ico clinical guidelines

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November 2010

ICO International Clinical Guidelines

This document contains 24 International Clinical Guidelines defined by theInternational Council of Ophthalmology ICO!"

The Guidelines are designed to be translated and adapted by ophthalmologicsocieties to help ophthalmologists assess ho# they are treating patients" They areintended to serve a supportive and educational role and ultimately to improve the$uality of eye care for patients"

%elo# is a list of the Guidelines available #ith lin&s to each Guideline in thisdocument' follo#ed by the (reface to the Guidelines" )lso see the Introduction to

the ICO International Clinical Guidelines###"icoph"org*enhancing+eyecare*international+clinical+guidelines"html "

,or the latest information on the ICO Clinical Guidelines and to do#nloadindividual Guidelines as separate (-, files' see the ###"icoph"orgresourceslistings"

.ist of Guidelines )vailable

)ge/elated acular -egeneration Initial and ,ollo#/up valuation!

)ge/elated acular -egeneration anagement ecommendations!

)mblyopia Initial and ,ollo#/up valuation!

%acterial 3eratitis Initial valuation!

%acterial 3eratitis anagement ecommendations!

%lepharitis Initial and ,ollo#/up valuation!

Cataract Initial and ,ollo#/up valuation!

Conunctivitis Initial valuation and Therapy!

-iabetic etinopathy Initial and ,ollo#/up valuation!

-iabetic etinopathy anagement ecommendations!

-ry ye 5yndrome Initial valuation!

-ry ye 5yndrome anagement ecommendations!

sotropia Initial and ,ollo#/up valuation! 6otropia Initial and ,ollo#/up valuation!

ye -isease in .eprosy Initial valuation and anagement!

Idiopathic acular 7ole Initial valuation and Therapy!

3eratorefractive 5urgery Initial and ,ollo#/up valuation!

Ocular 7I8*)I-5 elated -iseases Initial and ,ollo#/up valuation!

(osterior 8itreous -etachment' etinal %rea&s and .attice -egeneration

Initial and ,ollo#/up valuation!
http://www.icoph.org/enhancing_eyecare/international_clinical_guidelines.htmlhttp://www.icoph.org/http://www.icoph.org/enhancing_eyecare/international_clinical_guidelines.htmlhttp://www.icoph.org/


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(rimary Open/)ngle Glaucoma Initial valuation!

(rimary Open/)ngle Glaucoma ,ollo#/up valuation!

(rimary Open/)ngle Glaucoma 5uspect Initial and ,ollo#/up valuation!

(rimary )ngle Closure Initial valuation and Therapy!

Trachoma

(reface to the Guidelines

International Clinical Guidelines are prepared and distributed by the InternationalCouncil of Ophthalmology"

These Guidelines are to serve a supportive and educational role forophthalmologists #orld#ide" These guidelines are intended to improve the $ualityof eye care for patients" They have been adapted in many cases from similardocuments %enchmar&s of Care! created by the )merican )cademy ofOphthalmology based on their (referred (ractice (atterns"

9hile it is tempting to e$uate these to 5tandards' it is impossible and inappropriateto do so" The multiple circumstances of geography' e$uipment availability' patientvariation and practice settings preclude a single standard"

Guidelines on the other hand are a clear statement of e6pectations" These includecomments of the preferred level of performance assuming conditions that allo# theuse of optimum e$uipment' pharmaceuticals and*or surgical circumstances"

Thus' a basic e6pectation is created and if the situation is optimum' the optimumfacets of diagnosis' treatment and follo# up may be employed" 6cellent'appropriate and successful care can also be provided #here optimum conditionsdo not e6ist"

5imply follo#ing the Guidelines does not guarantee a successful outcome" It isunderstood that' given the uni$ueness of a patient and his or her particularcircumstance' physician udgment must be employed" This can result in amodification in application of a guideline in individual situations"

edical e6perience has been relied upon in the preparation of these guidelines'and they are #henever possible' evidence/based" This means these Guidelinesare based on the latest available scientific information" The ICO is committed toprovide updates of these guidelines on a regular basis appro6imately every t#o tothree years!"

)lso see the Introduction to the ICO International Clinical Guidelines at###"icoph"org*guide*guideintro"html and the list of other Guidelines at###"icoph"org*guide*guidelist"html"!

ICO International Clinical Guidelines' 2010(age 2
http://www.icoph.org/guide/guideintro.htmlhttp://www.icoph.org/guide/guideintro.htmlhttp://www.icoph.org/guide/guideintro.htmlhttp://www.icoph.org/guide/guideintro.htmlhttp://www.icoph.org/guide/guideintro.html


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ICO International Clinical Guidelines' 2010(age :


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Age-Related Macular Degeneration(Initial and Follow-up Evaluation)

(Ratings:); ost important' %; oderately important' C; elevant but not criticaltrengt! o" Evidence: I; 5trong' II; 5ubstantial but lac&s some of I' III; consensus

of e6pert opinion in absence of evidence for I < II!

Initial 6am 7istory 3ey elements!

5ymptoms metamorphopsia' decreased vision! (A:II)

edications and nutritional supplements (#:III)

Ocular history (#:II)

5ystemic history any hypersensitivity reactions! (#:II)

,amily history' especially family history of )- (#:II)

5ocial history' especially smo&ing (#:II)

Initial (hysical 6am 3ey elements! 8isual acuity (A:III)

5tereo biomicroscopic e6amination of the macula (A:III)

)ncillary Tests

Intravenous fundus fluorescein angiography in the clinical setting of )- isindicated; (A:I)

o #hen patient complains of ne# metamorphopsia

o #hen patient has une6plained blurred vision

o #hen clinical e6am reveals elevation of the ( or retina' subretinalblood' hard e6udates or subretinal fibrosis

o to detect the presence of and determine the e6tent' type' si=e' and

location of C8N and to calculate the percentage of the lesioncomposed of or consisting of classic CN8

o to guide treatment laser photocoagulation surgery or verteporfin

(-T!o to detect persistent or recurrent CN8 follo#ing treatment

o to assist in determining the cause of visual loss that is not e6plained

by clinical e6am

ach angiographic facility must have a care plan or an emergency plan and aprotocol to minimi=e the ris& and manage any complications" (A:III)



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,ollo#/up 6am 7istory

8isual symptoms' including decreased vision and metamorphopsia (A:II)

Changes in medications and nutritional supplements (#:III)

Interval ocular history (#:III)

Interval systemic history (#:III)

Changes in social history' especially smo&ing(#:II)

,ollo#/up (hysical 6am

8isual acuity (A:III)

5tereo biomicroscopic e6amination of the fundus (A:III)

,ollo#/up Treatment after Neovascular )-

-iscuss ris&s' benefits and complications #ith the patient and obtain

informed consent (A:III)

6amine patients treated #ith ranibi=umab intravitreal inections

appro6imately 4 #ee&s after treatment (A:III)

6amine patients treated #ith bevaci=umab intravitreal inections

appro6imately 4 to > #ee&s after treatment (A:III)

6amine patients treated #ith pegaptanib sodium inection appro6imately ?

#ee&s follo#ing the treatment (A:III)

6amine and perform fluorescein angiography at least every : months for

up to 2 years after verteporfin (-T (A:I)

6amine patients treated #ith thermal laser photocoagulation appro6imately

2 to 4 #ee&s after treatment and then at 4 to ? #ee&s (A:III)

Optical coherence tomography' (A:III) fluorescein angiography'(A:I) and

fundus photography (A:III) may be helpful to detect signs of e6udation andshould be used #hen clinically indicated

5ubse$uent e6aminations should be performed as indicated depending on

the clinical findings and the udgment of the treating ophthalmologist (A:III)

(atient ducation

ducate patients about the prognosis and potential value of treatment as

appropriate for their ocular and functional status (A:III)

ncourage patients #ith early )- to have regular dilated eye e6ams for

early detection of intermediate )- (A:III)

ducate patients #ith intermediate )- about methods of detecting ne#symptoms of C8N and about the need for prompt notification to anophthalmologist (A:III)

Instruct patients #ith unilateral disease to monitor their vision in their fello#

eye and to return periodically even in absence of symptoms' but promptlyafter onset of ne# or significant visual symptoms (A:III)

Instruct patients to report symptoms suggestive of endophthalmitis'

including eye pain or increased discomfort' #orsening eye redness' blurredor decreased vision' increased sensitivity to light' or increased number of

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floaters promptly (A:III)

ncourage patients #ho are currently smo&ing to stop (A:I) because there

are observational data that support a causal relationship bet#een smo&ingand )- (A:II)and other considerable health benefits of smo&ing cessation

efer patients #ith reduced visual function for vision rehabilitation see

###"aao"org*smartsight! and social services (A:III)

A )dapted from the )merican )cademy of Ophthalmology 5ummary %enchmar&s'November 2010 ###"aao"org!

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Age-Related Macular Degeneration(Manage$ent Reco$$endations)



Treatment ecommendations and ,ollo#/up (lans for

)ge/elated acular -egeneration

Reco$$ended %reat$entDiagnoses Eligi&le "or

%reat$entFollow-up Reco$$endations

Observation #ith no medicalor surgical therapies (A:I)

No clinical signs of )-)-5 category 1!

arly )- )-5category 2!

)dvanced )- #ithbilateral subfovealgeographic atrophy ordisciform scars

)s recommended in the Comprehensive )dultedical ye valuation ((( (A:III)

eturn e6am at ? to 24 months if asymptomatic prompt e6am for ne# symptoms suggestive of C(A:III)

No fundus photos or fluorescein angiographyunless symptomatic (A:I)

)ntio6idant vitamin andmineral supplements asrecommended in the )-5reports (A:I)

Intermediate )-)-5 category :!

)dvanced )- in oneeye )-5 category 4!

onitoring of monocular near visionreading*)msler grid! (A:III)

eturn e6am at ? to 24 months if asymptomatic prompt e6am for ne# symptoms suggestive of C

(A:III)

,undus photography as appropriate

,luorescein angiography if there is evidence ofedema or other signs and symptoms of C8N

anibi=umab intravitrealinection 0"@ mg asrecommended in ranibi=umabliterature (A:I)

5ubfoveal CN8 (atients should be instructed to report anysymptoms suggestive of endophthalmitis promptincluding eye pain or increased discomfort'#orsening eye redness' blurred or decreasedvision' increased sensitivity to light' or increasednumber of floaters (A:III)

eturn e6am appro6imately 4 #ee&s aftertreatmentB subse$uent follo#/up depends on theclinical findings and udgement of the treatingophthalmologist (A:III)


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%evaci=umab intravitrealinection as described inpublished reports (A:III)

The ophthalmologist shouldprovide appropriate informedconsent #ith respect to theoff/label status (A:III)

5ubfoveal CN8 (atients should be instructed to report anysymptoms suggestive of endophthalmitis promptincluding eye pain or increased discomfort'

#orsening eye redness' blurred or decreasedvision' increased sensitivity to light' or increasednumber of floaters (A:III)

eturn e6am appro6imately 4 to > #ee&s aftertreatmentB subse$uent follo#/up depends on theclinical findings and udgement of the treatingophthalmologist (A:III)


(egaptanib sodium

intravitreal inection asrecommended in pegaptanibsodium literature (A:I)

5ubfoveal CN8' ne# orrecurrent' forpredominantly classiclesions D12 (5 discarea in si=e

inimally classic' oroccult #ith no classiclesions #here the entirelesion is D12 disc areas insi=e' subretinalhemorrhage associated#ith C8N comprises

D@0E of lesion' and*orthere is lipid present'and*or the patient haslost 1@ or more letters ofvisual acuity during theprevious 12 #ee&s

(atients should be instructed to report anysymptoms suggestive of endophthalmitis promptincluding eye pain or increased discomfort'#orsening eye redness' blurred or decreasedvision' increased sensitivity to light' or increasednumber of floaters (A:III)

eturn e6am #ith retreatments every ? #ee&s aindicated (A:III)


(-T #ith verteporfin asrecommended in the T)( and8I( reports (A:I)

5ubfoveal CN8' ne# orrecurrent' #here theclassic component isF@0E of the lesion andthe entire lesion is D@400

microns in greatest lineardiameter

Occult CN8 may beconsidered for (-T #ithvision D20*@0 or if theC8N is D4 (5 discareas in si=e #hen thevision is F20*@0

eturn e6am appro6imately every : months untistable' #ith retreatments as indicated (A:III)


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Thermal laserphotocoagulation surgery asrecommended in the (5reports (A:I)

6trafoveal classic CN8'ne# or recurrent

ay be considered foru6tapapillary C8N

eturn e6am #ith fluorescein angiographyappro6imately 2 to 4 #ee&s after treatment' andthen at 4 to ? #ee&s and thereafter depending o

the clinical and angiographic findings (A:III)

etreatments as indicated


)- )ge/related acular -egenerationB )-5 )ge/related ye -isease 5tudyB CN8 choroidal neovasculari=ationB (5 acular (hotocoagulation 5tudyB (-T photodynamictherapyB T)( Treatment of )ge/related acular -egeneration #ith (hotodynamic TherapyB 8I( 8erteporfin in (hotodynamic Therapy


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A$&l'opia (Initial and Follow-up Evaluation)

(Ratings:); ost important' %; oderately important' C; elevant but not criticaltrengt! o" Evidence: I; 5trong' II; 5ubstantial but lac&s some of I' III; consensusof e6pert opinion in absence of evidence for I < II!


Ocular symptoms and signs (A:III)

Ocular history (A:III)

5ystemic history' including revie# of prenatal' perinatal' and postnatal

medical factors (A:III)

,amily history' including eye conditions and relevant systemic diseases

(A:III)

Initial (hysical 6am 3ey elements!

)ssessment of visual acuity and fi6ation pattern (A:III)

Ocular alignment and motility (A:III)

ed refle6 or binocular red refle6 %rc&ner! test (A:III)

(upil e6amination (A:III)

6ternal e6amination (A:III)

)nterior segment e6amination (A:III)

Cycloplegic retinoscopy*refraction (A:III)

,unduscopic e6amination (A:III)

%inocularity*stereoacuity testing (A:III)

Care anagement

Choose treatment based on patientJs ageB visual acuityB compliance #ith

previous treatmentB and physical' social' and psychological status" (A:III)

Treatment goal is to achieve e$uali=ation*normali=ation of fi6ation patterns

or visual acuity" (A:III)

Once ma6imal visual acuity has been obtained' treatment should be tapered

and eventually stopped" (A:III)

,ollo#/up valuation

,ollo#/up visits should include;

o Interval history (A:III)

o Tolerance to therapy (A:III)

o 6aminations and testing as indicated (A:III)



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)mblyopia ,ollo#/up valuation Intervals -uring )ctive Treatment (eriod(A:III)

Age('ears)

ig!- ercentageOcclusion

(*+, or $ore o"

waing !ours./ 0!ours per da')

1ow-ercentageOcclusion

(2*+, o" waing

!ours.20 !ours perda') or enali3ation

Maintenance%reat$ent or

O&servation

0/1 1/4 #ee&s 2/> #ee&s 1/4 months

1/2 2/> #ee&s 2/4 months 2/4 months

2/: :/12 #ee&s 2/4 months 2/4 months

:/4 4/1? #ee&s 2/? months 2/? months

4/@ 4/1? #ee&s 2/? months 2/? months

@/ ?/1? #ee&s 2/? months 2/? months

/H >/1? #ee&s :/? months :/12 months

(atient ducation

1K -iscuss diagnosis' severity of disease' prognosis and treatment plan #ithpatient' parents and *or caregivers" (A:III)

2K 6plain the disorder and recruit the family in a collaborative approach totherapy" (A:III)




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#acterial 4eratitis (Initial Evaluation)



Initial 6am 7istory

Ocular symptoms (A:III)

Contact lens history (A:II)

evie# of other ocular history (A:III)

evie# of other medical problems and systemic medications (A:III)

Current and recently used ocular medications (A:III)

edication allergies (A:III)

Initial (hysical 6am


General appearance of patient (#:III)

,acial e6amination (#:III)

yelids and eyelid closure (A:III)

Conunctiva (A:III)

Nasolacrimal apparatus (#:III)

Corneal sensation (A:III)

5lit/lamp biomicroscopy

o yelid margins (A:III)

o Conunctiva (A:III)

o 5clera (A:III)

o Cornea (A:III)

o )nterior chamber (A:III)

o )nterior vitreous(A:III)

Contralateral eye (A:III)

-iagnostic Tests

anage maority of community/ac$uired cases #ith empiric therapy and

#ithout smears or cultures" (A:III) Indications for smears and cultures;

o 5ight/threatening or severe &eratitis of suspected microbial origin

prior to initiating therapy(A:III)o ) large corneal infiltrate that e6tends to the middle to deep stroma

(A:III)o Chronic in nature (A:III)

o Lnresponsive to broad spectrum antibiotic therapy (A:III)

o Clinical features suggestive of fungal' amoebic' or mycobacterial



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&eratitis (A:III)

The hypopyon that occurs in eyes #ith bacterial &eratitis is usually sterile'

and a$ueous or vitreous taps should not be performed unless there is ahigh suspicion of microbial endophthalmitis" (A:III)

Corneal scrapings for culture should be inoculated directly onto appropriate

culture media to ma6imi=e culture yield" (A:III)" If this is not feasible' place

specimens in transport media" (A:III)" In either case' immediately incubatecultures or ta&e promptly to the laboratory" (A:III)

Care anagement

Topical antibiotic eye drops are preferred method in most cases" (A:III)

Lse topical broad/spectrum antibiotics initially in the empiric treatment of

presumed bacterial &eratitis" (A:III)

,or central or severe &eratitis e"g"' deep stromal involvement or an infiltrate

larger than 2 mm #ith e6tensive suppuration!' use a loading dose e"g"'every @ to 1@ minutes for the first 1 to : hours!' follo#ed by fre$uent

applications e"g"' every :0 minutes to 1 hour around the cloc&!" (A:III),orless severe &eratitis' a regimen #ith less fre$uent dosing is appropriate"

(A:III)

Lse systemic therapy for gonococcal &eratitis" (A:II)

In general' modify initial therapy #hen there is a lac& of improvement or

stabili=ation #ithin 4> hours" (A:III)

,or patients treated #ith ocular topical corticosteroids at time of

presentation of suspected bacterial &eratitis' reduce or eliminatecorticosteroids until infection has been controlled" (A:III)

9hen the corneal infiltrate compromises the visual a6is' may add topical

corticosteroid therapy follo#ing at least 2 to : days of progressiveimprovement #ith topical antibiotics" (A:III)Continue topical antibiotics athigh levels #ith gradual tapering" (A:III)

6amine patients #ithin 1 to 2 days after initiation of topical corticosteroid

therapy" (A:III)


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#acterial 4eratitis(Manage$ent Reco$$endations)



,ollo#/up valuation

,re$uency depends on e6tent of disease' but follo# severe cases initially at

least daily until clinical improvement or stabili=ation is documented" (A:III)

(atient ducation

Inform patients #ith ris& factors predisposing them to bacterial &eratitis of

their relative ris&' the signs and symptoms of infection' and to consult an

ophthalmologist promptly if they e6perience such #arning signs orsymptoms (A:III)

ducate about the destructive nature of bacterial &eratitis and need for strict

compliance #ith therapy" (A:III)

-iscuss possibility of permanent visual loss and need for future visual

rehabilitation"(A:III)

ducate patients #ith contact lenses about increased ris& of infection

associated #ith contact lens' overnight #ear' and importance of adherenceto techni$ues to promote contact lens hygiene" (A:III)

efer patients #ith significant visual impairment or blindness for vision

rehabilitation if they are not surgical candidates see

###"aao"org*smartsight!" (A:III)



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)ntibiotic Therapy of %acterial 3eratitis M);III

Organis$ Anti&iotic %opicalConcentration

u&con5unctivalDose

No organism identified

or multiple types oforganisms

Cefa=olin #ith

Tobramycin orgentamicinor ,luoro$uinolones

@0 mg*ml H/14

mg*ml: or @ mg*ml8ariousAA

100 mg in 0"@ ml

20 mg in 0"@ ml

Gram/positive Cocci Cefa=olin8ancomycinAAA%acitracinAAA,luoro$uinolonesA

@0 mg*ml1@/@0 mg*ml10'000 IL8ariousAA

100 mg in 0"@ ml2@ mg in 0"@ ml

Gram/negative rods Tobramycin or

gentamicinCefta=idime,luoro$uinolones

H/14 mg*ml

@0 mg*ml8ariousAA

20 mg in 0"@ ml

100 mg in 0"@ ml

Gram/negativeCocciAAAA

Ceftria6oneCefta=idime,luoro$uinolones

@0 mg*ml@0 mg*ml8ariousAA

100 mg in 0"@ ml100 mg in 0"@ ml

Nontuberculousycobacteria

)mi&acinClarithromycin

)=ithromycinAAAAA,luoro$uinolones

20/40 mg*ml10 mg*ml10 mg*ml8ariousAA

20 mg in 0"@ ml

Nocardia 5ulfacetamide)mi&acinTrimethoprim*5ulfametho6a=ole;Trimethoprim5ulfametho6a=ole

100 mg*ml20/40 mg*ml

1? mg*ml>0 mg*ml

20 mg in 0"@ ml

A,e#er gram/positive cocci are resistant to gatiflo6acin and mo6iflo6acin than otherfluoro$uinolones"AACiproflo6acin : mg*mlB gatiflo6acin : mg*mlB levoflo6acin 1@ mg*mlB mo6iflo6acin @mg*mlBoflo6acin : mg*ml' all commercially available at these concentrations"AAA,or resistant nterococcus and 5taphylococcus species and penicillin allergy"

8ancomycin and %acitracin have no gram/negative activity and should not be used as asingle agent empirically in treating bacterial &eratitis"AAAA 5ystemic therapy is necessary for suspected gonococcal infection"

AAAAA -ata from Chandra N5' Torres ,' 9inthrop 3." Cluster of ycobacterium chelonae&eratitis cases follo#ing laser in/situ &eratomileusis" )m Ophthalmol 2001B 1:2;>1H/:0"


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#lep!aritis (Initial and Follow-up Evaluation)


Initial 6am 7istory


Time of day #hen symptoms are #orse (A:III)

-uration of symptoms (A:III)

Lnilateral or bilateral presentation (A:III)

6acerbating conditions e"g"' smo&e' allergens' #ind' contact lens' lo#

humidity' retinoids' diet' alcohol consumption' eye ma&eup! (A:III)

5ymptoms related to systemic diseases e"g"' rosacea' allergy! (A:III)

Current and previous systemic and topical medications (A:III)

ecent e6posure to an infected individual e"g"' pediculosis! (C:III) Ocular historye"g"' previous intraocular and eyelid surgery' local trauma'

including mechanical' thermal' chemical' and radiation inury! (A:III)

5ystemic history e"g"' dermatological diseases' such as rosacea' atopic

disease' and herpes =oster ophthalmicus! (A:III)



6ternal e6amination

o 5&in(A:III)

o yelids (A:III)


o Tear film(A:III)

o )nterior eyelid margin (A:III)

o yelashes (A:III)

o (osterior eyelid margin(A:III)

o Tarsal conunctiva (A:III)

o %ulbar conunctiva (A:III)

o Cornea (A:III)

easurement of IO( (A:III)

-iagnostic Tests Cultures may be indicated for patients #ith recurrent anterior blepharitis #ith

severe inflammation as #ell as for patients #ho are not responding totherapy" (A:III)

%iopsy of the eyelid to e6clude the possibility of carcinoma may be indicated

in cases of mar&ed asymmetry' resistance to therapy or unifocal recurrentchala=ia that do not respond #ell to therapy" (A:II)

Consult #ith the pathologist prior to obtaining the biopsy if sebaceous cell

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carcinoma is suspected"(A:II)

Care anagement

Treat patients #ith blepharitis initially #ith a regimen of #arm compress and

eyelid hygiene" (A:III) ,or patients #ith staphylococcal blepharitis' a topical antibiotic such as

erythromycin can be prescribed to be applied one or more times daily or atbedtime on the eyelids for one or more #ee&s" (A:III)

,or patients #ith meibomian gland dysfunction' #hose chronic symptoms

and signs are not ade$uately controlled #ith eyelid hygiene' oraltetracyclines can be prescribed" (A:III)

) brief course of topical corticosteroids may be helpful for eyelid or ocular

surface inflammation" The minimal effective dose of corticosteroids shouldbe utili=ed and long/term corticosteroid therapy should be avoided ifpossible" (A:III)

,ollo#/up valuation



o 8isual acuity (A:III)

o 6ternal e6am (A:III)

o 5lit/lamp biomicroscopy (A:III)

If corticosteroid therapy is prescribed' re/evaluate patient #ithin a fe#

#ee&s todetermine the response to therapy' measure intraocular pressure' and

assess treatment compliance (A:III)

(atient ducation

Counsel patients about the chronicity and recurrence of the disease

process" (A:III)

Inform patients that symptoms can fre$uently be improved but are rarely

eliminated" (A:III)

)dvise patient that if #arm compress and eyelid hygiene treatment is

effective' symptoms often recur if treatment is stopped so may benecessary long term (A:III)


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Cataract (Initial and Follow-up Evaluation)


Initial 6am 7istory

5ymptoms (A:II)


5ystemic history (A:III)

)ssessment of visual functional status (A:II)


8isual acuity' #ith current correction (A:III)

easurement of %C8) #ith refraction #hen indicated! (A:III)

Ocular alignment and motility(A:III) (upil reactivity and function (A:III)


6ternal e6amination (A:III)

5lit/lamp biomicroscopy (A:III)

valuation of the fundusthrough a dilated pupil!(A:III)

)ssessment of relevant aspects of general and mental health (#:III)

Care anagement

Treatment is indicated #hen visual function no longer meets the patientJs

needs and cataract surgery provides a reasonable li&elihood ofimprovement" (A:II)

Cataract removal is also indicated #hen there is evidence of lens/induced

diseases or #hen it is necessary to visuali=e the fundus in an eye that hasthe potential for sight" (A:III)

5urgery should not be performed under the follo#ing circumstances; (A:III)

glasses or visual aids provide vision that meets the patientJs needsP' surgery#ill not improve visual functionB the patient cannot safely undergo surgerybecause of coe6isting medical or ocular conditionsB appropriatepostoperative care cannot be obtained"

Indications for second eye surgery are the same as for the first eye" (A:II)#ith consideration given to the needs for binocular function!

(reoperative Care

Ophthalmologist #ho is to perform the surgery has the follo#ing responsibilities;

6amine the patient preoperatively (A:III)

nsure that the evaluation accurately documents symptoms' findings and

indications for treatment (A:III)

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Inform the patient about the ris&s' benefits and e6pected outcomes of

surgery (A:III)

,ormulate surgical plan' including selection of an IO. (A:III)

evie# results of presurgical and diagnostic evaluations #ith the patient

(A:III)

,ormulate postoperative plans and inform patient of arrangements (A:III)

,ollo#/up valuation

7igh/ris& patients should be seen #ithin 24 hours of surgery" (A:III)

outine patients should be seen #ithin 4> hours of surgery" (A:III)

,re$uency and timing of subse$uent visits depend on refraction' visual

function' and medical condition of the eye"

ore fre$uent follo#/up usually necessary for high ris& patients"

Components of each postoperative e6am should include;

o Interval history' including ne# symptoms and use of postoperative

medications(A:III)o (atientJs assessment of visual functional status (A:III)

o )ssessment of visual function visual acuity' pinhole testing! (A:III)

o easurement of IO( (A:III)


Nd;Q)G .aser Capsulotomy

Treatment is indicated #hen vision impaired by posterior capsular

opacification does not meet the patientJs functional needs or #hen itcritically interferes #ith visuali=ation of the fundus" (A:III)

ducate about the symptoms of posterior vitreous detachment' retinal tearsand detachment and need for immediate e6amination if these symptoms arenoticed" (A:III)

(atient ducation

,or patients #ho are functionally monocular' discuss special benefits and

ris&s of surgery' including the ris& of blindness" (A:III)


ICO International Clinical Guidelines' 2010(age 1H


20/76

Con5unctivitis (Initial Evaluation and %!erap')


Initial 6am 7istory

Ocular symptoms and signs e"g"' itching' discharge' irritation' pain'

photophobia' blurred vision! (A:III)


6acerbating factors(A:III)

Lnilateral or bilateral presentation (A:III)

Character of discharge (A:III)

ecent e6posure to an infected individual (A:III)

Trauma mechanical' chemical' ultraviolet! (A:III)

Contact lens #ear e"g"' lens type' hygiene and use regimen! (A:III) 5ymptoms and signs potentially related to systemic diseases e"g"'

genitourinary discharge' dysuria' upper respiratory infection' s&in andmucosal lesions! (A:III)

)llergy' asthma' ec=ema (A:III)

Lse of topical and systemic medications (A:III)

Lse of personal care products (A:III)

Ocular history e"g"' previous episodes of conunctivitis (A:III) and previous

ophthalmic surgery! (#:III)

5ystemic history e"g"' compromised immune status' current and prior

systemic diseases! (#:III) 5ocial history e"g"' smo&ing' occupation and hobbies' travel and se6ual

activity!(C:III)



6ternal e6amination

o egional lymphadenopathy particularly preauricular!(A:III)

o 5&in(A:III)

o )bnormalities of the eyelids and adne6ae (A:III)

o

Conunctiva (A:III) 5lit/lamp biomicroscopy


o yelashes (A:III)

o .acrimal puncta and canaliculi(#:III)

o Tarsal and forniceal conunctiva (A:II)

o %ulbar conunctiva*limbus(A:II)

o Cornea (A:I)

o )nterior chamber*iris (A:III)



21/76

o -ye/staining pattern conunctiva and cornea! (A:III)

-iagnostic Tests

Cultures' smears for cytology and special stains are indicated in cases of

suspected infectious neonatal conunctivitis" (A: I) 5mears for cytology and special stains are recommended in cases of

suspected gonococcal conunctivitis"(A:II)

Confirm diagnosis of adult and neonate chlamydial conunctivitis #ith

immunodiagnostic test and*or culture" (A:III)

%iopsy the bulbar conunctiva and ta&e a sample from an uninvolved area

adacent to the limbus in an eye #ith active inflammation #hen ocularmucous membrane pemphigoid is suspected" (A:III)

) full/thic&ness lid biopsy is indicated in cases of suspected sebaceous

carcinoma" (A:II)

Care anagement

)void indiscriminate use of topical antibiotics or corticosteroids because

antibiotics can induce to6icity and corticosteroids can prolong adenoviralinfections and #orsen herpes simple6 virus infections (A:III)

Treat mild allergic conunctivitis #ith an over/the/counter

antihistamine*vasoconstrictor agent or second/generation topical histamine71/receptor antagonists" (A:III) If the condition is fre$uently recurrent orpersistent' use mast/cell stabili=ers (A:I)

,or contact lens/related &eratoconunctivitis' discontinue contact lens #ear

for 2 or more #ee&s (A:III)

If corticosteroids are indicated' prescribe the minimal amount based on

patient response and tolerance (A:III)

If corticosteroids are used' perform baseline measurement of intraocular

pressure (A:III)

Lse systemic antibiotic treatment for conunctivitis due to Neisseria

gonorrhoeae(A:I) or Chlamydia trachomatis" (A:II)

Treat se6ual partners to minimi=e recurrence and spread of disease #hen

conunctivitis is associated #ith se6ually transmitted diseases and referpatients and their se6ual partners to an appropriate medical specialist"(A:III)

efer patients #ith manifestation of a systemic disease to an appropriatemedical specialist" (A:III)

,ollo#/up valuation



o 8isual acuity (A:III)




22/76

If corticosteroids are used' perform periodic measurement of intraocular

pressure andpupillary dilation to evaluate for cataract and glaucoma (A:III)



23/76


24/76

Dia&etic Retinopat!'(Initial and Follow-up Evaluation)




-uration of diabetes (A:I)

(ast glycemic control hemoglobin )1c! (A:I)

edications (A:III)

5ystemic history e"g"' obesity (A:III)' renal disease (A:II)' systemic

hypertension (A:I)' serum lipid levels (A:II)' pregnancy (A:I)!

Ocular history(A:III)

Initial (hysical 6am 3ey elements! 8isual acuity (A:I)


Gonioscopy #hen indicated for neovasculari=ation of the iris or increased

IO(! (A:III)

5lit/lamp biomicroscopy (A:III)

-ilated funduscopy including stereoscopic e6amination of the posterior pole

(A:I)

6amination of the peripheral retina and vitreous' best performed #ith

indirect ophthalmoscopy or #ith slit/lamp biomicroscopy' combined #ith a

contact lens (A:III)

-iagnosis

Classify both eyes as to category and severity of diabetic retinopathy' #ith

presence*absence of C5"(A:III) ach category has an inherent ris& forprogression"

,ollo#/up 7istory

8isual symptoms (A:III)

5ystemic status e"g"' pregnancy' blood pressure' serum cholesterol' renal

status!(A:III) Glycemic status hemoglobin )1c! (A:I)

,ollo#/up (hysical 6am

8isual acuity (A:I)


5lit/lamp biomicroscopy #ith iris e6amination(A:II)

Gonioscopy if neovasculari=ation is suspected or present or if intraocular



25/76

pressure is increased! (A:II)

5tereo e6amination of the posterior pole after dilation of the pupils(A:I)

6amination of the peripheral retina and vitreous #hen indicated(A:II)

Ancillar' %ests ,undus photography is seldom of value in cases of minimal diabetic

retinopathy or #hen diabetic retinopathy is unchanged from the previousphotographic appearance" (A:III)

,undus photography may be useful for documenting significant progression

of disease and response to treatment" (#:III)

,luorescein angiography is used as a guide for treating C5 (A:I) and as

a means of evaluating the causes! of une6plained decreased visual acuity"(A:III))ngiography can identify macular capillary nonperfusion (A:II) orsources of capillary lea&age resulting in macular edema as possiblee6planations for visual loss"

,luorescein angiography is not routinely indicated as part of the

e6amination of patients #ith diabetes" (A:III) ,luorescein angiography is not needed to diagnose C5 or (-' both of

#hich are diagnosed by means of the clinical e6am"

(atient ducation

-iscuss results or e6am and implications" (A:II)

ncourage patients #ith diabetes but #ithout diabetic retinopathy to have

annual dilated eye e6ams" (A:II)

Inform patients that effective treatment for diabetic retinopathy depends on

timely intervention' despite good vision and no ocular symptoms" (A:II)

ducate patients about the importance of maintaining near/normal glucoselevels and near/normal blood pressure and lo#ering serum lipid levels"(A:III)

Communicate #ith the attending physician' e"g"' family physician' internist'

or endocrinologist' regarding eye findings" (A:III)

(rovide patients #hose conditions fail to respond to surgery and for #hom

treatment is unavailable #ith proper professional support and offer referralfor counseling' rehabilitative' or social services as appropriate" (A:III)

efer patients #ith reduced visual function for vision rehabilitation see

###'aao"org*smartsight! and social services (A:III)




26/76

Dia&etic Retinopat!'(Manage$ent Reco$$endations)

anagement ecommendations for (atients #ith -iabetes

everit' o"Retinopat!'

resenceo"

CME6

Follow-up

(Mont!s)

anretinal!otocoagulation (catter) 1aser

FluoresceinAngiograp!

'

Focaland.or1aserR

Normal orminimal N(-

No 12 No No No

ild to moderateN(-

NoQes

?/122/4

NoNo

NoLsually

NoLsuallyAS

5evere N(- NoQes

2/42/4

5ometimes5ometimes

arelyLsually

NoLsuallyAA

Non/high/ris&(- NoQes 2/42/4 5ometimes5ometimes arelyLsually NoLsuallyS

7igh/ris& (- NoQes

2/42/4

LsuallyLsually

arelyLsually

NoLsuallyAA

Inactive*involuted(-

NoQes

?/122/4

NoNo

NoLsually

LsuallyLsually

C5 clinically significant macular edemaB N(- nonproliferative diabeticretinopathyB (- proliferative diabetic retinopathyA 6ceptions include; hypertension or fluid retention associated #ith heart failure'renal failure' pregnancy' or any other causes that may aggravate macular edema"

-eferral of photocoagulation for a brief period of medical treatment may beconsidered in these cases" )lso' deferral of C5 treatment is an option #hen thecenter of the macula is not involved' visual acuity is e6cellent' and the patientunderstands the ris&s"

R )dunctive treatment that may be considered include intravitreal corticosteroidsor anti/vascular endothelial gro#th factor agents off/label use!" -ata from the-iabetic etinopathy Clinical esearch Net#or& in 2010 demonstrated that' at oneyear of follo#/up' intravitreal ranibi=umab #ith prompt or deferred laser resulted ingreater visual acuity gain and intravitreal triamcinolone acetonide plus laser alsoresulted in greater visual gain in pseudopha&ic eyes compared #ith laser alone"

Individuals receiving the intravitreal inections of anti/vascular endothelial gro#thfactor agents may be e6amined one month follo#ing inection"

S -eferring focal photocoagulation for C5 is an option #hen the center of themacula is not involved' visual acuity is e6cellent' close follo#/up is possible' andthe patient understands the ris&s" 7o#ever' initiation of treatment #ith focalphotocoagulation should also be considered because although treatment #ith focalphotocoagulation is less li&ely to improve the vision' it is more li&ely to stabili=e the



27/76

current visual acuity" Treatment of lesions close to the foveal avascular =one mayresult in damage to central vision and #ith time' such laser scars may e6pand andcause further vision deterioration" ,uture studies may help guide the use ofintravitreal therapies including corticosteroids and anti/vascular endothelial gro#thfactor agents in these cases in #hich laser photocoagulation cannot beadministered safely" Closer follo#/up may be necessary for macular edema that is

not clinically significant"

(anretinal photocoagulation surgery may be considered as patients approachhigh/ris& (-" The benefit of early panretinal photocoagulation at the severenonproliferative or #orse stage of retinopathy is greater in patients #ith type 2diabetes than in those #ith type 1" Treatment should be considered for patients#ith severe N(- and type 2 diabetes" Other factors' such as poor compliance#ith follo#/up' impending cataract e6traction or pregnancy' and status of fello#eye #ill help in determining the timing of the panretinal photocoagulation"

AA It is preferable to perform the focal photocoagulation first' prior to panretinalphotocoagulation laser/induced e6acerbation of the macular edema"




28/76

Dr' E'e 'ndro$e (Initial Evaluation)


Initial 6am 7istory


6acerbating conditions (#:III)


Topical medications used and their effect on symptoms (A:III)

Ocular history' including

o Contact lens #ear' schedule and care(A:III)

o )llergic conunctivitis (#:III)

o Ocular surgical history (A:III) prior &eratoplasty' cataract surgery'

&eratorefractive surgery!o (unctal surgery (A:III)

o Ocular surface disease (A:III)e"g"' herpes simple6 virus' varicella

=oster virus' ocular mucous membrane pemphigoid' 5tevens/ohnson syndrome' aniridia' graft/versus/host disease!

o (unctal surgery (A:III)

o yelid surgery (A:III) e"g" prior ptosis repair' blepharoplasty'

entropion*ectropion repair!o %ell palsy (A:III)

5ystemic history' including

o 5mo&ing or e6posure to second/hand smo&e (A:III)

o -ermatological diseases (A:III)e"g"' rosacea!

o Techni$ue and fre$uency of facial #ashing including eyelid and

eyelash hygiene (A:III)o )topy (A:III)

o enopause (A:III)

o 5ystemic inflammatory diseases (A:III)e"g"' 5ogrenPs syndrome'

graft/versus/ host disease' rheumatoid arthritis' systemic lupuserythematosus' scleroderma!

o Other systemic conditions (A:III) e"g"' lymphoma' sarcoidosis!

o 5ystemic medications (A:III)e"g"' antihistamines' diuretics'

hormones and hormonal antagonists' antidepressants' cardiacantiarrhythmic drugs' isotretinoin' dipheno6ylate*atropine' beta/adrenergic antagonists' chemotherapy agents' any other drug #ithanticholinergic effects!

o Trauma (A:III)e"g"' chemical!

o Chronic viral infections (#:III)e"g"' hepatitis C' human

immunodeficiency virus!o Nonocular surgery (#:III)e"g"' bone marro# transplant' head and

nec& surgery' trigeminal neuralgia surgery!



29/76

o adiation of orbit(#:III)

o Neurological conditions (#:III)e"g"' (ar&insonPs disease' %ell palsy'

iley/-ay syndrome' trigeminal neuralgia!o -ry mouth' dental cavities' oral ulcers (#:III)

Initial (hysical 6am 8isual acuity (A:III)

6ternal e6amination

o 5&in (A:III)

o yelids (A:I)

o )dne6ae(A:III)

o (roptosis (#:III)

o Cranial nerve function (A:III)

o 7ands (#:III)


o Tear film (A:III)o yelashes (A:III)

o )nterior and posterior eyelid margins (A:III)

o (uncta (A:III!

o Inferior forni6 and tarsal conunctiva (A:III)

o %ulbar conunctiva (A:III)

o Cornea (A:III)


ICO International Clinical Guidelines' 2010(age 2H


30/76

Dr' E'e 'ndro$e(Manage$ent Reco$$endations)



Care anagement

Treat any causative factors that are amenable to treatment as patients #ith

dry eye symptoms often have many contributory factors (A:III)

5e$uence and combination of therapies is determined based on the

patientPs needs and preferences and the treating ophthalmologistPs medicaludgment (A:III)

,or mild dry eye' the follo#ing measures are appropriate;

o ducation and environmental modifications (A:III)

o limination of offending topical or systemic medications (A:III)o )$ueous enhancement using artificial tear substitutes' gels*ointments

(A:III)o yelid therapy #arm compresses and eyelid hygiene! (A:III)

o Treatment of contributing ocular factors such as blepharitis or

meibomianitis (A:III)

,or moderate dry eye' in addition to above treatments' the follo#ing

measures are appropriate;o )nti/inflammatory agents topical cyclosporine(A:I)and

corticosteroids' (A:II)systemic omega/: fatty acids supplements

(A:II)!o (unctal plugs(A:III)

o 5pectacle side shields and moisture chambers(A:III)

,or severe dry eye' in addition to above treatments' the follo#ing measures

are appropriate;o 5ystemic cholinergic agonists (A:I)

o 5ystemic anti/inflammatory agents (A:III)

o ucolytic agents (A:III)

o )utologous serum tears (A:III)

o Contact lenses (A:III)

o Correction of eyelid abnormalities (A:III)

o (ermanent punctal occlusion (A:III) onitor patients prescribed corticosteroids for adverse effects such as

increased intraocular pressure' corneal melting' and cataract formation(A:III)

(atient ducation

Counsel patients about the chronic nature of dry eye and its natural history"

ICO International Clinical Guidelines' 2010(age :0


31/76

(A:III)

(rovide specific instructions for therapeutic regimens" (A:III)

eassess periodically the patientJs compliance and understanding of the

disease' ris&s for associated structural changes and realistic e6pectationsfor effective management' and reinforce education" (A:III)

efer patients #ith manifestation of a systemic disease to an appropriate

medical specialist" (A:III)

Caution patients #ith pre/e6isting dry eye that &eratorefractive surgery may

#orsen their dry eye condition" (A:III)




32/76

Esotropia (Initial and Follow-up Evaluation)


Initial E7a$ istor' (4e' ele$ents) Ocular symptoms and signs (A:III)

Ocular history date of onset and fre$uency of the deviation' presence or

absence of diplopia! (A:III)

5ystemic history revie# of prenatal' perinatal and postnatal medical

factors! (A:III)

,amily history' including presence of strabismus' amblyopia' e6traocular

muscle surgery' genetic diseases" (A:III)



Ocular alignment at distance and near! and motility (A:III)

6traocular muscle function (A:III)

-etection of nystagmus (A:III)

5ensory testing (A:III)


,undoscopic e6amination (A:III)

Care anagement

Consider all forms of esotropia for treatment and re/establish ocularalignment promptly (A:III)

(rescribe corrective lenses for any clinically significant refractive error (A:I)

If optical correction does not align the eyes' then surgical correction is

indicated (A:III)

5tart amblyopia treatment before surgery to reduce angle of strabismus or

increase li&elihood of binocularity (A:III)

,ollo#/up valuation

(eriodic evaluations necessary until visual maturity reached (A:II)

7yperopia should be assessed every 1 to 2 years (A:III)

ore fre$uent cycloplegic e6aminations are indicated in cases #ith changes

in acuity' amblyopia' or unstable alignment (A:III)

If the e6amination has been stable' follo#/up evaluations are appropriate

every 1 to 2 years during teenage years (A:I)



33/76

Esotropia Follow-up Evaluation Intervals (A:III)

Age ('ears) Interval ($ont!s)

0/1 :/?

1/@ ?/12

@ 12/24

8ote: ore fre$uent visits may be necessary if amblyopia is present or if there isa recent deterioration of alignment"

atient Education -iscuss findings #ith the patient #hen appropriate and*or

parents*caregivers to enhance understanding of disorder and to recruit themin a collaborative approach to therapy"(A:III)

,ormulate treatment plans in consultation #ith the patient and*or

family*caregivers"(A:III)


ICO International Clinical Guidelines' 2010(age ::


34/76

E7otropia (Initial and Follow-up Evaluation)




Ocular history date of onset and fre$uency of the deviation' presence or

absence of diplopia! (A:III)

5ystemic history revie# of prenatal' perinatal and postnatal medical

factors! (A:III)

,amily history' including presence of strabismus' amblyopia' e6traocular

muscle surgery' genetic diseases (A:III)



Ocular alignment at distance and near! and motility (A:III)

6traocular muscle function (A:III)

-etection of nystagmus (A:III)

5ensory testing (A:III)


,undoscopic e6amination (A:III)

Care anagement

Consider all forms of e6otropia for treatment and re/establish ocularalignment as soon as possible if deviation is manifest a large percentage ofthe time" (A:III)

(rescribe corrective lenses for any clinically significant refractive error"

(A:III)

Optimal modes of therapy are not #ell established"

,ollo#/up valuation

eriodic evaluations necessar' until visual $aturit' reac!ed );III!

Intervals are reduced i" stra&is$us is sta&le );III!

Includes interval history' tolerance to treatment if any!' and routine

e6amination and testing of ocular motility (A:III)



35/76

E7otropia Follow-up Evaluation Intervals (A:III)

Age ('ears) Interval ($ont!s)

0/1 :/?

1/@ ?/12

@ 12/24

8ote: ore fre$uent visits may be necessary if patching therapy is being administered' orif there is a recent deterioration of alignment"

(atient ducation

-iscuss findings #ith the patient #hen appropriate and*or parents*caregivers to

enhance understanding of disorder and recruit them in a collaborative approach totherapy" (A:III)

,ormulate treatment plans in consultation #ith the patient and*or

family*caregivers" (A:III)


ICO International Clinical Guidelines' 2010(age :@


36/76

E'e Disease in 1epros'(Initial Evaluation and Manage$ent)



Initial 6am 7istory

Ocular symptoms decreased vision' epiphora' symptoms of irritation! (A:III)

-uration of lagophthalmos DorF? months! (A:III)

-uration of leprosy usually from date of diagnosis! (#:III)

Type of leprosy (A:III)

-T treatmentB #hat drugs and for ho# long (A:III)

7istory of leprosy reactions (#:III)

Initial (hysical 6am 8isual acuity (A:III)

yelids and lid closure (A:III)

Corneal sensation (A:III)

Conunctiva (A:III)

5clera (A:III)

(upil (A:III)

Nasolacrimal apparatus (A:III)

5lit lamp biomicroscopy

o Corneal epithelial integrity(A:III)

o Corneal nerve beading' stromal opacity (#:III)

o )nterior chamber(A:III)

o Iris atrophy (A:III)

o Iris UpearlsU (#:III)

o (osterior synechiae (A:III)

o Cataract (A:III)

Care anagement

The main important conditions cataract' lagophthalmos' anterior uveitis! aremanaged as for any patient' and people #ith leprosy should be integrated into the

normal eye care service' specifically;

Cataract should be removed #hen it adversely affects patientJs visual

function (A:III)

IO. is not contraindicated as long as $uality of surgery is good and eye is

$uiet (A:III)

Chronic lagophthalmos should be treated surgically if cornea is

compromised or cosmesis is a problem' regardless of severity oflagophthalmos' by #hatever procedure the surgeon does best (A:III)

ICO International Clinical Guidelines' 2010(age :?


37/76

5pecial considerations in a person afflicted #ith leprosy include;

o Ne# onset lagophthalmos duration D? months! should be treated

#ith oral prednisolone 2@/:0 mg per day tapered over ? months"(A:III)

o )cute uveitis should be treated #ith intensive topical steroidB

associated systemic leprosy reaction must be ruled out or treated ifpresent #ith systemic steroid give dose! (A:III)

(atient ducation

)t the end of -T all patients should be #arned that lagophthalmos could

develop and understand the ris&s associated #ith this" (A:III)

(atients #ith residual lagophthalmos must be told about the ris& form

e6posure and specifically #arned about development of red eye anddecreased vision" (A:III)

(atients should understand ris&s to eye during reaction and given e6plicit

instructions on #here to report if reaction develops" (A:III)

)ll patients should be informed of significance of decreased vision and toldto report this to case #or&er for referral to higher level" (A:III)

ICO International Clinical Guidelines' 2010(age :


38/76

Idiopat!ic Macular ole(Initial Evaluation and %!erap')





Ocular history; glaucoma or other prior eye diseases' inuries' surgery' or

other treatmentsB prolonged ga=ing at the sun (A:III)

edications that may be related to macular cysts (A:III)



5lit/lamp biomicroscopic e6amination of the macula and the vitreoretinal

interface (A:III)

Manage$ent Reco$$endations "or Macular ole

A )lthough surgery is usually performed' observation is also appropriate"

ICO International Clinical Guidelines' 2010(age :>

tage Manage$ent Follow-up 9A:III

1/) Observation M);II (rompt return if ne# symptoms

very 4 to ? months in the absence of symptoms

1/% Observation M);II (rompt return if ne# symptoms

very 4 to ? months in the absence of symptoms

2 5urgery M);IIA 1 to 2 days postoperatively' then 1 to 2 #ee&s

,re$uency and timing of subse$uent visits varies dependingon the outcome of surgery and the patientPs symptoms

If no surgery' every 4 to > months

: 5urgery M);I 1 to 2 days postoperatively' then 1 to 2 #ee&s


4 5urgery M);I 1 to 2 days postoperatively' then 1 to 2 #ee&s



39/76

5urgical and (ostoperative Care if (atient eceives Treatment

Inform the patient about relative ris&s' benefits' and alternatives to surgery'

and the need for use of e6pansile intraocular gas or special patientpositioning postoperatively (A:III)

,ormulate a postoperative care plan and inform the patient of these

arrangements (A:III) Inform patients #ith glaucoma of possible perioperative increase in IO(

(A:III)

6amine postoperatively #ithin 1 or 2 days and again 1 to 2 #ee&s after

surgery (A:III)

(atient ducation

Inform patients to notify their ophthalmologist promptly if they have

symptoms such as increase in floaters' a loss of visual field' or a decreasein visual acuity (A:II)

Inform patients that air travel' high altitudes' or general anesthesia #ithnitrous o6ide should be avoided until the gas tamponade is nearlycompletely gone (A:III)

Inform patients #ho have had a macular hole in one eye that they have a

10E to 20E chance of macular hole formation in the fello# eye' especially ifthe hyaloid remains attached (A:III)

efer patients #ith functionally limiting postoperative visual impairment for

vision rehabilitation see ###"aao"org*smartsight! and social services (A:III)


ICO International Clinical Guidelines' 2010(age :H
http://www.aao.org/smartsighthttp://www.aao.org/smartsight


40/76

4eratore"ractive urger'(Initial and Follow-up Evaluation)


Initial 6am 7istory

(resent status of visual function (A:III)


5ystemic history (A:III)

edications (A:III)


8isual acuity #ithout correction (A:III)

anifest' and #here appropriate' cycloplegic refraction (A:III)

Computeri=ed corneal topography (A:III)

Central corneal thic&ness measurement (A:III)

valuation of tear film (A:III)

valuation of ocular motility and alignment (A:III)

Care anagement

-iscontinue contact lenses before preoperative e6am and procedure (A:III)

Inform patient of the potential ris&s' benefits' and alternatives to and among

the different refractive procedures (A:III) -ocument informed consent processB patient should be given an

opportunity to have all $uestions ans#ered before surgery (A:III)

,or .)5I3' residual stromal bed thic&ness should not be less than 2@0 um

(A:III)

Chec& and calibrate instrumentation before the procedure (A:III)

5urgeon confirms the identity of the patient' the operative eye' and that the

parameters are correctly entered into the e6cimer laserPs computer (A:III)

(ostoperative Care

Operating surgeon is responsible for postoperative management (A:III) ,or surface ablation techni$ues' e6amine on the day follo#ing surgery and

every 2 to : days thereafter until the epithelium is healed (A:III)

,or uncomplicated .)5I3' e6amine #ithin 4> hours follo#ing surgery' a

second visit 1 to 4 #ee&s postoperatively' and further visits thereafter asappropriate (A:III)



41/76

(atient ducation

1-iscuss the ris&s and benefits of the planned procedure #ith the patient" (A:III)lements of the discussion include the follo#ing;

ange of e6pected refractive outcomes

esidual refractive error

eading and*or distance correction postoperatively .oss of best/corrected visual acuity

5ide effects and complications e"g"' microbial &eratitis' sterile &eratitis'

&eratectasia

Changes in visual function not necessarily measured by 5nellen acuity'

including glare and function under lo#/light conditions

Night vision symptoms e"g"' glare' haloes! developing or #orseningB careful

consideration should be given to this issue for patients #ith high degrees ofametropia or for individuals #ho re$uire a high level of visual function inlo#/light conditions

ffect on ocular alignment

-ry eye symptoms developing or #orsening

onovision advantages and disadvantages for patients of presbyopic age!

Conventional and #avefront/guided ablations advantages and

disadvantages

)dvantages and disadvantages of same/day bilateral &eratorefractive

surgery versus se$uential surgery" %ecause vision might be poor for sometime after bilateral same/day photorefractive &eratectomy' the patient shouldbe informed that activities such as driving might not be possible for #ee&s

(ostoperative care plans setting of care' providers of care!




42/76

Ocular I;.AID Related Diseases(Initial and Follow-up Evaluation)



General / Initial 6am 7istory

)ge (#:III)

Ocular symptoms including laterality (A:III)

5ystemic symptoms (A:III)

Complete revie# of systems (A:III)

(rior ocular history (A:III)

(rior medical history (A:III)

(rior surgical history(#:III)

7istory of other se6ually transmitted diseases (A:III) 7istory of )I-5/defining illnesses or complications (A:III)

ethod of 7I8 ac$uisition (#:III)

-uration of 7I8 infection (A:III)

(ast and current ris& factors V se6ual behavior' intravenous drug abuse'

transfusion history (A:III)

Current anti/7I8 regimen V duration and compliance (A:III)

Current medications (A:II)

Current C-4 count (A:II)

Current viral load (A:II)

edication allergies (#:III)

General / Initial (hysical 6am

General appearance (A:III)

6ternal e6amination V face' ocular adne6a (A:III)

.ymphatics V preauricular and submandibular nodes (A:III)


6traocular motility (A:III)

Confrontation visual fields(A:III)

yelids V lid closure' interpalpebral fissure height (#:III) .acrimal gland (#:III)

valuation of tear film V 5chirmer' rose bengal and fluorescein staining

(A:III)

Nasolacrimal function (#:III)

5lit/lamp e6amination


o Conunctiva (A:III)

o 5clera (A:III)



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o Cornea (A:III)

o )nterior chamber (A:III)

o Iris (A:III)

o .ens (A:III)

o )nterior vitreous (A:III)

-ilated ophthalmoscopic e6amination

o 8itreous V cell*flare' blood' condensations (A:III)

o Optic disc (A:III)

o etinal vasculature (A:III)

o acula*fovea (A:III)

o (eripheral retina #ith scleral depression (A:III)

o Choroid (A:III)

General / -iagnostic Tests

7I8 infection V for increased ris& populations and*or suspected infection

o

)nti/7I8 .I5) to screen for infection' follo#ed by confirmation #ith9estern blot (A:II)

)I-5

o (resence of )I-5/defining illnesses! (A:III)

o C-4 D 200 cells*Wl' per C-C criteria! (A:II)

3no#n 7I8*)I-5 patient

o C-4 count (A:II)

o 8iral load (A:II)

General / Care anagement

anagement of 7I8*)I-5 should involve a multidisciplinary team' includingan infectious disease specialist and an ophthalmologist (A:III)

)nti/etroviral Therapy )T! or 7ighly )ctive )nti/etroviral Therapy

7))T!' #here available (A:II)

mphasis on prevention of disease transmission (A:III)

Identification and treatment of 7I8*)I-5 associated illnesses*infections

particularly tuberculosis and syphilis! (A:II)

7I8 etinopathy V Initial 6am 7istory

C-4 count (A:II)

Ocular symptoms V usually asymptomatic (#:III)

I; Retinopat!' < Initial !'sical E7a$ 8isual acuity (A:III)

5lit lamp e6amination (#:III)

-ilated ophthalmoscopic e6amination (A:II)

5creen for other 7I8*)I-5 related illnesses*infections (#:III)

ICO International Clinical Guidelines' 2010(age 4:


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7I8 etinopathy / Care anagement

Treat immune compromise #ith 7))T (A:II)

Consider corticosteroids (#:III)or focal laser (A:II) for macular edema

I; Retinopat!' < Follow-up Evaluation

.esions usually resolve over #ee&s to months (A:II) -ilated ophthalmoscopic e6amination every : months for C-4 counts

persistently belo# @0 cells*Wl (A:II)

C'to$egalovirus (CM;) Retinitis < Initial E7a$ istor' Interval since )I-5 diagnosis (A:II)

7istory of C8 related systemic complications(A:II)

Ocular symptoms Vblurred vision' floaters' photopsias' scotomata (A:II)

C'to$egalovirus (CM;) Retinitis < Initial !'sical E7a$

8isual acuity (A:II) Cornea for small endothelial deposits (#:III)

)nterior chamber for signs of inflammation (A:II)

-ilated ophthalmoscopic e6amination of both eyes V including optic disc'

macula' and retinal periphery" The choroid should be e6amined to rule outco/infection #ith other agents (A:II)

C'to$egalovirus Retinitis < Diagnostic %ests C-4 count V typically less than @0 cells*Wl (A:II)

C'to$egalovirus Retinitis < Ancillar' %esting ,undus photography may be useful to document disease progression or

response to treatment and fluorescein angiography as indicated to evaluatefor the presence of macular edema or ischemia(A:III)

Test for syphilis and vitreous biopsy for other causes of necroti=ing retinitis

varicella =oster virus' herpes simple6 virus' to6oplasmosis! #hen diagnosisuncertain (A:II)

C'to$egalovirus < Care Manage$ent ain obectives include direct treatment of C8 retinitis #ith anti/C8

medications' and improvement of immune status #ith initiation*optimi=ation

of 7))T if not already ta&ing anti/retroviral therapy (A:II) To reduce the possibility of immune recovery uveitis' patients #ith ne#ly

diagnosed C8 retinitis #ho are not on 7))T should be treated #ith anti/C8 medications until the retinitis is inactive' or at least less active" 7))Tshould then be initiated (A:II)

)lso' in cases #ith e6pected persistent immune suppression' e"g" poor

response to or unavailability of )T' immediate treatment is indicated (A:II)

.ocal anti/C8 therapy' as might be achieved using intravitreal inection of

ganciclovir or foscarnet' may be used immediately #hen active C8 retinitis



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either involves or threatens the optic disc or macula (A:II)

Induction follo#ed by indefinite maintenance therapy in cases of persistent

immune suppression (A:II)

Ganciclovir

o Intravenous V @ mg*&g every 12 hours for 2 to : #ee&s' then @

mg*&g*day @ to times per #ee& indefinitely" (A:I) onitor forleu&openia' the ris& of #hich may be lessened by administeringleu&ocyte/stimulating factors such as granulocyte colony/stimulatingfactor (A:II)

o Intraocular V 2 to 2"@ mg*0"1 ml intravitreal inection t#ice per #ee&

until inactive' then #ee&ly (A:I)o Intravitreal sustained/release implant 8itrasert! V 4"@ mg implant that

releases 1 Wg*hr for eight months" This should be combined #ith oralvalganciclovir therapy for systemic coverage (A:I)

,oscarnet

o Intravenous V ?0 mg*&g every > hours or H0 mg*&g every 12 hours for

14 days' then H0 to 120 mg*&g*day" onitor for renal to6icity (A:I)o Intraocular V 1"2 mg*0"0@ ml or 2"4 mg*0"1 ml! (A:I)

8alganciclovir

o Oral V H00 mg t#ice daily for 2 #ee&s' (A:I) then H00 mg daily

indefinitely" (A:II)onitor for leu&openia (A:II)

C'to$egalovirus < Follow-up Evaluation ecurrence is very common' and patients being treated #ith anti/C8

medications should be evaluated monthly (A:II)

Intervals may be e6tended #hen C-4 counts are elevated' anti/C8

medications are discontinued' and the disease remains inactive in the

setting of immune recovery(A:II) 8isual symptoms (A:II)

C-4 count and 7I8 viral load (A:II)

evie# of systems for C8 related systemic complications or drug/induced

side effects (A:II)

C'to$egalovirus < Follow-up E7a$ination 8isual acuity (A:II)

5lit lamp e6amination (#:II)

Ophthalmoscopic e6amination V including the macula and peripheral retina

(A:II) 5erial fundus photography (#:II)

C'to$egalovirus < Follow-up Manage$ent No treatment can eliminate C8 from the eye (A:II)

(atient education about the symptoms of C8 retinitis is crucial (A:III)

,or recurrences' first line is re/induction #ith the same therapy in the

absence of side effects or evidence of drug resistance (A:II)



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(ersistent or progressive retinitis after ? #ee&s of induction/level therapy

implies resistance or incorrect diagnosis (A:II)

L.H and L.@4 mutations in C8 -N) are associated #ith relative

ganciclovir resistance (A:II)

)nti/C8 drugs may be discontinued in patients on 7))T #ith no signs of

active C8 retinitis in #hom C-4 counts are above 100 to 1@0 cells*Wl for atleast three to si6 months (A:II)

%u&erculosis < Initial E7a$ istor' C-4 count typically D 200 cells*Wl! (A:II)

8isual and ocular symptoms (A:II)

7istory M. Tuberculosis infection' systemic complications' or e6posure (A:II)

%u&erculosis < Initial !'sical E7a$ 8isual acuity (A:III)

6ternal e6amination V including eyelids and adne6a (#:III)


Intraocular pressure (#:III)

-ilated ophthalmoscopic e6amination / optic disc' macula' retinal periphery'

and choroid (A:II)

%u&erculosis < Diagnostic %ests (resumptive diagnosis by clinical e6amination combined #ith ((- s&in

testing and chest 6/ray (A:II)

e$uires a high inde6 of clinical suspicion (#:III)

Consider leu&ocyte stimulation based assays #here available' particularly

#hen ((- s&in testing is unreliable Xuanti,ONY/T% Gold TestB T"5(OT/T%Ytest! (A:II)

-efinitive diagnosis re$uires biopsy #ith histopathologic e6amination (A:III)

%u&erculosis < Ancillar' %esting ,luorescein angiography to evaluate suspected retinal vasculitis (A:III)

Indocyanine green angiography may be helpful to detect subclinical

choroidal involvement (A:III)

Optical coherence tomography to diagnose and monitor for cystoid macular

edema (A:III)

%u&erculosis < Care Manage$ent 5ystemic treatment is indicated #ith rifampin @00 mg*day for #eight F @0

&g and ?00 mg*day for #eight D @0 &g!' isonia=id @ mg*&g*day!'pyrimethamine 2@ to :0 mg*&g*day' and ethambutol 1@ mg*&g*day! for 2months then rifampin and isonia=id for another 4 to months (A:II)

Oral prednisone 1 mg*&g*day!' taper as directed by clinical response (A:II)

Initiate*optimi=e 7))T if not already ta&ing anti/retroviral therapy (A:II)

Coordinate care #ith an infectious disease specialist (A:III)



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%u&erculosis < Follow-up Evaluation onitor all patients for medication to6icity (A:II)

6amine patients monthly until there is significant clinical improvement

(A:III)

%o7oplas$osis (%= gondii) < Initial E7a$ istor' C-4 count typically D 200 cells*Wl! (A:II)

8isual and ocular symptoms (A:III)

7istory of T. gondiiinfection' systemic complications' or e6posure (A:III)

%o7oplas$osis < Initial !'sical E7a$ 8isual acuity (A:II)

Intraocular pressure (#:II)

5lit lamp e6amination (C:II)


%o7oplas$osis < Diagnostic %ests (rimarily a clinical diagnosis (A:III)

5erologic testing for anti/T. gondiiIg*IgG antibodies (A:II)

In unclear cases' can perform (C on a$ueous or vitreous for T. gondii

-N) (#:II)

%o7oplas$osis < Care Manage$ent Initial treatment involves oral antimicrobials for 4 to ? #ee&s" Options

include;

o Trimethoprim*sulfametho6a=ole >00*1?0! @00 mg (O t#ice daily(A:II)

o (yrimethamine 100 mg loading dose given over 24 hours' follo#ed

by 2@ to @0 mg daily! and sulfadia=ine 1 g given four times daily! for4 to ? #ee&s" 5hould be given concurrently #ith folinic acid : to @mg t#ice #ee&ly! to prevent leu&openia and thrombocytopenia (#:II)

o Clindamycin :00 mg orally every ? hours! for : or more #ee&s (#:II)

o )tova$uone @0 mg orally four times daily! for : months (#:II)

o Consider use of )=ithromycin in patients #ith sulfa/related allergy

(#:III)

aintenance therapy #ith at least one of the above medications is

recommended for patients #ith ocular to6oplasmosis #ho remain severelyimmunodeficient (A:III)

Oral corticosteroids may be considered #hen inflammation contributes to

vision loss vitritis' vasculitis' serous retinal detachment' lesion involving orthreatening the optic disc or macula! / 0"@ mg*&g*day #ith taper' initiatedand ended concurrent #ith antimicrobial therapy (A:III)

Topical corticosteroids may be considered for significant anterior chamber

inflammation (A:III)



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%o7oplas$osis < Follow-up Evaluation Initial follo#/up should be one #ee& after initiation of treatment' then as

indicated by e6amination and treatment response (A:III)

.esions typically ta&e several months to resolve (A:III)

'p!ilis < Initial E7a$ istor' C-4 count often less than 200 cells*Wl!" 7o#ever' ocular syphilis in the

setting of 7I8*)I-5 may occur at any C-4 count" (A:II)

8isual symptoms and rapidity of onset (A:III)

(revious syphilis infection' related complications' or e6posure (A:III)

7istory of other se6ually/transmitted diseases (#:III)

'p!ilis < Initial !'sical E7a$ 8isual acuity (A:II)

Intraocular pressure (#:II)



'p!ilis < Diagnostic %ests %oth non/treponemal ( or 8-.! and treponemal 7)/T( or ,T)/

)%5! testing should be obtained up to one/third of patients #ith syphiliticuveitis have a negative non/treponemal test! (A:II)

(atients #ith profound immune suppression may present #ith seronegative

syphilis (A:II)

C5, e6amination ( or 8-.! in all 7I8*)I-5 patients #ith ocular

syphilis (A:II)

'p!ilis < Care Manage$ent Treat as neurosyphilis (A:II)

Involve an infectious disease specialist in coordinating systemic

management (A:III)

,irst/line treatment is #ith I8 penicillin G' 1> to 24 million units for 14 days

(A:II)

9orsening ocular inflammation follo#ing the initiation of penicillin may be

indicative of a arish/7er6heimer reaction(A:II)

'p!ilis < Follow-up Evaluation 5erial serum and C5, antibody levels every month for : months' then every

? months until C5, cell count normali=es and C5, 8-.*( becomesnon/reactive (A:III)

5erum $uantitative nontreponemal testing every : months for one year' then

yearly(A:III)

aintenance therapy is not necessary or recommended (#:II)



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Table 1. Adnexal Manifestations of HIV/AIDS (A:III unless otherwise indicated)

EntityCD4coun

tHistory Examination Key Findings

Diagnosticworkup

Management

Herpes oster!phthal"icus

# $%%cells/&l(A:II"

'rior (osterinfection (A:II"

Ae

'eriorbita

*+elids

S,*

Sclera

A-

D!*

Vesiculobullousder"atitis in - V1distribution A:II"

-o"plications include0eratitis u2eitis scleritisretinitis and opticneuritis (A:II"

He"orrhaic h+pop+on(#:II"

-linicalexa"ination

-an con3r"dianosiswith 2iralculture

T(anc0s"ear '-4(A:II"

IV ac+clo2ir 1% "/0 e2er+ 5 hours for 6 da+s(A:II"

Alternati2es7 2alac+clo2ir 1 ra" '! 8 ti"esdail+) or oral ac+clo2ir 5%% " '! 9 ti"es dailclose follow;up for sins of disse"inated infectincludin cerebritis (A:II"

'atient recei2in hih doses of 2alac+clo2ir shobe "onitored for TT'/HsSarco"a

# $%%cells/&l(A:II"

Manner of HIVac?uisitionsexual "oreco""on) (#:II"

Dr+ e+es+"pto"s (#:II"

'ain rare) (#:II"

4educed 2isionrare) (C:II"

*xternalexa"ination

,+"phatics

!ral ca2it+

S,*

*+elids

,acri"alland

S0in of faceand upperbod+

Hihl+ 2asculari(edtu"or of the s0in or"ucous "e"branesA:II"

Ma+ in2ol2e e+elidsand/or con@uncti2a A:II"

*+elid lesions "a+appear as a purplishnodule A:II"

-on@uncti2al lesions can"i"ic S-H (#:II"

-linicalexa"ination

iops+ withhistopatholo+ ofsuspiciouslesions(A:II"

I""une reconstitution (A:II"

Indications for treat"ent7 1) loss of nor"al lidfunction $) disco"fort 8) cos"esis

Treat"ent depends on the si(e and location oflesions (A:II"

Treat"ent options include intralesional 2inblasor interferon;alpha local radiation therap+excision and cr+otherap+ (A:II"

S+ste"ic che"otherap+ if disse"inated diseas(A:II"

4educe si(e of lare lesions prior to excision

Molluscu"-ontaiosu"

An+(A:II"

Histor+ of"olluscu"exposure (A:II"

'eriorbita

S,*

Trun0 and

enitalia(#:III"

'apulonodular der"atitisof the s0in and "ucous"e"branes A:II"

Multiple s"allu"bilicated lesions A:II"

-linicalexa"ination

I""une reconstitution (A:II"

Topical aents7 li?uid nitroen trichloracetic accantharadin (A:II"

Incision with curettae excision or cr+otherap(A:II"

S?ua"ous -ell-arcino"aS--) and-on@uncti2alIntraepithelialeoplasia -I)

An+(A:II"

Ceoraphiclocation hiherris0 in Africa(A:II"

Histor+ of H'Vinfection (#:II"

VA

*xternalexa"ination

S,*

Conioscop+

'apillifor" elatinous orleu0opla0ic lesion at theinterpalpebral li"busA:II"

S--7 lesion is "oreextensi2e feeder 2essels"ore co""on A:II"

iops+ withhistopatholoicexa"ination(A:II"

Eide excision with cr+otherap+ for non;in2asi2lesions (A:II"

Fro(en section patholoic exa"ination (A:II"

Alternati2es include MM- 9;F


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s+"pto"s D!* (C:III" (A:II"

S,* G slit la"p exa"ination A- G anterior cha"ber D!* G dilated ophthal"oscopic exa"ination '-4 G pol+"erase chain reaction '! G per os b+ "outh) IV G intthro"botic thro"boc+topenic purpura/he"ol+tic ure"ic s+ndro"e HIV G hu"an i""unode3cienc+ 2irus S-H G subcon@uncti2al he"orrhae H'V G hu"an papillo"acuit+ MM- G "ito"+cin - 9;F< G 9;uorouracil FS G forein bod+ sensation G 2isual acuit+ MM- G "ito"+cin - 9;F< G 9;uorouracil FS G forein bod+ sensat

ICO International Clinical Guidelines' 2010

(age @0


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Table 1. continued) Adnexal Manifestations of HIV/AIDS (A:III unless otherwise indicated)

EntityCD4count

History Examination Key Findings Diagnostic

workup Management

-on@uncti2alMicro2asculopath+

An+(A:II"

T+picall+as+"pto"atic(#:II"

S,*

D!* (#:III"

Inferior perili"bus A:II"

Se"ental 2asculardilation and narrowinA:II"

-o""a;shaped 2ascularfra"ents A:II"

Microaneur+s"s A:II"

lood colu"n ranularit+A:II"

-linicalexa"ination

ot indicated

-on@uncti2itis An+(A:II"

S+"pto"s ofirritationdischare (A:II"

VA

S,*

-on@uncti2al er+the"aA:II"

Eater+ "ucoid orpurulent dischare A:II"

-linicalexa"ination

-ulture andra" stainof dischare(A:II"

Cuided b+ results of ra" stain and culture

-linical exa"ination should be used to initiatee"piric treat"ent

Atopic der"atit

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