1. Eye Care for Health Care Providers
Len Oshinskie, O.D.
Chief, Optometry Section
Newington VA Medical Center

2. Topics Laser-assisted Cataract surgery
Age-related macular degeneration
Diabetic Macular Edema
Glaucoma and Medications
Red eye
Dry eye
Practical advice

3. Common Causes of Blindness and Visual Impairment
Age-related macular degeneration
Diabetic retinopathy
Glaucoma
Cataract

4. Femtosecond laser
Approved by FDA for several steps in cataract surgery in
Uses laser energy at 1053 nm that is precise to 3 microns( lens capsule is 2-28 microns thick)
Ultra short pulse does not damage surrounding tissue
(10-15 of a sec)

6. Femtosecond laser assisted cataract surgery

7. Advantages to laser assisted cataract surgery
Incisions more reproducible than bladed incisions
Less risk for capsular rupture
More precise opening so IOL can be more accurately placed
Less energy from phaco probe for at risk pts, less inflammation
Perhaps less risk of infection

8. Disadvantages of laser assisted cataract surgery
Takes longer
Requires expensive equipment
Capsulorhexis not always complete
Not paid for by Medicare
Pts have higher expectations

9. Age-related macular degeneration
Leading cause of blindness over age 65
Drusen and pigment atrophy and clumping
exudative changes(heme, lipid, small central retinal detachments)
sudden distortion of vision, new unilateral blur, scotoma, difficulty reading

10. Macular Degeneration Types
Atrophic (dry) AMD %
Neovascular(wet) AMD 10-20%

12. Drusen

13. AREDS 1 500 mg vit C 400 IU vit E 15 mg betacarotene 80 mg zinc
2 mg copper
Over 5 yr followup reduced risk of progression to advanced AMD by 25 % if pt had certain macula findings(larger drusen)

14. AREDS 2 results May 2013 JAMA 2013: 309(19):2005-2015
Placebo controlled clinical trial(AREDS 1 was placebo)
Multiple arms: lutein 10 mg/zeathanthin 2 mg, DHA(350 mg) and EPA(650 mg), both, AREDS 1
AREDS 1 formula with lutein/zeaxanthin(removing betacarotene) slightly reduced risk of developing advanced AMD
Adding DHA and EPA did not reduce risk

16. Risks with AREDS 2 Large dose of vit E(prostate and heart failure)
Coumadin users

17. Genetics and AMD
One study to suggest genetic testing maybe important before prescribing AREDS supplement

18. Exudative (Wet) AMD

19. Early exudative AMD

22. OCT ocular coherence tomography

24. Br J Ophthal 1997; 81:
A significantly increased expression of VEGF (p= ) and TGF-β (p=0.019) was found in the retinal pigment epithelium (RPE) of maculae with AMD compared with control maculae.

26. Anti-VEGF medications
Macugen(Pegaptanib) 2004
Avastin(bevacizumab) 2005 but not FDA approved
Lucentis(ranibizumab) 2006
Eylea(aflibercept) 2011

27. Intravitreal injection

28. Studies on Treatment of Wet AMD (ETDRS visual acuity chart)

31. Visual Acuity with Eylea

32. Ocular side effects Cataract Inflammation Retinal detachment
endophthalmitis

33. Jetrea(ocriplamin) Intravitreal injection
Approved for treatment of vitreo-retinal adhesions
Side effects-transient vision decrease and inflammation

34. Aspirin use in pts with wet AMD
Conflicting reports
Recent studies suggest an increased risk, but not randomized
If risks for CV complications,
suggest continuing ASA

35. Trends in Treating Diabetic Retinopathy

36. Mechanism of Diabetic Macular Edema
Hyperglycemiathickened endothelial cellsIschemia  increased VEGF, loss of pericytes
Macular edema :
increased permeability
increased hydrostatic pressure
dilating blood vessels, pericytes disrupted
Inflammatory component

37. Treatment of Diabetic Macular Edema
Anti-VEGF treatment
Corticosteroids
Laser

38. Anti-VEGF treatment of DME
Lucentis more effective than sham or laser in decreasing thickness and improving vision
Lucentis as adjunct to laser more effective than laser alone in decreasing thickness and improving vision
Eylea showed improved vision compared to laser
Lucentis approved by FDA for Tx of DME

39. What to tell your patients about intravitreal injections
Does not hurt as much as you think
Very safe (2.1% have ocular complications)
Multiple injections needed
Very effective in preventing vision loss
It usually take several weeks for vision to improve/stabilize
Post op: expect mild soreness, irritation, floaters, subconj heme
Report any sudden vision changes or pain stat
There may be small risk for CVA

40. Marijuana and glaucoma
AAO June 2014 recommendations:
Only lowers IOP 3-4 hours
Not as effective as available medications
Potential for abuse
Potential for lung damage
Lowers BP (less perfusion)
Topical THC drops tried but not effective(not water soluble enough)
effects of Marinol on glaucoma are not impressive
No standardization of dose with various forms of marijuana plants
Not legal in federal system

41. Plaquenil Monitoring
Visual field
OCT and FAF
Focal ERG

42. Topiramate
Angle closure glaucoma
Visual field defects

43. Tear film composition
Lipid, aqueous, mucin

45. Tear film components Lipid-Meibomian glands aqueous-lacrimal gland
Mucin-goblet cells
Ideal tear film
has uniform thickness
maintains corneal coverage between blinks
limited debris

47. Dry eye Multifactorial disease of tears and ocular surface
Discomfort, vision changes and tear film instability
Decreased tear production, increased osmolarity and inflammation of ocular surface

48. Dry Eye Cascade Clin Ophthalmol. 2009; 3: 405–412.

49. Guidelines from the 2007 International Dry Eye Workshop BY MICHAEL A
Guidelines from the 2007 International Dry Eye Workshop BY MICHAEL A. LEMP, M. D. AND GARY N. FOULKS, M. D. .

50. Dry Eye Disease Stevenson et al in Arch Ophthalmology 2012;130:90-100

51. Dry Eye Symptoms Dryness Irritation/burning(“hurt”)
Foreign body sensation(“sand in my eyes”)
Watering
Intermittent blurred vision
Itching

52. Differential Diagnosis Pt with Symptoms of Dry Eye
Blepharitis
Rosacea
Exposure keratitis (TAO, CN 7 palsy,ectropion )

54. Risk factors for Dry Eye Stevenson et al
Risk factors for Dry Eye Stevenson et al. Arch Ophthalmology 2012;130:90-100
Increased age
Female >males
Hormonal inbalance
Autoimmune disease
Vitamin deficiency
Medications
Environmental stress
Contact lens use
Ophthalmic surgery(LASIK)

55. Contributors to Dry Eye
Air flow(AC, fans etc)
Humidity
Smoke
Alcohol
Antihistamines
Diuretics
Blink rate(reading and computer)

56. Evaluation of the Dry Eye Patient
History
Tear Breakup time-quality
Schirmer-quantity
Corneal staining(fluorescein or lissamine green)
Tear wedge-quantity
Osmolarity

58. Break up Time

59. Corneal staining

60. Tear Wedge

61. Lid Position Proptosis Lagophthalmus Ectropion Parkinson’s
CN VII palsy
Partial blinker
Sleep apnea

62. Treatment Artificial tears-preserved and non-preserved
Restasis(topical cyclosporin A)
Topical corticosteroids
Omega 3/Fish Oil
Qhs ointment
Tetracyclines
Punctal plugs
tarsorrhaphy

63. Using Artificial tears
Avoid OTC “gets the red out” drops
Use drops that say lubricant or artificial tears
Must use 4 times a day
Don’t touch tip of bottle to eye or lids
Systane Balance
Refresh Optive Advanced
FreshKote(by Rx only)
Give ointment at night ?

64. Punctal plugs

66. My patient has glaucoma, is it safe to prescribe them_____?
antihistamines
tricyclic antidepressants
Parkinson's disease
anti-cholinergics such as atropine
anti-spasmolytics
anti-psychotic medications

67. Glaucoma Classification
Primary, chronic or idiopathic type(open angle)
secondary forms: pseudoexfoliation, pigmentary, uveitic, steroid induced, traumatic, post-op, others)
low-tension or normal-tension type
developmental type
angle-closure type

68. Narrow angle and dilated pupil

69. Meds to avoid if pt has narrow angles
Antihistamines and decongestants: Pseudoephedrine, diphenhydramine , hydroxyzine, and clemastine fumarate
Asthma medicines: Albuterol, metaproterenol sulfate, isoetharine, and theophylline
Motion sickness medicines: Scopolamine and dimenhydrinate
Tricyclic antidepressants, such as amitriptyline, nortriptyline , doxepin, clomipramine amoxapine, chlordiazepoxide and amitriptyline ), trimipramine and imipramine.

70. Risk factors for acute angle-closure glaucoma
Age 55-70
Hyperopia
females
Asians

71. Signs/Symptoms of Acute Angle Closure Glaucoma
Pain
hazy/blurred vision
haloes around lights
frontal HA
nausea/vomiting
Fixed pupil
Steamy cornea
Red eye

72. Glaucoma Medications
Prostaglandin analogs(Xalatan, Lumigan, Travatan Z, Zioptan, latanoprost)
beta-blockers( Ocupress, Betagan, Betoptic S, Betimol, Istalol, timolol)
alpha agonist(Alphagan P, brimonidine)
CAI(Trusopt, Azopt, dorzolamide)
Combo meds(Cosopt, Combigan, Simbrinza)
miotics(pilocarpine)
Oral carbonic anhydrase inhibitors(Diamox)

73. Differential Diagnosis of the Red Eye
Infectious(bacterial, viral, fungal)
Inflammatory(uveitis, episcleritis,scleritis)
Increased IOP
Allergic
Mechanical(lid, FB, contact lens)
Dry eye
Toxic

74. Differential Diagnosis of the Red Eye
Systemic disorders/dermatologic disease
thryroid disease
Chlamydia
rosacea
atopic dermatitis
subconjunctival hemorrhage

75. When to refer the red eye
History important for deciding when to refer
Refer if associated with :
Blur
Pain
Hx of narrow angles
Pupil unresponsive to light
Hx of Herpes keratitis or zoster, light sensitivity
Contact lens wearer
Chemical injury involving alkaline

76. Clinical exam Stain the cornea with fluorescein
examine lids(entropion, bleparitis)
pupil(ACG, uveitis)
cul-de-sacs for FB

77. Older Ophthalmic antibiotics
Erythromycin
Sulfacetamide
gentamicin
neomycin/polymyxin B/gramicidin/dexamethasone(Maxitrol)

78. Current trends
Fluoroquinolones(Vigamox/Moxema, Zymaxid, Quixin/Iquix, Besivance)
Tobradex(beware steroids)
Polytrim(trimethoprim/polymyxin B)
Polysporin ointment

79. When to refer the red eye
Vision changes
Pain
Redness getting worse
History of narrow angles
Light sensitivity
Fixed pupil or steamy cornea
Previous bouts of uveitis or Herpes simplex keratitis

80. Urgent Eye/Visual Symptoms
eye pain(keratitis, uveitis, ACG)
photophobia(keratitis, uveitis)
numerous floaters(retinitis, RD, VH)
sudden onset distortion or blur(AMD)
sudden unilateral vision loss(CRAO/CRVO,
RD, AION)
red eye with blur(ACG, keratitis, posterior uveitis)
Fixed pupil with pain or diplopia

81. Topical Steroids Increases IOP in 10-15%
allow proliferation of destructive organisms(HSK, Pseudomonas)
cataracts
duty to warn
limit refills
Try Lotemax