Eye Center of Texas, Houston HE SAID, SHE SAID Jill Autry, OD, RPh Eye Center of Texas, Houston drjillautry@tropicalce.com 1

FUCH’S DYSTROPHY Endothelial corneal disorder Women > Men, 3:1 and more severely Progresses with age Stages Guttata Stromal and epithelial edema Corneal scarring Muro-128 5% solution/ung DSAEK

Who Gets Dry Eye? Women>Men Older>Younger Patients with autoimmune diseases Lupus, rheumatoid arthritis, sarcoid, Sjogren’s, thyroid disease, rosacea, etc. Post-menopausal Medication induced Hormonal therapy, antidepressants, anxiolytics

Inflammation and Dry Eye Research clearly shows corneal, conjunctival and lacrimal gland inflammation as a major cause of dry eye syndrome. Ongoing inflammation results in the increase production of cytokines and activated T-Cells that mediate the inflammatory process Inflammation acts to shut down the components of good tears

SJOGREN’S Autoimmune disease that attacks the exocrine glands Associated with rheumatoid arthritis Specifically lacrimal and salivary glands Women>Men Increases with age Diagnosis often made with signs/symptoms Positive SSA and SSB serum autoantibodies

Restasis® Proven To: Decreases inflammation in the cornea, conjunctiva, and lacrimal gland Increases tear production Increases goblet cell density Decreases SPK Decrease dependence on artificial tears Excellent safety profile Cyclosporine undetectable in blood

Restasis® Recommendations BID dosing in most cases-not PRN Severe cases use QID with a steroid initially Continue artificial tear use initially Burning initially or later as ocular surface heals Use before and after contact lenses (15 minutes) Persistence with therapy Results are 2-3 months away Discuss long-term therapy May attempt once daily dosing when controlled Mail order (90 day supply);2 boxes=1 month supply

One month supply (2 boxes=one month supply) Edward Wade, M.D. Ting Fang-Suarez, M.D. Mark Mayo, M.D. Chris Allee, O.D. Jill Autry, O.D. Randy Reichle, O.D. 6565 West Loop South 4415 Crenshaw Rd. 15400 SW Frwy Bellaire, TX 77401 Pasadena, TX 77504 Sugar Land, TX 77478 Phone (713)797-1010 Phone (281)998-3333 (281)277-1010 450 Medical Ctr Blvd, #305 11914 Astoria Boulevard, #325 21700 Kingsland Blvd. Webster, TX 77598 Houston, TX 77089 Katy, TX 77450 (281) 332-1397 (281) 484-2030 (281) 578-4815 NAME Jill Autry AGE ______________ ADDRESS_____________________________________________________DATE 3-3-11 Rx Restasis 1 gtt bid OU One month supply (2 boxes=one month supply) Three month supply (6 boxes=three month supply) Pharmacist please note: 1 month supply=2 boxes per PPI REFILLS-- one year Jill Autry, O.D.

Estrogens vs. Androgens Androgens important in the quality/quantity of oily secretions Androgen levels decrease with age resulting in Increased meibomian gland dysfunction Results in evaporative dry eye Lacrimal gland inflammation Results in aqueous deficiency May explain post-menopausal dry eye Sjogren’s patients show decreased androgen levels

ACNE ROSACEA Redness/telangiectasia/papules on the cheeks, nose, and forehead More common in women More severe in men Fair or light skinned patients more common and more severe Increased meibomian dysfunction and blepharitis with ocular rosacea

DOXYCYCLINE 50mg bid No with children < 8 years old/pregnant/nursing. qd to bid dosing Can take with food Can take with dairy products Cannot take with antacids Can cause photosensitivity Cannot take before lying down Must wait 2 hours to avoid esophageal ulceration

VERNAL KERATOCONJUNCTIVITIS Young Males > Young Females, 3:1 Seasonal pattern during warmer weather Bilateral, severe itching with thick, ropy discharge Exam Giant papillae under upper lid SPK Trantas’ dots Shield ulcers (severe cases) Thickened eyelids

VERNAL KERATOCONJUNCTIVITIS Mast cell stabilizers Topical and oral antihistamines Topical and oral NSAIDS Restasis Topical steroids for severe exacerbations Shield ulcer Antibiotics Cycloplegic Bandage CL

EPISCLERITIS Women > Men and more severely Sectoral injection on bulbar conjunctiva Mild tenderness to area Superficial conjunctival vessels and deeper episcleral vessels involved Treat with PF/Durezol q2h to start Taper as usual with response

MANAGEMENT Refer for bloodwork with multiple recurrences/bilateral involvement Nodular episcleritis more typical of systemic disease Refer if severe pain and/or bluish color to conjunctiva Typical of scleritis Refer if unresponsive to topical steroid treatment

IRITIS Women > Men Unilateral pain, circumcorneal injection, photophobia, decreased VA C/F in AC, KP on corneal endothelium, posterior synechiae, decreased/increased IOP Traumatic, postoperative, idiopathic, systemic associations PF/Durezol q1-2h, cycloplegic, glaucoma drops PRN

MANAGEMENT Most cases easily managed without referral Need to taper steroid over 1-2 weeks Refer for bloodwork/x-rays if repeat episodes or bilateral Refer if unresponsive to topical therapy May need subconjunctival steroid injection Refer if posterior uveitis present

GENDER & INFLAMMATION Lupus (W) Sarcoid (W) Rheumatoid arthritis (W) Ankylosing spondylitis (M) Reiter’s (M) Juvenile rheumatoid arthritis (W) Psoriatic arthritis (W = M)

INFLAMMATORY LABS Lupus (ANA) Sarcoid (ACE, Chest X-ray) Rheumatoid arthritis (RF) Ankylosing spondylitis (HLA-B27, sacroiliac spinal films) Reiter’s (HLA-B27, joint x-rays) Pars planitis (HLA-B27) Psoriatic arthritis (ESR-Sed rate)

MACULAR HOLE Progress from Stage 1 to Stage 4 Women>Men Older>Younger Idiopathic mostly, occasionally traumatic Best diagnosed with OCT Full-thickness holes generally 20/200 VA Round, dark red colored area in the center of the macula Often with yellow, lipofuscin granules

MACULAR HOLE Distinguish from ERM pseudohole Macular hole perfectly round Poor vision with macular hole Positive Watzke-Allen with macular hole Pseudohole with tortuous surrounding vessels Can follow Stage 1 and 2 holes but get macular OCT for follow-up Amsler grid

MACULAR HOLE SURGERY Vitrectomy with membrane peel (ILM) Gas fluid exchange Face-down positioning for 2 weeks until gas bubble absorbs Watch IOP closely with gas bubble No flying until gas bubble completely resorbs Can use silicone oil but need second surgery

EXPECTED OUTCOMES 90% expected closure Expected visual outcomes dependent on length of time macular hole present Best outcomes within one year Prognosis decreases with each year Average gain is 2 lines VA

CENTRAL SEROUS RETINOPATHY Mostly in young (20-50yo), male patients Recently being reported more in women, especially during pregnancy Mildly reduced VA, metamorphopsia Round, serous RPE detachment Usually resolves in 2-3 months without tx Controversial treatment with Diamox

MANAGEMENT Need baseline fluorescein to rule-out other causes of serous detachments Pinpoint leakage followed by smokestack Can follow thereafter by monitoring VA and macular appearance Watch for recurrences over time Rare CNV or PED in future secondary to RPE disturbances

PIGMENTARY GLAUCOMA Flacid, peripheral iris bows posteriorly Believed to rub against lens zonules Releases iris pigment Decreases trabecular meshwork function One-third of pigmentary dispersion patients will develop pigmentary glaucoma Bilateral

CHARACTERISTICS Demographics Young Male Myopic Caucasian Mid-peripheral iris transilluminating defects (TID) Krukenberg spindle (K spindle) Heavy pigment in trabecular meshwork on gonioscopy Acute IOP rise after exercising

POSSNER-SCHLOSSMAN More common in middle-aged males Open angle with high IOP (40-60) Patient not in pain, eye is white, cornea without edema Mild C/F in AC, KP on cornea, mildly decreased VA PF/Durezol q2h and glaucoma drops; avoid prostaglandins if possible

MANAGEMENT Can be easily managed without referral HOWEVER… Watch for exacerbations Requires close and frequent follow-up Trabecular meshwork often weakened and IOP is hard to control even when uveitis subsides Patient often without symptoms and IOP could be very high causing VF loss

OPTIC NEURITIS Decreased vision over days Unilateral Pain on eye movements Decreased color vision (red cap test) + RAPD Visual field defects vary Swollen disc or retrobulbar MRI of Brain and Orbits with Flair sequencing

OPTIC NEURITIS TREATMENT TRIAL (ONTT) Recommends treatment with IV methylprednisolone x 3 days Avoid prednisone orally until AFTER treatment with IV (10-14 days) Hastens visual recovery but not final visual outcome Prolongs time to development of MS Do not use oral steroids alone

MULTIPLE SCLEROSIS Female > Male 18-45 years old Intermittent diplopia Optic neuritis Nystagmus Tingling or numbness in extremities Uhtoff’s sign Worsening vision with increased body temperature Lhermitte’s sign Shock-like sensation with neck flexion

PSEUDOTUMOR CEREBRI Papilledema Negative MRI of Brain Negative MRV of Brain Increased opening pressure on lumbar puncture Normal CSF composition Obese females (Diamox and weight loss) Pregnancy (Diamox after 20 weeks gestation) Medication induced (remove offending agent)

PAPILLEDEMA SIGNS Bilateral ONH swelling caused by increased intracranial pressure Peripapillary swollen NFL Blurring of disc margins Blurring of ONH vasculature Peripapillary flame shaped hemorrhages Enlarged blind spots on VF testing No RAPD

PAPILLEDEMA SYMPTOMS Transient obscurations of vision lasting seconds (usually bilateral) Headaches worse upon wakening Diplopia secondary to 6th nerve palsy Little or no vision loss *unless chronic Color vision intact

FLOMAX® Alpha-1 blocker used in men for BPH Benign Prostatic Hypertrophy (BPH) Initial study; 15/16 patients exhibited floppy iris syndrome Can cause miosis, prolapse, excessive movement, PC rupture during cataract surgery Pre-op atropine or intraoperative alpha agonists may help

FLOMAX® Notice how pupil dilates in office Discontinue before referral; however, may not stop the syndrome Other alpha agonists are not as selective and have not consistently shown syndrome prazosin-Minipress® terazosin-Hytrin® doxazosin-Cardura®

TAMOXIFEN® Breast cancer oral treatment/prophylaxis Most commonly after one year of therapy Macular refractile bodies and RPE changes Does not warrant discontinuation Color vision decreases or CME develops STOP MED

RETINAL CHANGES Chloroquine/Hydroxychloroquine (Plaquenil) Early changes Retinal parafoveal granularity of RPE Late changes Bull’s eye appearance of the macula Choroidal filling defects on FA Distorted color vision

PLAQUENIL MONITORING Baseline (or within one year of initiation) Routine monitoring Dose and risk factor dependent More frequent Dose > 6.5 mg/kg/day for greater than 5 years Age > 60, kidney/liver disease, coexisting retinal disease Dilated fundus examination Amsler grid 10-2 Visual field Color vision testing

ERECTILE DYSFUNCTION Viagra® Cialis ® Levitra ® Bluish color vision defects reported especially with increased dosage amounts Concomitant nitrate use causes hypotension Avoid in Retinitis Pigmentosa patients Association with ischemic optic neuropathy Cialis ® Levitra ®

OPTIC NEUROPATHY Sildenafil (Viagra®) Used in the treatment of erectile dysfunction WHO classification: Possible Anterior Ischemic Optic Neuropathy Painless, immediate loss of vision Swollen optic nerve with APD Altitudinal defect Users are older with vasculopathic conditions Consider not using med with history of AION or small optic nerve cupping

TOPAMAX Acute myopia; up to 6-8 diopters Most cases within one month of initiation Secondary angle closure Choroidal effusion and ciliary body edema Can lead to anterior displacement of lens and acute angle closure with increased IOP

TOPAMAX INDUCED ANGLE CLOSURE Secondary angle closure Shallow AC Red eye, pain, high IOP, mydriasis Superchoroidal effusion, not related to pupillary block Ciliary body edema, not relieved by peripheral iridotomy (PI) Need to DC med as quick as possible Must be tapered;cannot stop abruptly Hyperosmotic therapy, cycloplegic, topical antiglaucoma agents

MIGRAINES Women>Men; 3:1 Generally starts before 20 years of age Often have family history May have nausea and vomiting, fatigue, photophobia Headaches predominantly on same side;may occasionally switch sides Headache triggers -Stress -Chocolate -BC pills -Bright lights -Alcohol -Pregnancy

MIGRAINE RELATED AURA Flashing lights, heat waves, jagged objects, tunnel vision, colored spots Lasting 15 to 30 minutes May or may not be accompanied by HA Acephalic migraine History of migraine is common

CLUSTER HEADACHES Unilateral Very painful Typically affects men Lasts minutes to hours; typically occurs at same time each day May disappear as easily as they appeared May see ipsilateral tearing, rhinorrhea, Horner’s

ADIE’S TONIC PUPIL Usually female Poor reaction to light Slow constriction to near Slow redilation following near constriction Vermiform movement Constricts to 0.125% pilocarpine Long standing can result in small pupil