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Eyecare Review— For Primary Care Practitioners. Primary Care Practitioners. See variety of eye problems Discuss treatment options Facilitate referrals Positioned to explain optometry's role as primary eye care providers. Outline. Anatomy Optics Turned Eyes Lazy Eye

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primary care practitioners
Primary Care Practitioners
  • See variety of eye problems
  • Discuss treatment options
  • Facilitate referrals
  • Positioned to explain optometry's role as primary eye care providers
outline
Outline
  • Anatomy
  • Optics
  • Turned Eyes
  • Lazy Eye
  • External Conditions
  • Internal Conditions
  • Diabetic Retinopathy
basic anatomy
Basic Anatomy

Choroid

Sclera

Retina

Cornea

Fovea

Pupil

Lens

Optic Nerve

Iris

Ciliary Body

slide6

Lids

  • Lashes—protection from foreign material
  • Glands—lubricate anterior surface
    • Meibomian glands
    • Glands of Zeis
    • Glands of Moll
slide7

Conjunctiva

  • Thin, transparent, vascular layer lining
    • Backs of eyelids
    • Fornices
    • Anterior sclera
slide8

Sclera

  • Tough outer shell
  • Composed of collagen bundles
  • Protects from penetration
slide9

Cornea

  • Composed of regularly oriented collagen fibers
  • 5 layers
slide10

Anterior Chamber

  • Space between cornea and iris
  • Filled with aqueous humor produced by ciliary body
slide11

Iris

  • Iris gives eye color
  • 2 muscles:
    • Dilator—opens
    • Sphincter—constricts
slide12

Pupil

  • Allows light to enter
  • Enables view to back of eye and eye health evaluation
slide13

Lens

  • Located behind iris
  • Focuses light on retina
  • Allows for accommodation
  • Normally transparent
  • Where cataracts form
slide14

Ciliary Body

  • Primary functions
    • Pulls on lens for accommodation
    • Epithelium secretes aqueous fluid that fills anterior chamber
red reflex
Red Reflex
  • Light reflection off retina
  • Useful for assessing media clarity
  • Affected by any opacity of cornea, lens, vitreous
  • White reflex = leukocoriaRefer immediately!
vitreous humor
Vitreous Humor
  • Gel-like fluid that fills back cavity
  • Serves as support structure for blood vessels while eye formed—before birth
  • After birth, just ‘hangs out’ in there
  • Where floaters are located
fundus
Fundus
  • Interior surface of eye
  • Includes
    • Optic nerve
    • Retina
    • Vasculature
optic nerve head
Optic Nerve Head
  • Collection of nerve fibers and blood vessels from retina
  • Transfers info to brain’s visual cortex
  • Slightly yellow-pink when healthy
  • White ‘full moon’ appearance can mean trouble!
optic nerve head19
Optic Nerve Head
  • Cup is natural depression in center of nerve
  • Cup size varies between people
  • Very large cup, or change in appearance over time, can indicate glaucoma

Optic Disc

Physiologic Cup

Optic Nerve

macula
Macula
  • Dense collection of cone photoreceptors
  • Fine detail and color vision
  • Macular degeneration affects this area
retinal vessels
Retinal Vessels
  • Include arteries and veins
  • Only place in body where you can directly visualize blood vessels
  • Excellent indicators of systemic diseases
    • HTN
    • Diabetes
    • High cholesterol
    • Carotid disease
peripheral retina
Peripheral Retina
  • Can only be evaluated with dilated pupil
  • Important to evaluate periodically to fully assess eye health
optics review
Optics Review
  • Myopia
  • Hyperopia
  • Astigmatism
  • Presbyopia
myopia
Myopia
  • Nearsightedness
  • See well up close but blurry in distance
  • Eye is too long
  • Light focuses in front of retina
hyperopia
Hyperopia
  • Farsightedness
  • See well in distance
  • Eye is too short
  • Focus point is behind retina
hyperopia27
Hyperopia
  • Blurry image on retina
  • Lens focuses to compensate
  • Hyperopes often asymptomatic much their of lives
  • Can cause headaches or eyestrain with extended reading
  • These problems can get worse after age 40
astigmatism
Astigmatism
  • Surface of cornea isirregular or misshapen
  • Light focuses at various points causing distorted vision
  • Often combined with nearsightedness and farsightedness
presbyopia
Presbyopia
  • Normal, age-related change
  • Near vision becomes difficult
  • Mid-40s lens becomes less elastic and losesability to change focus
  • Time for bifocals…
turned eyes strabismus
Eye misalignment

One or both turn in, out, up or down

Caused by muscle imbalance

3 Kinds of Strabismus

Esotropia

Exotropia

Hypertropia

Turned Eyes - Strabismus
1 esotropia
1. Esotropia
  • Eye turns in towards nose
3 types of esotropia
3 Types of Esotropia
  • Infantile (congenital)
    • Develops in first 3 months of life
    • Surgery usually recommended—along with vision therapy and glasses
  • Accommodative
    • Usually noted around age 2
    • Child typically farsighted
    • Focusing to make images clear can cause eyes to turn inward
    • Treated with glasses but vision therapy may also be needed
3 types of esotropia34
3 Types of Esotropia
  • Partially Accommodative
    • Combination of
      • accommodative dysfunction and
      • muscle imbalance
    • Glasses and vision therapy won’t completely correct eye turn
    • Surgery may be required for best binocularity
if you see esotropia
If you see Esotropia
  • Refer to pediatric optometrist or ophthalmologist
  • Sooner the better for best chance of good vision
2 exotropia
2. Exotropia
  • Eye turns outward
  • Congenital—present at birth
  • Surgery usually needed to re-align
  • Many exotropias are intermittent
    • May occur when patient is tired or not paying attention
    • Concentration can force eyes to re-align
    • Vision therapy and/or glasses can help
2 exotropia37
2. Exotropia
  • When intermittent
    • Brain sometimes receives info from both eyes (binocular)
    • Less chance of amblyopia
    • However, important to be seen by eyecare provider when deviation noted
3 hypertropia
3. Hypertropia
  • One eye vertically misaligned
  • Usually from paresis of an extra-ocular muscle
  • Typically much more subtle for patient to describe and provider to diagnose
2 types
2 Types
  • Congenital
    • Most common type
    • Patients can compensate for years by tilting head
    • Can be discovered by looking at childhood photos
2 types40
2 Types
  • Acquired
    • Trauma—Extra-ocular muscle ‘trapped’ by orbital fracture
    • Vascular infarct—Systemic diseases that affect blood supply to nerves can cause temporary nerve palsy
      • Diabetes and HTN most common
      • Palsies tend to resolve over weeks or months
    • Neurological—In rare cases a tumor or aneurysm can cause symptoms
lazy eye amblyopia
Lazy Eye - Amblyopia
  • Decreased vision uncorrectable by glasses or contacts—not due to eye disease
  • For some reason, brain doesn’t fully acknowledge images seen
lazy eye amblyopia43
3 Types of Amblyopia

Strabismic

Anisometropic

Stimulus deprivation

Lazy Eye - Amblyopia
1 strabismic amblyopia
1. Strabismic Amblyopia
  • One eye deviates from other and sends conflicting info to brain
  • Brain doesn’t like to see double—so “turns off” info from deviated eye
  • Results in under developed visual cortex for that eye
  • Can usually be reversed or decreased if treated during first 9 years
  • Need to visit eyecare provider ASAP to determine cause
treatment
Treatment
  • If caught early, treatment can teach brain how to see better
    • Vision therapy/patching
    • Glasses
    • Surgical re-alignment
  • Early vision screenings are critical!
2 anisometropic amblyopia
2. Anisometropic Amblyopia
  • Anisometropia—significant difference in Rx between eyes
  • Commonly one eye more farsighted
  • Farsighted eye works hard to see clearly—and sometimes gives up
  • Brain relies on info from other eye
2 anisometropic amblyopia47
2. Anisometropic Amblyopia
  • If not caught, one eye won’t learn to see as well as other
  • Vision therapy and glasses are both beneficial
  • Sooner the better
3 deprivational amblyopia
3. Deprivational Amblyopia
  • Any opacity in visual pathway can be devastating to developing visual system
    • Congenital cataracts
    • Corneal opacities
    • Ptosis (droopy eyelid)
    • Other media opacities
common external ocular conditions
Blepharitis

Hordeolum—stye

Preseptal cellulitis

Orbital cellulitis

Pterygium

Corneal ulcer

Conjunctivitis

Viral “pink eye”

Adenovirus

Bacterial

Allergic

Hyperacute

Chlamydial

Common External Ocular Conditions
blepharitis
Blepharitis
  • Inflammation of eyelids (anterior or posterior)
  • Symptoms
    • Itching
    • Burning
    • Crusting
    • Dry eye sensation
    • Foreign body sensation
blepharitis52
Signs

Crusts on lid margins

Thickened, reddened eyelids

Plugged or inspisated meibomian glands along eyelid

Treatment

Warm compresses, 10 minutes 1-2 x/day

Lid scrubs with diluted baby shampoo

Artificial tears

Erythromycin ointment at night

Blepharitis
hordeolum stye
Hordeolum (stye)
  • Abscessed meibomian gland
  • Raised, tender nodule
  • Often gets larger over days to a week
hordeolum
Signs

Raised nodule protruding out from or under lid

Red, swollen lid

Capped glands at site of infection

Treatment

Warm compresses, BID-TID for 10 mins

Topical meds don’t penetrate abscess

Oral antibiotics if no response to traditional treatment

Hordeolum
preseptal cellulitis
Preseptal Cellulitis
  • Bacterial infection of eyelid anterior to orbital septum
  • Can arise from
    • concurrent sinus infection
    • penetrating lid trauma
    • dental infection
    • hordeolum
    • insect bite
preseptal cellulitis56
Preseptal Cellulitis
  • Signs
    • Painful, swollen lid extending past orbital rim
    • May be unable to open eye
    • No decreased vision, restricted ocular motility or proptosis
    • White conjunctiva
  • Treatment
    • Amoxicillin (augmentin) 500 mg PO TID
    • Treat infection quickly to minimize risk of orbital cellulitis
orbital cellulitis
Orbital Cellulitis
  • Serious infection of soft tissues behind orbital septum
  • Can be life-threatening
  • Causes
    • Sinus infection
    • Extension of preseptal cellulitis
    • Dental infection
    • Penetrating lid injury
    • After ocular surgery
orbital cellulitis58
Signs

Tender, warm periorbital lid edema

Proptosis

Painful ophthalmoplegia

Decreased vision

Severe malaise, fever and pain

Orbital Cellulitis
  • Treatment
    • Medical emergency
    • Hospitalization with IV antibiotics
    • Consider orbit/head CT to look for abscess
    • Consult pediatrician or infectious disease specialist
preseptal vs orbital cellulitis
Preseptal

Painful, swollen lid extending beyond orbital rim

Normal vision

Full EOMs

White conjunctiva

No proptosis

No fever

Orbital

Painful, swollen lid that stops at orbital rim

Decreased vision

Restricted ocular motilities

Proptosis

Fever/malaise

Preseptal vs. Orbital Cellulitis
pterygium
Pterygium
  • Triangular-shaped growth of conjunctival tissue onto cornea
  • Causes
    • UV exposure
    • Dryness
    • Irritants
      • Smoke
      • Dust
pterygium61
Signs

Dry eye

Irritation

Redness

Blurred vision

Management and Treatment

UV tint on glasses

Avoid irritating environments

Artificial tears

Topical vasoconstrictor or mild steroid

Surgery

Pterygium
corneal ulcer
Corneal Ulcer
  • Infection of cornea
    • Bacterial
    • Fungal
    • Acanthamoeba
  • Causes
    • SCL wearer
    • Trauma
    • Compromised cornea from pre-existing condition
corneal ulcer63
Signs

Pain

Photophobia

Blurred vision

Discharge

Hypopyon

Treatment:

Start immediately

Fortified antibiotics

Fluoroquinolones

Culture may not be necessary if ulcer is small

Must be monitored daily!

Corneal Ulcer
conjunctivitis red eye
Conjunctivitis (red eye)
  • Various Causes
    • Viral/Adenovirus
    • Bacterial
    • Allergic
    • Chlamydial
    • Herpetic
    • Toxic
conjunctivitis
Signs

Irritation

Burning/stinging

Watering

Photophobia

Pain or foreign body sensation

Itching

Discharge

Watery

Mucoid

Mucopurulent

Purulent

Conjunctivitis
1 viral conjunctivitis pink eye
1. Viral Conjunctivitis (pink eye)
  • Most viral infections are fairly mild and self-limiting
  • Signs & Symptoms
    • Watering
    • Redness
    • Photophobia
    • Discomfort/foreign body sensation
    • Palpable preauricular node
1 viral conjunctivitis
1. Viral Conjunctivitis
  • Patients often have recent history of URI
  • Treat symptoms
    • Cool compresses
    • Artificial tears
    • Topical vasoconstrictors or mild anti-inflammatory
  • Frequent handwashing
  • Usually runs course in 1-3 weeks
2 adenoviral conjunctivitis
2. Adenoviral Conjunctivitis
  • Highly contagious
  • Most common types
    • Pharyngoconjunctival fever (PCF)— can be caused by adenovirus types 3, 4 & 7
    • Epidemic keratoconjunctivitis (EKC)—caused most commonly by adenovirus types 8 & 19
2 adenoviral conjunctivitis69
2. Adenoviral Conjunctivitis
  • Signs
    • Watering
    • Conjunctival follicles
    • Subconjunctival hemorrhages
    • Chemosis
    • Pseudomembranes
    • Lymphadenopathy
    • Keratitis
3 bacterial conjunctivitis
3. Bacterial Conjunctivitis
  • Common, especially in children
  • Usually self-limiting
  • Signs/symptoms
    • Acute redness
    • Burning/grittiness
    • Mucopurulent discharge
    • Lids stuck shut in morning
3 bacterial conjunctivitis71
3. Bacterial Conjunctivitis
  • Common organisms: S. aureus, S. epidermidis, S. pneumonia, H. influenza (esp. peds)
  • Usually self-limiting
  • But important to use broad-spectrum antibiotic until discharge cleared (5-7 days)
  • Antibiotics
    • Tobramycin
    • Polytrim—polymyxin + trimethoprim
    • Fluoroquinolones like Ocuflox or Ciloxan
5 hyperacute conjunctivitis
5. Hyperacute Conjunctivitis
  • Cause
    • Sexually transmitted
    • Neisseria gonorrhoeae
  • Signs
    • Swollen, tender lids
    • Copious purulent discharge
    • Significant conjunctival redness and swelling
    • Lymphadenopathy
5 hyperacute conjunctivitis73
5. Hyperacute Conjunctivitis
  • Treatment
    • Lavage
    • Take scrapings for culture and sensitivity testing
    • Patients usually hospitalized and started on IM Ceftriaxone
    • Topical antibiotics not effective
6 chlamydial conjunctivitis
6. Chlamydial Conjunctivitis
  • Cause
    • Sexually transmitted ocular infection
  • Signs
    • Patients typically have mild but persistent follicular conjunctivitis non respondent to topical antibiotics
    • Any conjunctivitis lasting longer than 3 weeks despite therapy should be suspect
6 chlamydial conjunctivitis75
6. Chlamydial Conjunctivitis
  • Patients can have concomitant genital infection (could be asymptomatic)
    • Refer for work-up if necessary
  • Treatment
    • Oral—Azithromycin 1g, doxycycline 100mg bid x 7 days, erythromycin 500mg qid x 7 days. Also need to tx partners!
    • Topical—erythromycin, tetracycline, or sulfacetamide ung bid-tid x 2-3 weeks
4 allergic conjunctivitis
4. Allergic Conjunctivitis
  • Can be seasonal or acute
  • Signs/symptoms
    • Itching is hallmark
    • Conjunctival redness
    • Chemosis
    • Lid edema
    • Thin, watery discharge
    • No palpable preauricular nodes
4 allergic conjunctivitis77
4. Allergic Conjunctivitis
  • Treatment
    • Eliminate offending agent
    • If mild
      • Cool compresses
      • Artificial tears/vasoconstrictors
    • If moderate or severe
      • Topical antihistamine/mast-cell stabilizer (ie. Patanol)
      • Topical NSAID
      • Topical steroid
      • Oral antihistamine
internal ocular conditions
Glaucoma

Cataracts

Macular Degeneration

Retinal detachment

Internal Ocular Conditions
glaucoma
Glaucoma
  • Progressive loss of Nerve fiber layer at ONH (increased cupping)
  • Can lead to peripheral visual field loss
  • Sometimes caused by elevated intraocular pressure
glaucoma81
Glaucoma
  • Pathophysiology of progression not well understood
  • Increased IOP
    • Damages nerves as they leave eye, causing cell death
    • Reduces blood supply to ONH, indirectly destroying cells by starving them of oxygen and nutrients
  • Abnormal levels of neurotransmitter (glutamate) cause cells to die off
glaucoma82
Glaucoma
  • Monitoring
    • IOP
    • ONH appearance
    • Visual field testing
    • Newer methods include
      • HRT (Heidelberg Retinal Tomograph II)
      • GDx Nerve Fiber Analyzer
      • Genetic testing
glaucoma83
Glaucoma
  • IOP reduction is mainstay of treatment
  • Decrease aqueous production
    • B-blockers
    • Alpha-agonists
    • Carbonic anhydrase inhibitors
  • Increase uveoscleral outflow
    • prostaglandin analogs
cataract
Cataract
  • Clouding of natural lens
  • Patients experience
    • Blurred/dim vision
    • Glare, especially at night
    • Halos around lights
    • Doubling or ghost images of objects
etiology
Etiology
  • Everyone develops them if they live long enough!
  • Types of cataracts
    • Age-related—senile
    • Trauma—blunt or perforating injury
    • Systemic conditions—diabetes
    • Medications—steroids
main types
Main Types
  • Age-related
    • Nuclear sclerotic
    • Cortical spokes
    • Posterior sub-capsular
    • Mature cataract
treatment87
Treatment
  • Surgery
  • When loss of vision interferes with daily activities
    • Driving
    • Reading
    • Hobbies
outpatient surgery
Outpatient Surgery
  • 5-10 minutes with skilled surgeon
    • Incision through cornea or sclera under upper lid
    • Circular tear in anterior capsule
    • Lens broken up with ultra sound instrument
    • Fragments suctioned out
    • Lens implant inserted
secondary cataract
Secondary Cataract
  • Cloudiness forms on posterior capsule after cataract surgery
  • 30-50% of patients
  • YAG laser used to create opening
  • Vision quickly restored
macular degeneration
Macular Degeneration
  • #1 cause of blindness in Americans over age 65
pathophysiology
Pathophysiology
  • Causes not well understood
  • Theorized link to
    • UV light exposure
    • subsequent release of free radicals
    • oxidation within retinal tissues
  • Another theory—areas of decreased vascular perfusion in retina, lead to cell death
two types
Two Types
  • Dry (atrophic)
    • 90% of those diagnosed
  • Wet (exudative)
    • 10% of those diagnosed
    • But accounts for 90% of blindness caused by disease
symptoms
Symptoms
  • None
  • Blurred vision
  • Metamorphopsia—straight lines appear wavy or distorted
  • Scotomas—missing areas in vision
dry form
Dry Form
  • Slow, progressive loss of central vision
  • Breakdown of underlying retinal tissues, resulting in mottling or clumping of normal pigment
  • Drusen begin to accumulate
  • Geographic atrophy can also occur
wet form
Wet Form
  • Can quickly degrade central vision
  • Break in underlying tissues allows new blood vessels or fluid to come through
  • New blood vessels are weak so frequently break and bleed
treatment for dry form
Regular eye exams

Careful discussion regarding family history

Education

UV protection

Antioxidants

AREDS

PreserVision

Stop smoking

Treatment for Dry Form
treatment for wet form
Refer to retinal specialist

Photocoagulation

Photo-dynamic therapy (PDT)

Submacular surgery

Macular translocation

Anti-angiogenic drug therapy

Treatment for Wet Form
retinal detachment
Retinal Detachment
  • Several types
    • Rhegmatogenous—caused by break in retina
    • Exudative—caused by fluid accumulation beneath retina
    • Tractional—proliferative fibrovascular vitreal strands
signs symptoms
Signs & Symptoms
  • Flashing lights in peripheral vision
  • New floaters—black spots or ‘cobwebs’
  • Peripheral scotoma—dark shadow or “curtain” blocking vision
emergency
Emergency
  • Patients with these symptoms must see eyecare provider immediately
  • Additional risk factors
    • Highly nearsighted
    • Diabetic
    • Recent trauma/injury
treatment101
Treatment
  • Laser photocoagulation or cryotherapy
  • Pneumatic retinopexy—gas bubble to tamponade retina back into place
  • Scleral buckle
  • Silicone oil
diabetic retinopathy103
Diabetic Retinopathy
  • Diabetes affects retinal micro-vasculature
  • One of leading causes of blindness among ages 20-64
progression
Progression
  • Over time, elevated and fluctuating blood sugar damages vessel walls
  • Vessels leak fluid, lipids or blood into retina
  • New vessels grow to bring more oxygen to retina
symptoms105
Symptoms
  • Fluctuating vision
  • Blurred vision
  • Distortion
  • Sudden loss of vision
treatment106
Treatment
  • Control blood sugar
  • Refer to retinal specialist when vision threatened
      • PRP (pan-retinal photocoagulation)
      • Focal laser
      • Vitrectomy
      • Retinal detachment repair
working together
Working Together
  • Together we can catch vision threatening conditions earlier
  • Glad to answer questions
  • Always happy to take your calls