from carrots to keratitis: an eye update for non-ophthalmologists

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From Carrots to Keratitis: An Eye Update for Non-Ophthalmologists Rachel Bishop, MD, MPH CDR, USPHS Chief, Consult Service, National Eye Institute, NIH Objects in mirror are closer than they appear.

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From Carrots to Keratitis: An Eye Update for Non-Ophthalmologists . Objects in mirror are closer than they appear. Rachel Bishop, MD, MPH CDR, USPHS Chief, Consult Service, National Eye Institute, NIH. Objectives. Update: what’s new for t he “Big 4”? Glaucoma Diabetic eye disease - PowerPoint PPT Presentation

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Page 1: From Carrots to Keratitis:  An Eye Update for Non-Ophthalmologists

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.

Page 2: From Carrots to Keratitis:  An Eye Update for Non-Ophthalmologists

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

Page 3: From Carrots to Keratitis:  An Eye Update for Non-Ophthalmologists
Page 4: From Carrots to Keratitis:  An Eye Update for Non-Ophthalmologists

Normal Anatomy

Page 5: From Carrots to Keratitis:  An Eye Update for Non-Ophthalmologists

Glaucoma

Page 6: From Carrots to Keratitis:  An Eye Update for Non-Ophthalmologists

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

Page 7: From Carrots to Keratitis:  An Eye Update for Non-Ophthalmologists

Diabetic Retinopathy

non-proliferative proliferative

Page 8: From Carrots to Keratitis:  An Eye Update for Non-Ophthalmologists

Diabetic Retinopathy Management

• Prevention: control chronic medical conditions

• Treatment– Macular edema:

focal laser

– Proliferative retinopathy: scatter laser

8

Page 9: From Carrots to Keratitis:  An Eye Update for Non-Ophthalmologists

Diabetic Retinopathy

9

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

• Intravitreal injection

Page 10: From Carrots to Keratitis:  An Eye Update for Non-Ophthalmologists

Age-Related Macular Degeneration

Dry Neovascular (“Wet”)

Page 11: From Carrots to Keratitis:  An Eye Update for Non-Ophthalmologists

Macular Degeneration: Management

Dry AMD: Prevention– NEW: anti-oxidants

Neovascular AMD– NEW: VEGF inhibitors

Page 12: From Carrots to Keratitis:  An Eye Update for Non-Ophthalmologists

pre: 20/100 post: 20/50

Page 13: From Carrots to Keratitis:  An Eye Update for Non-Ophthalmologists

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

intraocular lenses

Page 14: From Carrots to Keratitis:  An Eye Update for Non-Ophthalmologists

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

Page 15: From Carrots to Keratitis:  An Eye Update for Non-Ophthalmologists

Preventive Ophthalmology

Page 16: From Carrots to Keratitis:  An Eye Update for Non-Ophthalmologists

Preventive Lifestyle Tips: Not Much New

• Dilated eye exams

• “Healthy Living”

• Protective eyewear: safety, UV-blocking

Page 17: From Carrots to Keratitis:  An Eye Update for Non-Ophthalmologists

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

floaters• Acute loss of vision

Page 18: From Carrots to Keratitis:  An Eye Update for Non-Ophthalmologists

The Tool Box

Page 19: From Carrots to Keratitis:  An Eye Update for Non-Ophthalmologists

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

Page 20: From Carrots to Keratitis:  An Eye Update for Non-Ophthalmologists
Page 21: From Carrots to Keratitis:  An Eye Update for Non-Ophthalmologists

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

movements?• Uncertain? CT orbits

Page 22: From Carrots to Keratitis:  An Eye Update for Non-Ophthalmologists
Page 23: From Carrots to Keratitis:  An Eye Update for Non-Ophthalmologists

Conjunctivitis

• Majority: viral

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

• Other– allergic– irritant– dry eye– blepharitis

Page 24: From Carrots to Keratitis:  An Eye Update for Non-Ophthalmologists
Page 25: From Carrots to Keratitis:  An Eye Update for Non-Ophthalmologists

Episcleritis/Scleritis

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

• Painful? …Scleritis– Refer

Page 26: From Carrots to Keratitis:  An Eye Update for Non-Ophthalmologists
Page 27: From Carrots to Keratitis:  An Eye Update for Non-Ophthalmologists

Sub-Conjunctival Hemorrhage

Treatment: observation only

Page 28: From Carrots to Keratitis:  An Eye Update for Non-Ophthalmologists
Page 29: From Carrots to Keratitis:  An Eye Update for Non-Ophthalmologists

Corneal Abrasion

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

Page 30: From Carrots to Keratitis:  An Eye Update for Non-Ophthalmologists
Page 31: From Carrots to Keratitis:  An Eye Update for Non-Ophthalmologists
Page 32: From Carrots to Keratitis:  An Eye Update for Non-Ophthalmologists

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

Page 33: From Carrots to Keratitis:  An Eye Update for Non-Ophthalmologists
Page 34: From Carrots to Keratitis:  An Eye Update for Non-Ophthalmologists

Corneal Ulcer

• Contact lens user?– Think: pseudomonas

• Refer • Initiate ABX

treatment if referral will be delayed

• Close follow-up

Page 35: From Carrots to Keratitis:  An Eye Update for Non-Ophthalmologists
Page 36: From Carrots to Keratitis:  An Eye Update for Non-Ophthalmologists

Angle Closure Glaucoma

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

Page 37: From Carrots to Keratitis:  An Eye Update for Non-Ophthalmologists
Page 38: From Carrots to Keratitis:  An Eye Update for Non-Ophthalmologists

Uveitis

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

Page 39: From Carrots to Keratitis:  An Eye Update for Non-Ophthalmologists

Ocular Trauma

Page 40: From Carrots to Keratitis:  An Eye Update for Non-Ophthalmologists

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

Page 41: From Carrots to Keratitis:  An Eye Update for Non-Ophthalmologists

Suspected Penetrating Trauma: “Ruptured Globe”

• Protect the eye • NPO• Urgent referral

Page 42: From Carrots to Keratitis:  An Eye Update for Non-Ophthalmologists

Chemical Injury• Defer vision check and

detailed history• Copious irritation• Antibiotic ointment• Urgent referral

Page 43: From Carrots to Keratitis:  An Eye Update for Non-Ophthalmologists

Floaters and Flashes

• Chronic floaters– Benign vitreous changes

• New floaters– Refer

• Photopsias– Urgent referral

Page 44: From Carrots to Keratitis:  An Eye Update for Non-Ophthalmologists

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

Page 45: From Carrots to Keratitis:  An Eye Update for Non-Ophthalmologists
Page 46: From Carrots to Keratitis:  An Eye Update for Non-Ophthalmologists

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!

Page 47: From Carrots to Keratitis:  An Eye Update for Non-Ophthalmologists

QUESTIONS?

Page 48: From Carrots to Keratitis:  An Eye Update for Non-Ophthalmologists
Page 49: From Carrots to Keratitis:  An Eye Update for Non-Ophthalmologists

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

Page 50: From Carrots to Keratitis:  An Eye Update for Non-Ophthalmologists
Page 51: From Carrots to Keratitis:  An Eye Update for Non-Ophthalmologists

Herpetic Keratitis

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

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

Page 52: From Carrots to Keratitis:  An Eye Update for Non-Ophthalmologists

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