologist when decrease in vision becomes symptomatic and/or interfere with functionCataract removal+IOL implant is one of the most frequently-performed and successful procedures in all of surgeryCould be BL.
17 Other types of cataracts Cortical cataractPosterior subcapsular cataractImplantable IOL
18 Case 463M with 17 yr hx of Type 2 DM comes to GP to c/o decrease in vision in both eyesDenies pain, distortions, double visionHb A1c 7.5% despite being on metformin and gliclazideAlso has dyslipidemia, on atorvastatinNo previous eye complaints
19 Case 4 OD 20/40, OS 20/60 Pupils equal reactive, red reflex present EOM full VF intactAC deep and quietFundoscopy:Make sure this shows macularlipid. moderate NPDR would not usually beassociated with vision loss in the absence ofsome macular pathology. Also, type 2 often ispresent for many years prior to diagnosis.Important as retinopathy tends to develop10-15 years after diagnosis(AAO, 2012)
20 Diagnosis What is the cause of this pt’s decreased vision? A. Non-proliferative diabetic retinopathyB. Age related macular degenerationC. Proliferative diabetic retinopathyD. Branch retinal vein occlusionAns: A: NPDR ft: 1st sign is microaneurysms, then hard exudates, cotton wool spots, dob blot hemmorhage, venous beading, CSME.
21 Diabetic retinopathy Microvascular complication of DM Most common cause of vision loss in adults yrIn NPDR, vision loss arise from macular edemaIn PDR, vision loss can be rapid, secondary to scarring and vitreous hemorrhageOphthalmologist referral when:Newly diagnosed DM patientEye exam every 1-2 years afterPatient who develop rapid vision changeGlycemic control is the cornerstone of systemic management. DR is managed with laser and anti-VEGFWill have CSME in NPDR with vision lossGuideline: baseline eye exam, then q1-2 yrType 1: 5 years after dx, then q1-2 yr
22 PDRProliferative disease, characterized by formation of new and fragile vessels that form a tangle on the disc and elsewhere.Pan-retinal photocoagulation uses laser to destroy ischemic retina in order to prevent neovascularization and preserve the macula.
23 Summary4 most common causes of chronic visual loss and their features:Open angle glaucoma- insidious, treat IOPAge related macular degeneration- distortions, most commonCataract- often unilateral, good result with surgeryDiabetic retinopathy- check in all DM pt, bilateral visual lossAll are either reversible or can be managed well (slow/stop vision loss) if detected earlyTherefore, primary care’s role is vital in screening of chronic eye diseases
24 Questions? Edited by: Steven Schendel, PGY-4 Reviewed by: Drs. Fred Mikelberg, David Maberley, Francis LawContact:R Tom Liu
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