From Carrots to Keratitis: An Eye Update for Non-Ophthalmologists

Rachel Bishop, MD, MPHCDR, USPHS

Chief, Consult Service, National Eye Institute, NIH

Objects in mirror are closer than they appear.

Objectives

• Update: what’s new for the “Big 4”?– Glaucoma– Diabetic eye disease– Macular degeneration– Cataract

• A few words on preventive ophthalmology

• Managing acute eye problems

Normal Anatomy

Glaucoma

Glaucoma Management: What’s new? Not much.• Prevention: none• Treatments– Medical: pressure lowering drops– Laser to the trabecular meshwork– Surgery: shunt

• Good news: most patients maintain vision

Diabetic Retinopathy

non-proliferative proliferative

Diabetic Retinopathy Management

• Prevention: control chronic medical conditions

• Treatment– Macular edema:

focal laser

– Proliferative retinopathy: scatter laser

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Diabetic Retinopathy

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• NEW: VEGF inhibitors– Bevacizumab (Avastin)– Ranibizumab (Lucentis)– Aflibercept (Eylea)

• Intravitreal injection

Age-Related Macular Degeneration

Dry Neovascular (“Wet”)

Macular Degeneration: Management

Dry AMD: Prevention– NEW: anti-oxidants

Neovascular AMD– NEW: VEGF inhibitors

pre: 20/100 post: 20/50

Cataract • Prevention: UV protection (but not really…) • Treatment: surgery• NEW: multifocal and accommodating

intraocular lenses

Refractive Error

• Half of Americans– myopia, hyperopia, astigmatism– excludes presbyopia

• 11 million Americans have impaired vision (<20/40) due to uncorrected refractive error

• Accounts for 80% of vision impairment

Preventive Ophthalmology

Preventive Lifestyle Tips: Not Much New

• Dilated eye exams

• “Healthy Living”

• Protective eyewear: safety, UV-blocking

Managing Acute Ocular Problems• The red eye• Ocular trauma• Flashes and

floaters• Acute loss of vision

The Tool Box

DDx: The Red Eye• Cellulitis• Conjunctivitis • Episcleritis and scleritis• Subconjunctival hemorrhage• Corneal abrasion • Corneal or conjunctival foreign body• Corneal ulcer• Keratitis• Angle closure glaucoma• Uveitis

Cellulitis• Pre-septal vs. orbital• Pain with eye

movements?• Uncertain? CT orbits

Conjunctivitis

• Majority: viral

• Purulent discharge– Bacterial– Topical ABX (NOT gent)

• Other– allergic– irritant– dry eye– blepharitis

Episcleritis/Scleritis

• Often sectoral• Episcleritis– Minimal pain– Blanches with neo– Treatment: NSAIDS

• Painful? …Scleritis– Refer

Sub-Conjunctival Hemorrhage

Treatment: observation only

Corneal Abrasion

• Treatment: ABX ointment and close f/u• If large, refer to ophthalmology• Do not patch

Corneal or Conjunctival Foreign Body

• Remove with Q-tip or small clean instrument

• Topical ABX and f/u until healed

• Refer if rust or deep penetration

Corneal Ulcer

• Contact lens user?– Think: pseudomonas

• Refer • Initiate ABX

treatment if referral will be delayed

• Close follow-up

Angle Closure Glaucoma

• Start pressure lowering drops and Diamox • Urgent referral• Treatment– peripheral laser iridotomy

Uveitis

• History of same?• Auto-immune DZ?• Ciliary flush?• Refer

Ocular Trauma

Blunt Ocular Trauma• Assess vision

(if possible)• Refer if…– Floaters and/or flashes– Change in vision– Eye too swollen to

examine– Blood in eye– Suspected blow-out FX

Suspected Penetrating Trauma: “Ruptured Globe”

• Protect the eye • NPO• Urgent referral

Chemical Injury• Defer vision check and

detailed history• Copious irritation• Antibiotic ointment• Urgent referral

Floaters and Flashes

• Chronic floaters– Benign vitreous changes

• New floaters– Refer

• Photopsias– Urgent referral

Acute Loss of Vision

• Refer urgently to ophthalmology

• Differential diagnosis is extensive– Acute angle closure glaucoma– Retinal vascular disease– Vitreous or retinal hemorrhage– Retinal detachment– Optic neuropathy– Optic neuritis– CNS disease

Concluding Pearls• Most vision impairment is correctable or

avoidable• Dilated eye exams necessary for detection of

eye disease • Urgent referral if significant change in vision or

trauma • If in doubt: email a picture to your favorite

ophthalmologist!

QUESTIONS?

Objectives

• Update: what’s new for the “Big 4”?– Glaucoma: 2.2million – Diabetic eye disease: 5.3 million – Macular degeneration: 1.8 million– Cataract: 20 million

• A few words on preventive ophthalmology

• Managing acute eye problems

Herpetic Keratitis

• Herpes simplex keratitis– Risk of corneal scarring– Ophtho referral for

aggressive Rx• Herpes zoster (VZV)– Acyclovir– Artificial tears– Erythromycin ointment

The Assessment• Chief complaint • Ocular and medical history• VISION• Pupil exam• Visual fields: less important• Ocular motility • How does the eye look?