Ophthalmology for Primary Care Providers

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Presentation transcript:

Ophthalmology for Primary Care Providers Bob Avery, MD, PhD Ophthalmology/Surgery University of New Mexico School of Medicine bavery@salud.unm.edu

Preview How the eye works The red eye Chronic vision loss Pearls

How the eye works The red eye Chronic vision loss Pearls

How the eye works Front part collects light Light is refracted by two surfaces Cornea Lens Back part forms the image and sends it to the brain

Anterior segment Lids Conjunctiva/sclera Cornea Anterior chamber Iris Lens

Posterior segment Vitreous Optic disk Vessels Retina Choroid Macula Periphery Choroid

Light path Cornea Anterior chamber Pupil Lens Vitreous humor Retina aqueous humor Pupil Lens Vitreous humor Retina

How the eye works The red eye Chronic vision loss Pearls

Red eye Conjunctiva Eyelids Cornea Intraocular Orbit Dry eye syndrome Allergic conjunctivitis Viral conjunctivitis Bacterial conjunctivitis Pingueculitis Pterygium Subconjunctival hemorrhage Episcleritis Scleritis Eyelids Blepharitis Stye / Chalazion Dacryocystitis Cornea Abrasion Bacterial keratitis Viral keratitis Intraocular Acute glaucoma Uveitis / Iritis Endophthalmitis Orbit Pre-septal cellulitis Orbital cellulitis C-C fistula

The Red Eye Red Pain Blurred vision Eyelid or eyeball? Why is eyeball red? Where is it red? Pain Foreign-body sensation? Improve with anesthetic? Blurred vision

Eyelids Conjunctiva Eyelids Cornea Intraocular Orbit Dry eye syndrome Allergic conjunctivitis Viral conjunctivitis Bacterial conjunctivitis Pingueculitis Pterygium Subconjunctival hemorrhage Episcleritis Scleritis Eyelids Blepharitis Stye / Chalazion Dacryocystitis Cornea Abrasion Bacterial keratitis Viral keratitis Intraocular Acute glaucoma Uveitis / Iritis Endophthalmitis Orbit Pre-septal cellulitis Orbital cellulitis C-C fistula

Blepharitis Inflammation of eyelids Presentation Treatment Red, thickened eyelids Crusting Gritty, burning Treatment Warm compresses Antibiotic ointment

Stye/Chalazion Inflammation of lash follicle or oil gland Painful bump on eyelid Treatment Warm compresses x 6 weeks May need excision/drainage

Dacryocystitis Inflammation of lacrimal sac Hot nodule next to nose Usually infection secondary to obstruction Treatment Referral Systemic antibiotics I&D, Surgery

Cornea Conjunctiva Eyelids Cornea Intraocular Orbit Dry eye syndrome Allergic conjunctivitis Viral conjunctivitis Bacterial conjunctivitis Episcleritis Scleritis Pingueculitis Pterygium Subconjunctival hemorrhage Eyelids Blepharitis Stye / Chalazion Dacryocystitis Cornea Abrasion Bacterial keratitis Viral keratitis Intraocular Acute glaucoma Uveitis / Iritis Endophthalmitis Orbit Pre-septal cellulitis Orbital cellulitis C-C fistula

Corneal Abrasion Disruption of corneal epithelium Extremely painful foreign-body sensation Fluorescein staining Antibiotic ointment +/- Pain meds No need to patch

Bacterial keratitis Infection of the cornea Presentation Treat Photophobia Foreign-body sensation Ciliary flush Treat Quinolone drops (Cipro) Referral

Viral keratitis Herpetic infection of cornea Simplex or Zoster Dendritic or geographic epithelial defect +/- skin findings Referral Antivirals Topical or systemic

Conjunctiva Conjunctiva Eyelids Cornea Intraocular Orbit Dry eye syndrome Allergic conjunctivitis Viral conjunctivitis Bacterial conjunctivitis Pingueculitis Pterygium Subconjunctival hemorrhage Episcleritis Scleritis Eyelids Blepharitis Stye / Chalazion Dacryocystitis Cornea Abrasion Bacterial keratitis Viral keratitis Intraocular Acute glaucoma Uveitis / Iritis Endophthalmitis Orbit Pre-septal cellulitis Orbital cellulitis C-C fistula

Dry Eye Syndrome Very, very common in NM Symptoms Etiology Treatment Wind, smoke, reading, end of day Waxing/waning vision Blinking or resting eyes helps Tearing Etiology Inadequate tear production Sjogren’s Syndrome Tear film instability Treatment Lubricant eye drops (artificial tears) Warm compresses Flaxseed or fish oil

Allergic conjunctivitis Often seasonal April and September Itchy Both eyes OTC: Ketotifen Generic, Alaway,Zaditor RX: Patanol Cromolog

Bacterial conjunctivitis Rare and self-limited in adults Thick, yellowish discharge Treatment Quinolone drops Refer if compromised host, significant vision loss, or no improvement in 3 days

Viral conjunctivitis Pink eye Adenovirus Discharge is clear or mucoid Discharge is highly contagious Contacts Children Other eye few days later Self-limited ~ 1 week Hygiene – don’t rub Quarantine Refer only if worsens

Pingueculitis Pinguecula is abundant conjunctival tissue Nasal or temporal globe Very common Often unnoticed until surrounding tissues get inflamed Vision unaffected Treatment OTC lubricant drops or vasoconstrictor

Pterygium Fibrovascular proliferation of palpebral conjunctiva Usually nasal Slow-growing Extends onto cornea Vascularity creates chronic redness Treatment – usually none Only cure is surgical excision

Subconjunctival Hemorrhage Blood between conjunctiva and sclera No vision changes Trauma(rubbing), sneezing, spontaneous No treatment

Episcleritis Focal inflammation of deep subconjunctival tissue Mild pain/redness Dilated vessels usually away from cornea Self-limited Lubricant eye drops

Scleritis Inflammation of sclera Focal or diffuse Deep, severe pain Associated with collagen-vascular/auto-immune diseases Referral Systemic meds

Intraocular Conjunctiva Eyelids Cornea Intraocular Orbit Dry eye syndrome Allergic conjunctivitis Viral conjunctivitis Bacterial conjunctivitis Episcleritis Scleritis Pingueculitis Pterygium Subconjunctival hemorrhage Eyelids Blepharitis Stye / Chalazion Dacryocystitis Cornea Abrasion Bacterial keratitis Viral keratitis Fungal keratitis Intraocular Acute glaucoma Uveitis / Iritis Endophthalmitis Orbit Pre-septal cellulitis Orbital cellulitis C-C fistula

Acute glaucoma Sudden increase in intraocular pressure (IOP) Red, pain, blurred vision, mid-dilated pupil Nauseous Emergency – hours count This is why you need to know how to check IOP Immediate treatment and referral

Uveitis / Iritis Inflammation inside eye Uveitis (iris, ciliary body, choroid) Photophobia Ciliary flush (near limbus) Referral Steroids Work-up

Endophthalmitis Infection inside eyeball Red, painful eye Hypopion Sources Surgery Trauma Endogenous

Endogenous Endophthalmitis Sources Endocarditis, GI, urinary tract, indwelling catheters If focal source, think bacterial If compromised host, think fungal

Fungal Endophthalmitis Management Candidemia with eye or valve involvement receives a longer course of anti-fungals Anti-fungals Vitrectomy (especially if Aspergillus) Culture Ampho B Recommended if substantial vision loss

Orbit Conjunctiva Eyelids Cornea Intraocular Orbit Dry eye syndrome Allergic conjunctivitis Viral conjunctivitis Bacterial conjunctivitis Episcleritis Scleritis Pingueculitis Pterygium Subconjunctival hemorrhage Eyelids Blepharitis Stye / Chalazion Dacryocystitis Cornea Abrasion Bacterial keratitis Viral keratitis Fungal keratitis Intraocular Acute glaucoma Uveitis / Iritis Endophthalmitis Orbit Pre-septal cellulitis Orbital cellulitis C-C fistula

Preseptal Cellulitis Peri-ocular skin infection Limited to the skin Systemic antibiotics Cephalexin

Orbital Cellulitis Infection in the orbit Diplopia Admission I-V antibiotics Drain abscesses

Carotid-Cavernous sinus fistula A-V fistula Carotid-Cavernous sinus Orbital vascular congestion Chronic redness from corkscrew vessels Whooshing sound in head Referral Observe Self-limited Embolization

The Red Eye Red Pain Blurred vision Eyelid or eyeball? Why is eyeball red? Where is it red? Pain Foreign-body sensation? Improve with anesthetic? Blurred vision

Red Eye Conjunctiva Eyelids Cornea Intraocular Orbit Dry eye syndrome Allergic conjunctivitis Viral conjunctivitis Bacterial conjunctivitis Pingueculitis Pterygium Subconjunctival hemorrhage Episcleritis Scleritis Eyelids Blepharitis Stye / Chalazion Dacryocystitis Cornea Abrasion Bacterial keratitis Viral keratitis Intraocular Acute glaucoma Uveitis / Iritis Endophthalmitis Orbit Pre-septal cellulitis Orbital cellulitis C-C fistula

Triage PCP REFERRAL Non-urgent Urgent Blepharitis Stye Corneal abrasion Dry eyes Allergic conjunctivitis Viral conjunctivitis Bacterial conjunctivitis Pingueculitis Pterygium Subconjunctival heme Preseptal cellulitis Dacryocystitis Episcleritis C-C fistula Bacterial keratitis Viral keratitis Scleritis Acute glaucoma Iritis Endophthalmitis Orbital cellulitis

How the eye works The red eye Chronic vision loss Pearls

Chronic vision loss Cataract Diabetic Retinopathy Macular Degeneration Glaucoma

Cataract Clouding of the lens Usually age-related Causes glare problems and blurred vision Only treatment is surgery (replacement)

Diabetic retinopathy Vasculopathy Clinically, yellow and red spots Hemorrhages, aneurysms, edema, neovascularization, infarcts/ischemia

Diabetic retinopathy Two stages Non-proliferative Proliferative Red and yellow spots Tx: Diabetic control Proliferative Neovascularization Retina or iris Serious complications Tx: Laser or injection

Macular Degeneration Age-related Degenerative process affecting retina, RPE, and choroid Yellow spots (drusen) Lipoprotein deposits

Macular Degeneration Two stages Dry Wet Atrophic changes Tx: AREDS vitamins (anti-oxidant) Wet Choroidal neovascularization Most of severe vision loss Tx: Injections

Glaucoma Damage to optic nerve Risk factors: Large cup-to-disk ratio Increased intraocular pressure Usual IOP 10-20 mm Hg Age Family history of glaucoma

Glaucoma Damage to optic nerve The P’s Painless Permanent Progressive Preventable

Glaucoma Normal Glaucoma

Chronic visual loss Cataract - opacification of the natural lens Diabetes in the eye is a retinal vascular disease Non-proliferative and proliferative stages Macular Degeneration affects the central retina Dry and wet stages Glaucoma - damage to the Optic Nerve Progressive, Painless, Permanent, Preventable

How the eye works The red eye Chronic vision loss Pearls

Primary treatments For dry eyes, use artificial tears and warm compresses For allergies, use ketotifen eyedrops For antibiotic, use a quinolone (Cipro) For ointment, use erythromycin Don’t give topical steroids

Eye exam pearls Visual acuity is measured by the smallest line with at least half correct An Afferent Pupillary Defect (APD) suggests Optic Nerve dysfunction Know how to check pressure Use as little fluorescein as possible Use anesthetic to exam painful eyes

Eye pain Ocular surface Intraocular Extraocular (orbit) Helped by anesthetic Foreign-body sensation Intraocular Photophobia Ciliary flush Extraocular (orbit) Pain with eye movements Diplopia

Eye pain If the patient has eye pain, use anesthetic drops Note how much it helps Ocular surface pain is quite sensitive and responsive Intraocular or orbital pain will be minimally responsive

Acute eye conditions Emergencies Urgencies Alkali burn Acute angle closure glaucoma Central retinal artery occlusion (CRAO) Ruptured globe Urgencies Lid lac (marginal or canalicular) Retinal detachment Papilledema

Acute eye conditions Flush all chemical exposures with at least 2L Acute glaucoma presents with nausea Papilledema is optic disk swelling secondary to increased intracranial pressure

REVIEW

How the eye works Front part collects light Back part forms the image and sends it to the brain

Light path Cornea Anterior chamber/aqueous humor Pupil Lens Vitreous humor Retina

The Red Eye Red Pain Blurred vision Eyelid or eyeball? Why is eyeball red? Where is it red? Pain Foreign-body sensation? Improve with anesthetic? Blurred vision

Red Eye Conjunctiva Eyelids Cornea Intraocular Orbit Dry eye syndrome Allergic conjunctivitis Viral conjunctivitis Bacterial conjunctivitis Pingueculitis Pterygium Subconjunctival hemorrhage Episcleritis Scleritis Eyelids Blepharitis Stye / Chalazion Dacryocystitis Cornea Abrasion Bacterial keratitis Viral keratitis Intraocular Acute glaucoma Uveitis / Iritis Endophthalmitis Orbit Pre-septal cellulitis Orbital cellulitis C-C fistula

Triage PCP REFERRAL Non-urgent Urgent Blepharitis Stye Corneal abrasion Dry eye syndrome Allergic conjunctivitis Viral conjunctivitis Bacterial conjunctivitis Pingueculitis Pterygium Subconjunctival heme Preseptal cellulitis Dacryocystitis Episcleritis C-C fistula Bacterial keratitis Viral keratitis Scleritis Acute glaucoma Iritis Endophthalmitis Orbital cellulitis

Chronic vision loss Cataract Diabetic Retinopathy Macular Degeneration Glaucoma

THANK YOU