From Carrots to Keratitis: An Eye Update for Non-Ophthalmologists Rachel Bishop, MD, MPH CDR, USPHS...
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Transcript of From Carrots to Keratitis: An Eye Update for Non-Ophthalmologists Rachel Bishop, MD, MPH CDR, USPHS...
![Page 1: From Carrots to Keratitis: An Eye Update for Non-Ophthalmologists Rachel Bishop, MD, MPH CDR, USPHS Chief, Consult Service, National Eye Institute, NIH.](https://reader036.fdocuments.us/reader036/viewer/2022062803/56649c9e5503460f9495ebf6/html5/thumbnails/1.jpg)
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.
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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
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Normal Anatomy
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Glaucoma
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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
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Diabetic Retinopathy
non-proliferative proliferative
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Diabetic Retinopathy Management
• Prevention: control chronic medical conditions
• Treatment– Macular edema:
focal laser
– Proliferative retinopathy: scatter laser
8
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Diabetic Retinopathy
9
• NEW: VEGF inhibitors– Bevacizumab (Avastin)– Ranibizumab (Lucentis)– Aflibercept (Eylea)
• Intravitreal injection
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Age-Related Macular Degeneration
Dry Neovascular (“Wet”)
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Macular Degeneration: Management
Dry AMD: Prevention– NEW: anti-oxidants
Neovascular AMD– NEW: VEGF inhibitors
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pre: 20/100 post: 20/50
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Cataract • Prevention: UV protection (but not really…) • Treatment: surgery• NEW: multifocal and accommodating
intraocular lenses
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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
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Preventive Ophthalmology
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Preventive Lifestyle Tips: Not Much New
• Dilated eye exams
• “Healthy Living”
• Protective eyewear: safety, UV-blocking
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Managing Acute Ocular Problems• The red eye• Ocular trauma• Flashes and
floaters• Acute loss of
vision
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The Tool Box
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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
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Cellulitis• Pre-septal vs. orbital• Pain with eye
movements?• Uncertain? CT orbits
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Conjunctivitis
• Majority: viral
• Purulent discharge– Bacterial– Topical ABX (NOT gent)
• Other– allergic– irritant– dry eye– blepharitis
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Episcleritis/Scleritis
• Often sectoral• Episcleritis– Minimal pain– Blanches with neo– Treatment: NSAIDS
• Painful? …Scleritis– Refer
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Sub-Conjunctival Hemorrhage
Treatment: observation only
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Corneal Abrasion
• Treatment: ABX ointment and close f/u• If large, refer to ophthalmology• Do not patch
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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
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Corneal Ulcer
• Contact lens user?– Think: pseudomonas
• Refer • Initiate ABX
treatment if referral will be delayed
• Close follow-up
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Angle Closure Glaucoma
• Start pressure lowering drops and Diamox • Urgent referral• Treatment– peripheral laser iridotomy
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Uveitis
• History of same?• Auto-immune DZ?• Ciliary flush?• Refer
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Ocular Trauma
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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
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Suspected Penetrating Trauma: “Ruptured Globe”
• Protect the eye • NPO• Urgent referral
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Chemical Injury• Defer vision check and
detailed history• Copious irritation• Antibiotic ointment• Urgent referral
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Floaters and Flashes
• Chronic floaters– Benign vitreous changes
• New floaters– Refer
• Photopsias– Urgent referral
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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
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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!
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QUESTIONS?
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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
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Herpetic Keratitis
• Herpes simplex keratitis– Risk of corneal scarring– Ophtho referral for
aggressive Rx
• Herpes zoster (VZV)– Acyclovir– Artificial tears– Erythromycin ointment
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The Assessment• Chief complaint • Ocular and medical history• VISION• Pupil exam• Visual fields: less important• Ocular motility • How does the eye look?