HE SAID, SHE SAID

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HE SAID, SHE SAID

• Jill Autry, OD, RPh
• Eye Center of Texas, Houston
• drjillautry_at_tropicalce.com

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FUCHS DYSTROPHY

• Endothelial corneal disorder
• Women gt Men, 31 and more severely
• Progresses with age
• Stages
• Guttata
• Stromal and epithelial edema
• Corneal scarring
• Muro-128 5 solution/ung
• DSAEK

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Who Gets Dry Eye?

• WomengtMen
• OldergtYounger
• Patients with autoimmune diseases
• Lupus, rheumatoid arthritis, sarcoid, Sjogrens,
  thyroid disease, rosacea, etc.
• Post-menopausal
• Medication induced
• Hormonal therapy, antidepressants, anxiolytics

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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

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SJOGRENS

• Autoimmune disease that attacks the exocrine
  glands
• Associated with rheumatoid arthritis
• Specifically lacrimal and salivary glands
• WomengtMen
• Increases with age
• Diagnosis often made with signs/symptoms
• Positive SSA and SSB serum autoantibodies

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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

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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 boxes1 month supply

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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 [phone] Phone
[phone] [phone] 450 Medical Ctr
Blvd, 305 11914 Astoria Boulevard, 325
21700 Kingsland Blvd. Webster, TX 77598
Houston, TX 77089 Katy, TX 77450 (281)
332-1397
[phone] [phone] NAME Jill
Autry AGE ______________ ADDRE
SS________________________________________________
_____DATE 3-3-11 Rx Restasis 1 gtt bid
OU One month supply (2 boxesone month
supply) ?Three month supply (6 boxesthree
month supply) Pharmacist please note 1
month supply2 boxes per PPI REFILLS-- one
year Jill Autry, O.D.
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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
• Sjogrens patients show decreased androgen levels

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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

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DOXYCYCLINE

• 50mg bid
• No with children lt 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

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VERNAL KERATOCONJUNCTIVITIS

• Young Males gt Young Females, 31
• 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

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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

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EPISCLERITIS

• Women gt 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

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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

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IRITIS

• Women gt 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

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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

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GENDER INFLAMMATION

• Lupus (W)
• Sarcoid (W)
• Rheumatoid arthritis (W)
• Ankylosing spondylitis (M)
• Reiters (M)
• Juvenile rheumatoid arthritis (W)
• Psoriatic arthritis (W M)

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INFLAMMATORY LABS

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

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MACULAR HOLE

• Progress from Stage 1 to Stage 4
• WomengtMen
• OldergtYounger
• 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

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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

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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

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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

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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

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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

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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

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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

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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

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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

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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

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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

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MULTIPLE SCLEROSIS

• Female gt Male
• 18-45 years old
• Intermittent diplopia
• Optic neuritis
• Nystagmus
• Tingling or numbness in extremities
• Uhtoffs sign
• Worsening vision with increased body temperature
• Lhermittes sign
• Shock-like sensation with neck flexion

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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)

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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

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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
• unless chronic

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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

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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

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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

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RETINAL CHANGES

• Chloroquine/Hydroxychloroquine (Plaquenil)
• Early changes
• Retinal parafoveal granularity of RPE
• Late changes
• Bulls eye appearance of the macula
• Choroidal filling defects on FA
• Distorted color vision

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PLAQUENIL MONITORING

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

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ERECTILE DYSFUNCTION

• Viagra
• 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

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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

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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

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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 taperedcannot stop abruptly
• Hyperosmotic therapy, cycloplegic, topical
  antiglaucoma agents

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MIGRAINES

• WomengtMen 31
• Generally starts before 20 years of age
• Often have family history
• May have nausea and vomiting, fatigue,
  photophobia
• Headaches predominantly on same sidemay
  occasionally switch sides
• Headache triggers
• -Stress -Chocolate -BC pills
• -Bright lights -Alcohol -Pregnancy

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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

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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, Horners

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ADIES 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