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UBC Ophthalmology Club 2012

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Presentation on theme: "UBC Ophthalmology Club 2012"— Presentation transcript:

1 UBC Ophthalmology Club 2012
Chronic Visual Loss Objective: Introduce 4 common conditions causing chronic vision loss and describe cardinal features of each Highlight the preventability/treatability of each Emphasize the role of primary care in screening and referral of patients 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 Arch Ophthalmol 122(4): ) 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 Exam: 55M comes to GP for routine physical
OD 20/30 OS 20/30 (both 20/25 2 years ago) Pupils equal reactive No RAPD EOM full Confrontational VF grossly intact 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 Would 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 weeks C. Reassess pt in 3 months D. Increase his thiazide dose and consider adding a second antihypertensive Ans: B Discuss dx, confirm it first with audience, then present with management options Photo courtesy Dr. Fred Mikelberg

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

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 Note: there are many causes of secondary glaucoma. Look for signs eg. rubeosis, pseudoexfoliation, transillumination defects, shallow AC May or may not have IOP African american, high myop high risk group Pt usually not going to c/o sx, use Fhx to screen Tx:

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 May or may not have fhx

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 Ans: D Pt 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 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
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 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 Question 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 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 Systemic 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 on Nuclear 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, 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 Could be BL.

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: Make sure this shows macular lipid. moderate NPDR would not usually be associated with vision loss in the absence of some macular pathology. Also, type 2 often is present for many years prior to diagnosis. Important as retinopathy tends to develop 10-15 years after diagnosis (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 Ans: 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 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 Will have CSME in NPDR with vision loss Guideline: baseline eye exam, then q1-2 yr Type 1: 5 years after dx, then q1-2 yr

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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