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Chronic Visual Loss UBC Ophthalmology Club 2012. Approach  History, physical, tests  Patient population tends to be the elderly, but 2% of adults in.

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Presentation on theme: "Chronic Visual Loss UBC Ophthalmology Club 2012. Approach  History, physical, tests  Patient population tends to be the elderly, but 2% of adults in."— Presentation transcript:

1 Chronic Visual Loss UBC Ophthalmology Club 2012

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. 2004. Arch Ophthalmol 122(4):477-85.)  Prevalence increases with age  Early detection may lead to early intervention and preservation of vision  Primary care is the first screen, know when to refer

3 Case 1  55M comes to GP for routine physical  Has HTN, currently on thiazide  Denies visual loss, eye pain, headaches  Sister was taking an eye drop but not sure what that’s for  Exam:  OD 20/30 OS 20/30 (both 20/25 2 years ago)  Pupils equal reactive  No RAPD  EOM full  Confrontational VF grossly intact

4 Case 1  Management:  A. This pt needs urgent treatment to lower his IOP  B. Refer pt to ophthalmologist 1-2 weeks  C. Reassess pt in 3 months  D. Increase his thiazide dose and consider adding a second antihypertensive Photo courtesy Dr. Fred Mikelberg

5 Pseudoexfoliation. (Shaw, AAO 2003) Transillumination defect. (Kuo & Noecker, AAO 2009)

6 Primary Open Angle Glaucoma  Progressive optic neuropathy of unknown etiology with persistent VF defect  Risk factors incl. elevated IOP, family hx, race, age, myopia  Sx incl. gradual loss of peripheral visual field  Further tests:  VF testing of this pt reveals nasal step defect  IOP: OD 29mmHg, OS 23mmHg  Retina tomography shows moderate thinning of nerve fibre layer  AAO recommends refer pt when:  disc:cup >0.5 or one cup significantly larger than the other  IOP > 21mmHg or >5mmHg difference between the eyes  Sx of acute glaucoma

7 Common Rx for glaucoma  The only pharmacological target is lowering IOP  Alpha agonists( ↑drain, ↓aq) : clonidine, brimonidine  Beta blocker ( ↓aq): timolol  CA 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 TV  No eye conditions in the past  Hx significant for obesity and 50 pkyr smoking, quit 5 years ago  Family history unremarkable

9 Case 2  OD 20/80, OS 20/100  (last 2 years decreased)  Pupils equal reactive  EOM full  CVF intact  IOP within normal limits  Fundoscopy:  Amsler grid: (Khanifar et al. Retinal Physician, 2007)

10  What do you tell this patient?  A. he has missed the window for effective intervention  B. he needs immediate antioxidant and zinc supplement  C. his children are at increased risk of this disease  D. his condition probably won’t cause complete blindness

11 Age Related Macular Degeneration  2 forms: atrophic (dry) and exudative (wet)  Leading cause of blindness in adults >75 yr, mostly from exudative form  Multifactorial disease, see characteristic drusen  Early diagnosis enables detection of exudative form, which can be effectively treated with anti-VEGF agents  Screening in primary care:  Visual distortions, especially in central vision  Presence of drusen in macula, retinal pigment breakdown  Refer to ophthalmologist for full evaluation

12 Wet AMD 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 necessary  No eye disease or trauma  No family hx of eye diseases  Meds 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 full  Fundus visualized, unremarkable (Espandar, AAO 2009)

15 Management  What’s your course of action?  A. Inform pt that her cataract is the result of her prednisone use  B. This pt needs to see an ophthalmologist STAT because of risk of irreversible visual loss  C. This pt’s presbyopia is improving so she should be followed up in 6 months at your office  D. Referral to ophthalmologist for evaluation and treatment options

16 Cataract  Etiology: opacified lens  Most commonly associated with increasing age, but also congenital, DM, steroid use, trauma, radiation  Pt complain of painless gradual unilateral vision decrease  “Second sight” refers to myopic shift as cataract increases power of lens; this is temporary  Referral to ophthalmologist when decrease in vision becomes symptomatic and/or interfere with function  Cataract removal+IOL implant is one of the most frequently-performed and successful procedures in all of surgery

17 Other types of cataracts Cortical cataract Posterior subcapsular cataract Implantable IOL

18 Case 4  63M with 17 yr hx of Type 2 DM comes to GP to c/o decrease in vision in both eyes  Denies pain, distortions, double vision  Hb A1c 7.5% despite being on metformin and gliclazide  Also has dyslipidemia, on atorvastatin  No previous eye complaints

19 Case 4  OD 20/40, OS 20/60  Pupils equal reactive, red reflex present  EOM full VF intact  AC deep and quiet  Fundoscopy: (AAO, 2012)

20 Diagnosis  What is the cause of this pt’s decreased vision?  A. Non-proliferative diabetic retinopathy  B. Age related macular degeneration  C. Proliferative diabetic retinopathy  D. Branch retinal vein occlusion

21 Diabetic retinopathy  Microvascular complication of DM  Most common cause of vision loss in adults 25-74 yr  In NPDR, vision loss arise from macular edema  In PDR, vision loss can be rapid, secondary to scarring and vitreous hemorrhage  Ophthalmologist referral when:  Newly diagnosed DM patient  Eye exam every 1-2 years after  Patient who develop rapid vision change  Glycemic control is the cornerstone of systemic management. DR is managed with laser and anti-VEGF

22 PDR Proliferative 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 Summary  4 most common causes of chronic visual loss and their features:  Open angle glaucoma- insidious, treat IOP  Age related macular degeneration- distortions, most common  Cataract- often unilateral, good result with surgery  Diabetic retinopathy- check in all DM pt, bilateral visual loss  All are either reversible or can be managed well (slow/stop vision loss) if detected early  Therefore, 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 Law  Contact:  R Tom Liu 

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