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Ophthalmology for Primary Care Providers

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Presentation on theme: "Ophthalmology for Primary Care Providers"— Presentation transcript:

1 Ophthalmology for Primary Care Providers
Bob Avery, MD, PhD Ophthalmology/Surgery University of New Mexico School of Medicine

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

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

4 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

5

6 Anterior segment Lids Conjunctiva/sclera Cornea Anterior chamber Iris
Lens

7 Posterior segment Vitreous Optic disk Vessels Retina Choroid Macula
Periphery Choroid

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

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

10 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

11 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

12 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

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

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

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

16 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

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

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

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

20 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

21 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

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

23 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

24 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

25 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

26 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

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

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

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

30 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

31 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

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

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

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

35 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

36 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

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

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

39 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

40 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

41 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

42 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

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

44 Chronic vision loss Cataract Diabetic Retinopathy Macular Degeneration
Glaucoma

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

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

47 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

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

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

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

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

52 Glaucoma Normal Glaucoma

53 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

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

55 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

56 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

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

58 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

59 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

60 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

61 REVIEW

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

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

64 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

65 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

66 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

67 Chronic vision loss Cataract Diabetic Retinopathy Macular Degeneration
Glaucoma

68 THANK YOU

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