1. Vision and Eye Problems:
How to recognize them and what we can do about them
Nicholas J. Volpe, MD
Tarry Professor and Chairman
Department of Ophthalmology
Feinberg School of Medicine
Northwestern University

2. Goals common visual symptoms in elderly people
followed by a discussion of what we do to make the diagnosis
how we treat common problems including dry eye, glaucoma, cataract, eyelid problems, diabetic retinopathy, macular degeneration and double vision"

3. Strategies to Preserve Your Vision
Prevention is our most potent tool in the quest to reduce disease (and healthcare costs)
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

4. Major Causes of Chronic Visual Loss Preventable and Treatable
Cataracts
Glaucoma
Macular degeneration
Diabetic retinopathy
Other Issues
Dry eye
Double Vision
Eyelid Abnormalities
Presbyopia near vision blurring

5. Stop Smoking Clearly a risk factor for cataracts 3X the risk
Clearly a risk factor for macular degeneration and its response to treatment

6. 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. Regular Check Ups Many diseases can be detected
Every 2-3 years from age 40-65
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. Common Eye Symptoms Foreign body sensation Itching and burning
Blurred vision
flashes and floaters
Distortion of shape
Blind spots
Loss of peripheral vision
Double vision
Eyelid position changes

9. Foreign Body Sensation,Itching and Burning
Dry eye
Blepharitis
Allergy
Eyelid malposition

10. Dry Eye
Tears
Cyclosporine
Punctal plugs

11. Ptosis, Entropion, Ectropion

12. Flashes and Floaters
(ahujaeyecenter.com)

13. Cataracts Symptoms Age Steroids (PSC) Trauma Inflammation Diabetes
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

14. Subcapsular cataract
Anterior
Posterior

15. Nuclear cataract Progression Exaggeration of normal nuclear
ageing change
Increasing nuclear opacification
Causes increasing myopia
Initially yellow then brown

16. 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

17. Cataract Prevention Smoking cessation Reduces Vitamin C in the eye
Vitamin C levels are high in the eye and this helps remove prooxidants
Ultraviolet light
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

18. Age- Related Macular Degeneration
Age-related macular degeneration (AMD) is the most common cause of severe, irreversible vision loss in older Americans and Europeans
Worldwide, AMD disease affects million people.
Etiology is complex and poorly understood
Free-radical mediated damage to the photoreceptors and the RPE
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

19. AMD Risk Factors Gender ♀ > ♂ Race/Ethnicity Smoking Family History
Symptoms
early = None, mild distortion
late = acute loss of vision
Gender ♀ > ♂
Race/Ethnicity
Smoking
Family History
Atherosclerosis
Hypertension

20. Atrophic AMD Progression Initially drusen and non-specific RPE changes
Late RPE (geographic) atrophy

21. Atrophic AMD Fluorescein angiogram Management
Hyperfluorescence from RPE window defect
Low-vision aids if appropriate

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

23. Current Status of Therapies for CNV
Antiangiogenic therapy
Lucentis, Avastin, Eylea
CATT trial (Avastin vs Lucentis)
Photodynamic therapy with verteporfin
Steroids
Thermal Laser
Choroidal neovascularization (CNV) has proved difficult to treat. Laser photocoagulation reduces vision loss in some forms of CNV in the long term, but the technique has many limitations. It is suitable for only a minority of patients, and around half of all treated eyes have persistent or recurrent CNV within 2 years.[18]
Most other approaches to treatment of CNV – such as radiation,[32][93] antiangiogenic drugs[33] including steroids [83], transpupillary thermotherapy [97] and surgery [34][89] – are under investigation. Progress in patient selection and development of new drugs and operating techniques may bring about benefits in other therapies in the future.[32][33][34] At present, however, only photodynamic therapy (PDT) with verteporfin has been proven effective for treatment of CNV in clinical trials, [1][2][3][94] and may be suitable for a larger proportion of patients than laser photocoagulation.[1][2][3][94]

24. Treatment w/Anti VEGF

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.
(Category 3: extensive intermediate size drusen, or at least 1 large druse (> 125 ?m), or noncentral geographic atrophy in 1 or both eyes)
(Category 4: advanced or neovascular AMD in 1 eye or vision loss due to AMD in 1 eye) should consider taking high-dose anti-oxidants plus zinc on a daily basis.

27. 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. 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. 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. Diabetic Retinopathy most common cause of
new blindness among adults yo
Blindness in working adults
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
Diabetic retinopathy develops, to some degree, in nearly all patients with diabetes, and is the most common cause of new cases of blindness among adults. The most predominant causes of vision loss are clinically significant macular edema (CSME) and proliferative diabetic retinopathy (PDR). Vision loss can be avoided or minimized with proper ophthalmic care and examination to identify retinopathy in its early stages.

31. 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. Macular Edema (CSME)
Leading cause of visual impairment in patients with diabetes

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
Favorable prognostic factors
Circinate exudates of recent onset
Well-defined leakage
Good perifoveal perfusion
Unfavorable prognostic factors
Diffuse edema/multiple leaks
Lipid deposition in the fovea
Macular ischemia
Cystoid macular edema
Preoperative vision of less than 20/200
Hypertension
If specific microaneurysms leak- they are treated directly with focal laser photocoagulation.
Diffuse leakage - grid pattern of laser
Medium intensity burns ( µm) are placed at least 1 burn size apart
Intravitreal or sub-tenons steroid injections- when edema persists after multiple focal laser treatments.
CSME should be treated and observed closely (every 2-3 mo)

35. Ischemic diabetic maculopathy
Macula appears relatively normal
Capillary non-perfusion on FA
Poor visual acuity
Treatment not appropriate

36. PDR Proliferation of new blood vessels due to ischemia NVD Disc
NVE Elsewhere
NVI Iris
NVA Angle
When proliferation of new blood vessels occurs, the patient is diagnosed as having PDR. New blood vessel formation is caused by retinal ischemia. Neovascularization can occur at the optic disk (NVD) or elsewhere in the retina (NVE). These new vessels are weak and, when they break, can cause vitreous hemorrhage. They can also cause retinal traction, retinal tears, and retinal detachment over time.

37. PDR - cont. Treatment Options Pan-retinal photocoagulation
Peripheral Retinal Cryotherapy
Vitrectomy
Anti-VEGF
DRS proved that xenon and argon laser decreases to chances of visual loss in eye with high risk characteristics (HRC)
High risk characteristics (HRC) was defined as:
NVD > ½ the disc area
Any NVD and VH
NVE > ½ the disc area and VH or pre-retinal hemorrhage
Peripheral Retinal Cryotherapy
Employed when HRC is present but the media are too hazy for laser
Major complication is increased risk of traction RD, seen in 25-38%
Vitrectomy
Major indications: non-clearing vitreous hemorrhage, macular involving or threatening TRD, or combined traction-rhegmatogenous RD
Other indications: ME with a thickened and taut posterior hyaloid, macular heterotopia, ERM, severe pre-retinal hemorrhage, and NVG with cloudy media

38. Retinopathy Screening
Type 1 diabetes - screen within 3-5 years of diagnosis after age 101
Type 2 diabetes - screen at time of diagnosis1
Pregnancy - women with preexisting diabetes should be screened prior to conception and during first trimester1
Follow-up depends on severity of disease
A comprehensive eye exam should be given to all patients with diabetes. The exam should include all of the components recommended by the American Academy of Ophthalmology and the American Optometric Association for non-diabetic patients, however additional attention should be given to assess abnormalities of the retina and vitreous fluid. Dilated indirect ophthalmoscopy, slitlamp biomicroscopy, and fundus examination should be used to identify retinal or vitreous hemorrhages, microaneurysms, retinal tears or detachment, intraretinal microvascular abnormality (IRMA), neovascularization at the optic disk (NVD) and elsewhere in the retina (NVE).
Patients with type 1 diabetes should be screened for NPDR (non-proliferative diabetic retinopathy) within three to five years of diagnosis after age 10. Retinopathy leading to vision loss rarely develops in children prior to puberty, regardless of how long the child has had diabetes. Patients with type 2 diabetes should be screened at time of diagnosis.
Finally, women with preexisting diabetes should be screened prior to conception and during the first trimester. Follow-up exams should be scheduled at the physicians discretion based on the results of the first trimester exam.
Note that follow-up exams should be conducted yearly, however new ADA Clinical Practice Recommendations state that less frequent exams every 2-3 years can be considered in the setting of a normal eye exam upon the advice of an eye care professional.

39. Diabetic Eye Care
Like glaucoma, you will NOT HAVE SYMPTOMS UNTIL IT IS TOO LATE!
95-100% 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. Glaucoma Optic nerve 1.2 million nerve fibers Ganglion cells in retina
exit to brain as optic nerve

41. 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

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

45. 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%

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

47. 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”

48. 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)

49. Treatment for POAG Lower the IOP Medical therapy
Prostaglandin , B-blockers,Sypathomimetics, Carbonic-anyhrase inhibitors
Laser surgery (ALT, SLT)
Incisional surgery (Trab, shunt)

50. Tube Shunts

51. Double Vision Monocular vs binocular Eye misalignment
Stroke, tumor, cranial nerve palsy
However most are benign
Thyroid Eye Disease
Patch, prism, surgery
Utsavaeyelinic.com

52. Summary FBS, itching burning Floaters and flashes Diabetic Retinopathy
Prevention, treatment
Cataract
Surgical treatment continues to improve
Double Vision
Most benign-eye misalignment
Must be evaluated
Glaucoma
Silent blindness, family history
Medical and surgical rx
ARMD
New age of available prevention strategies and treatments exudative varietyFBS

53. Strategies to Preserve Your Vision
Prevention is our most potent tool in the quest to reduce disease (and healthcare costs)
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