Title: Eyecare Review
1Eyecare ReviewFor Primary Care Practitioners
2Primary Care Practitioners
- See variety of eye problems
- Discuss treatment options
- Facilitate referrals
- Positioned to explain optometry's role as
primary eye care providers
3Outline
- Anatomy
- Optics
- Turned Eyes
- Lazy Eye
- External Conditions
- Internal Conditions
- Diabetic Retinopathy
4ANATOMY
5Basic Anatomy
Choroid
Sclera
Retina
Cornea
Fovea
Pupil
Lens
Optic Nerve
Iris
Ciliary Body
6Lids
- Lashesprotection from foreign material
- Glandslubricate anterior surface
- Meibomian glands
- Glands of Zeis
- Glands of Moll
7Conjunctiva
- Thin, transparent, vascular layer lining
- Backs of eyelids
- Fornices
- Anterior sclera
8Sclera
- Tough outer shell
- Composed of collagen bundles
- Protects from penetration
9Cornea
- Composed of regularly oriented collagen fibers
- 5 layers
10Anterior Chamber
- Space between cornea and iris
- Filled with aqueous humor produced by ciliary
body
11Iris
- Iris gives eye color
- 2 muscles
- Dilatoropens
- Sphincterconstricts
12Pupil
- Allows light to enter
- Enables view to back of eye and eye health
evaluation
13Lens
- Located behind iris
- Focuses light on retina
- Allows for accommodation
- Normally transparent
- Where cataracts form
14Ciliary Body
- Primary functions
- Pulls on lens for accommodation
- Epithelium secretes aqueous fluid that fills
anterior chamber
15Red Reflex
- Light reflection off retina
- Useful for assessing media clarity
- Affected by any opacity of cornea, lens,
vitreous - White reflex leukocoriaRefer immediately!
16Vitreous Humor
- Gel-like fluid that fills back cavity
- Serves as support structure for blood vessels
while eye formedbefore birth - After birth, just hangs out in there
- Where floaters are located
17Fundus
- Interior surface of eye
- Includes
- Optic nerve
- Retina
- Vasculature
18Optic Nerve Head
- Collection of nerve fibers and blood vessels from
retina - Transfers info to brains visual cortex
- Slightly yellow-pink when healthy
- White full moon appearance can mean trouble!
19Optic 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
20Macula
- Dense collection of cone photoreceptors
- Fine detail and color vision
- Macular degeneration affects this area
21Retinal 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
22Peripheral Retina
- Can only be evaluated with dilated pupil
- Important to evaluate periodically to fully
assess eye health
23OPTICS
24Optics Review
- Myopia
- Hyperopia
- Astigmatism
- Presbyopia
25Myopia
- Nearsightedness
- See well up close but blurry in distance
- Eye is too long
- Light focuses in front of retina
26Hyperopia
- Farsightedness
- See well in distance
- Eye is too short
- Focus point is behind retina
27Hyperopia
- 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
28Astigmatism
- Surface of cornea isirregular or misshapen
- Light focuses at various points causing
distorted vision - Often combined with nearsightedness and
farsightedness
29Presbyopia
- Normal, age-related change
- Near vision becomes difficult
- Mid-40s lens becomes less elastic and
losesability to change focus - Time for bifocals
30MISALIGNED EYES
31Turned Eyes - Strabismus
- Eye misalignment
- One or both turn in, out, up or down
- Caused by muscle imbalance
- 3 Kinds of Strabismus
- Esotropia
- Exotropia
- Hypertropia
321. Esotropia
- Eye turns in towards nose
333 Types of Esotropia
- Infantile (congenital)
- Develops in first 3 months of life
- Surgery usually recommendedalong 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
343 Types of Esotropia
- Partially Accommodative
- Combination of
- accommodative dysfunction and
- muscle imbalance
- Glasses and vision therapy wont completely
correct eye turn - Surgery may be required for best binocularity
35If you see Esotropia
- Refer to pediatric optometrist or ophthalmologist
- Sooner the better for best chance of good vision
362. Exotropia
- Eye turns outward
- Congenitalpresent 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
372. 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
383. 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
392 Types
- Congenital
- Most common type
- Patients can compensate for years by tilting head
- Can be discovered by looking at childhood photos
402 Types
- Acquired
- TraumaExtra-ocular muscle trapped by orbital
fracture - Vascular infarctSystemic 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
- NeurologicalIn rare cases a tumor or aneurysm
can cause symptoms
41LAZY EYE
42Lazy Eye - Amblyopia
- Decreased vision uncorrectable by glasses or
contactsnot due to eye disease - For some reason, brain doesnt fully acknowledge
images seen
43Lazy Eye - Amblyopia
- 3 Types of Amblyopia
- Strabismic
- Anisometropic
- Stimulus deprivation
441. Strabismic Amblyopia
- One eye deviates from other and sends conflicting
info to brain - Brain doesnt like to see doubleso 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
45Treatment
- If caught early, treatment can teach brain how to
see better - Vision therapy/patching
- Glasses
- Surgical re-alignment
- Early vision screenings are critical!
462. Anisometropic Amblyopia
- Anisometropiasignificant difference in Rx
between eyes - Commonly one eye more farsighted
- Farsighted eye works hard to see clearlyand
sometimes gives up - Brain relies on info from other eye
472. Anisometropic Amblyopia
- If not caught, one eye wont learn to see as well
as other - Vision therapy and glasses are both beneficial
- Sooner the better
483. Deprivational Amblyopia
- Any opacity in visual pathway can be devastating
to developing visual system - Congenital cataracts
- Corneal opacities
- Ptosis (droopy eyelid)
- Other media opacities
49EXTERNALCONDITIONS
50Common External Ocular Conditions
- Blepharitis
- Hordeolumstye
- Preseptal cellulitis
- Orbital cellulitis
- Pterygium
- Corneal ulcer
- Conjunctivitis
- Viral pink eye
- Adenovirus
- Bacterial
- Allergic
- Hyperacute
- Chlamydial
51Blepharitis
- Inflammation of eyelids (anterior or posterior)
- Symptoms
- Itching
- Burning
- Crusting
- Dry eye sensation
- Foreign body sensation
52Blepharitis
- 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
53Hordeolum (stye)
- Abscessed meibomian gland
- Raised, tender nodule
- Often gets larger over days to a week
54Hordeolum
- 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 dont penetrate abscess
- Oral antibiotics if no response to traditional
treatment
55Preseptal Cellulitis
- Bacterial infection of eyelid anterior to orbital
septum - Can arise from
- concurrent sinus infection
- penetrating lid trauma
- dental infection
- hordeolum
- insect bite
56Preseptal 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
57Orbital 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
58Orbital Cellulitis
- Signs
- Tender, warm periorbital lid edema
- Proptosis
- Painful ophthalmoplegia
- Decreased vision
- Severe malaise, fever and pain
- Treatment
- Medical emergency
- Hospitalization with IV antibiotics
- Consider orbit/head CT to look for abscess
- Consult pediatrician or infectious disease
specialist
59Preseptal 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
60Pterygium
- Triangular-shaped growth of conjunctival tissue
onto cornea - Causes
- UV exposure
- Dryness
- Irritants
- Smoke
- Dust
61Pterygium
- 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
62Corneal Ulcer
- Infection of cornea
- Bacterial
- Fungal
- Acanthamoeba
- Causes
- SCL wearer
- Trauma
- Compromised cornea from pre-existing condition
63Corneal Ulcer
- 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!
64Conjunctivitis (red eye)
- Various Causes
- Viral/Adenovirus
- Bacterial
- Allergic
- Chlamydial
- Herpetic
- Toxic
65Conjunctivitis
- Signs
- Irritation
- Burning/stinging
- Watering
- Photophobia
- Pain or foreign body sensation
- Itching
- Discharge
- Watery
- Mucoid
- Mucopurulent
- Purulent
661. 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
671. 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
682. 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
692. Adenoviral Conjunctivitis
- Signs
- Watering
- Conjunctival follicles
- Subconjunctival hemorrhages
- Chemosis
- Pseudomembranes
- Lymphadenopathy
- Keratitis
703. Bacterial Conjunctivitis
- Common, especially in children
- Usually self-limiting
- Signs/symptoms
- Acute redness
- Burning/grittiness
- Mucopurulent discharge
- Lids stuck shut in morning
713. 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
- Polytrimpolymyxin trimethoprim
- Fluoroquinolones like Ocuflox or Ciloxan
725. Hyperacute Conjunctivitis
- Cause
- Sexually transmitted
- Neisseria gonorrhoeae
- Signs
- Swollen, tender lids
- Copious purulent discharge
- Significant conjunctival redness and swelling
- Lymphadenopathy
735. Hyperacute Conjunctivitis
- Treatment
- Lavage
- Take scrapings for culture and sensitivity
testing - Patients usually hospitalized and started on IM
Ceftriaxone - Topical antibiotics not effective
746. 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
756. Chlamydial Conjunctivitis
- Patients can have concomitant genital infection
(could be asymptomatic) - Refer for work-up if necessary
- Treatment
- OralAzithromycin 1g, doxycycline 100mg bid x 7
days, erythromycin 500mg qid x 7 days. Also
need to tx partners! - Topicalerythromycin, tetracycline, or
sulfacetamide ung bid-tid x 2-3 weeks
764. Allergic Conjunctivitis
- Can be seasonal or acute
- Signs/symptoms
- Itching is hallmark
- Conjunctival redness
- Chemosis
- Lid edema
- Thin, watery discharge
- No palpable preauricular nodes
774. 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
78INTERNALCONDITIONS
79Internal Ocular Conditions
- Glaucoma
- Cataracts
- Macular Degeneration
- Retinal detachment
80Glaucoma
- Progressive loss of Nerve fiber layer at ONH
(increased cupping) - Can lead to peripheral visual field loss
- Sometimes caused by elevated intraocular pressure
81Glaucoma
- 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
82Glaucoma
- Monitoring
- IOP
- ONH appearance
- Visual field testing
- Newer methods include
- HRT (Heidelberg Retinal Tomograph II)
- GDx Nerve Fiber Analyzer
- Genetic testing
83Glaucoma
- IOP reduction is mainstay of treatment
- Decrease aqueous production
- B-blockers
- Alpha-agonists
- Carbonic anhydrase inhibitors
- Increase uveoscleral outflow
- prostaglandin analogs
84Cataract
- Clouding of natural lens
- Patients experience
- Blurred/dim vision
- Glare, especially at night
- Halos around lights
- Doubling or ghost images of objects
85Etiology
- Everyone develops them if they live long enough!
- Types of cataracts
- Age-relatedsenile
- Traumablunt or perforating injury
- Systemic conditionsdiabetes
- Medicationssteroids
86Main Types
- Age-related
- Nuclear sclerotic
- Cortical spokes
- Posterior sub-capsular
- Mature cataract
87Treatment
- Surgery
- When loss of vision interferes with daily
activities - Driving
- Reading
- Hobbies
88Outpatient 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
89Secondary Cataract
- Cloudiness forms on posterior capsule after
cataract surgery - 30-50 of patients
- YAG laser used to create opening
- Vision quickly restored
90Macular Degeneration
- 1 cause of blindness in Americans over age 65
91Pathophysiology
- Causes not well understood
- Theorized link to
- UV light exposure
- subsequent release of free radicals
- oxidation within retinal tissues
- Another theoryareas of decreased vascular
perfusion in retina, lead to cell death
92Two Types
- Dry (atrophic)
- 90 of those diagnosed
- Wet (exudative)
- 10 of those diagnosed
- But accounts for 90 of blindness caused by
disease
93Symptoms
- None
- Blurred vision
- Metamorphopsiastraight lines appear wavy or
distorted - Scotomasmissing areas in vision
94Dry 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
95Wet 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
96Treatment for Dry Form
- Regular eye exams
- Careful discussion regarding family history
- Education
- UV protection
- Antioxidants
- AREDS
- PreserVision
- Stop smoking
97Treatment for Wet Form
- Refer to retinal specialist
- Photocoagulation
- Photo-dynamic therapy (PDT)
- Submacular surgery
- Macular translocation
- Anti-angiogenic drug therapy
98Retinal Detachment
- Several types
- Rhegmatogenouscaused by break in retina
- Exudativecaused by fluid accumulation beneath
retina - Tractionalproliferative fibrovascular vitreal
strands
99Signs Symptoms
- Flashing lights in peripheral vision
- New floatersblack spots or cobwebs
- Peripheral scotomadark shadow or curtain
blocking vision
100Emergency
- Patients with these symptoms must see eyecare
provider immediately - Additional risk factors
- Highly nearsighted
- Diabetic
- Recent trauma/injury
101Treatment
- Laser photocoagulation or cryotherapy
- Pneumatic retinopexygas bubble to tamponade
retina back into place - Scleral buckle
- Silicone oil
102DIABETICRETINOPATHY
103Diabetic Retinopathy
- Diabetes affects retinal micro-vasculature
- One of leading causes of blindness among ages
20-64
104Progression
- 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
105Symptoms
- Fluctuating vision
- Blurred vision
- Distortion
- Sudden loss of vision
106Treatment
- Control blood sugar
- Refer to retinal specialist when vision
threatened - PRP (pan-retinal photocoagulation)
- Focal laser
- Vitrectomy
- Retinal detachment repair
107Working Together
- Together we can catch vision threatening
conditions earlier - Glad to answer questions
- Always happy to take your calls
108Questions?