Common Eye Conditions Every Primary Care Clinician Should Know€¦ · Common Eye Conditions Every Primary Care Clinician Should Know Cynthia S. Chiu, MD, FACS Associate Professor

Common Eye Conditions

Every Primary Care

Clinician Should Know

Cynthia S. Chiu, MD, FACS

Associate Professor

UCSF Department of Ophthalmology

UCSF Family Medicine Board Review

March 9, 2016

http://www.timandjeni.com/images/cookiemonster.jpg

Disclosure

I have no financial interest in any of the

products mentioned in this presentation

The Eye Exam

Eye Vital Sign

Near Vision Card

Held at 14 inches

Glasses as needed

http://www.drbanker.com/images/Nearvision.gif

Pupils

Look for afferent pupillary defect

Swinging flashlight test

+APD indicates optic nerve or large retinal lesion

http://img.tfd.com/ElMill/thumb/F0P-24-S2958.jpg

Motility

Six extraocular muscles

Test cardinal fields of gaze

http://www.opsweb.org/OpPhoto/Extern/Motility/muscle.jpg

http://www.opsweb.org/OpPhoto/Extern/Motility/9gazedwg.jpg

Confrontational Visual Fields

Cover eyes on same side

Hold fingers midway between

Normal per eye:

60-60-60-90

http://www.ncbi.nlm.nih.gov/bookshelf/br.fcgi?book=cm&part=A3460&rendertype=figure&id=A3464

Penlight Exam

http://cache.heraldinteractive.com/blogs/sports/rap_sheet/wp-content/uploads/2009/11/bionic-eye.jpg

Lids

Lashes

Conjunctiva/Sclera

Cornea

Iris/Pupil

Lens Puncta

Anterior Chamber Depth

Deep chamber: illumination of nasal iris

Shallow chamber: shadow on nasal iris

Dilation: Phenylephrine 2.5%, Tropicamide 1%

http://www.ophthobook.com/wp-content/uploads/2007/12/video-glaucoma-shallowpenlight.jpg

http://iei.ico.edu/images/anatomy.jpg

Fundoscopy

PanOptic or Direct Ophthalmoscope

Evaluate optic nerve, retinal vessels, macula

http://www.welchallyn.com/images/corporate/0509_wa_bmurf/011810xx1PanOpticRedHe.jpg

http://webvision.med.utah.edu/imageswv/retina.jpeg

Primary Care Ophthalmology

http://www.factzoo.com/sites/all/img/reptiles/chameleon-eyes.jpg

The Red Eye

http://i.zdnet.com/blogs/lord-of-the-rings-ii-eye-of-sauron-4900244.jpg

Viral Conjunctivitis

URI

Clear or mucous discharge

Lymphadenopathy

Contagious!

Treat for comfort

Bacterial Conjunctivitis

Purulent discharge

Culture

Staph, Strep, Hflu

– Polymixin/Trimethoprim

– Fluoroquinolones

– NOT Tobra or Gent

GC, chlamydia

– Systemic Rx

Allergic Conjunctivitis

History of atopy

Conjunctival edema

Itchy!

Topical antihistamines

– Elestat

– Zaditor

– Patanol

Visine tachyphylaxis

Blepharitis

Redness, itching, “grit”, dry eyes

Rosacea, Staph, Demadex

Warm compresses, baby shampoo, artificial tears

Doxycycline, Azithromycin

http://www.stop-rosacea.com/

Herpes Simplex

When to refer:

V1, V2

red eye

eye pain

change in vision

Acyclovir

Herpes Zoster

Hutchinson’s sign: nasociliary nerve

Treat Post-Herpetic Neuralgia:

Lyrica, Neurontin, TCA’s

Uveitis

Inflammation of vascular tissue

Auto-immune

Infectious

Toxic

Masquerade

May require immunosuppression

Angle Closure Glaucoma

Headache

Loss of vision

Firm eye

IV Diamox, Mannitol

Glaucoma gtt’s

Surgical treatment

Subconjunctival Hemorrhage

Valsalva, HTN, anticoagulants, eye rubbing, spontaneous

In the setting of trauma: refer

Corneal Abrasion

Pain!

Loss of epithelium

Not infected

Erythromycin ung

Artificial Tears

Patching

Corneal Foreign Body

Iron is toxic

Surgical treatment

Hyphema

Severe eye trauma

Risk of rebleed

Risk of glaucoma

Ruptured Globe

Peaked pupil

Brown tissue outside the eye

CT scan NOT MRI

Fox shield, NPO

Common Diseases of Aging

http://www.jaredyellin.com/wp-content/uploads/2009/12/old-man-winking1.jpg

Cataract

Painless progressive loss of vision with age

Also caused by DM, XRT, trauma, medications

Difficulty reading, driving, glare

Outpatient surgery

Glaucoma

Chronic progressive optic neuropathy

Loss of visual field

Risk factors: age, tobacco, race, family hx

Medications may have systemic interactions http://img.medscape.com/fullsize/migrated/569/545/569545.fig2.gif

http://cdn.shopmedvet.com/images/uploads/2640_7780_thumb.jpg

Macular Degeneration

Risk factors: age, UV, tobacco, Family Hx

Loss of central vision

Dry form: AREDS vitamins, stop smoking

Wet form: anti-VEGF injections

Disorders of the

Eyelid and Orbit

http://greatpiercingshop.com/blog/wp-content/uploads/2009/12/eyelid-piercing-method-and-aftercare_49.jpg

Chalazion

Blocked oil gland

Inflammation

Warm compresses

Incision/curettage

Cellulitis

Preseptal vs Orbital

Preseptal: full EOM,

no proptosis, quiet eye

Treat PO Abx

Orbital: proptosis, strabismus, inflamed eye

Treat IV ABx

Thyroid Orbitopathy

Proptosis

Strabismus/Diplopia

Corneal exposure

Optic nerve compression

131-I may aggravate

Surgical treatment

Disorders of the Retina

http://webphysics.davidson.edu/faculty/dmb/EdibleOpticalMaterials/index_files/cyclops.jpg

Retinal Detachment

Flashes/Floaters

Loss of vision/field

Sudden, painless

Surgical treatment

http://www.rameshshahmd.com/pictures/retinal%20detach.%201.jpg?nxg_versionuid=published

Diabetic Retinopathy

Microvascular disease

Bleeding

Macular edema

Neovascularization

Glucose/BP control

Laser ablation

Anti-VEGF

Hypertensive Retinopathy

Mild: arteriolar narrowing

Mod: cotton wool spots, hemorrhages

Severe: disc edema, vessel leakage, infarcts

HIV/CMV Retinopathy

Microvascular disease

Annual exam if CD4>200

CMV retinitis

http://depts.washington.edu/hivaids/images/oit/oit_c7_d06.jpg

Retinal Artery Occlusion

Embolic: cardiac echo, carotid doppler

Vasculitic (GCA)

Retinal Vein Occlusion

Hypertension

Glaucoma

Young patients: hypercoagulable

Neuro-Ophthalmology

http://www.capitalgainsmedia.com/images/Development%20News%20Photos/Dev-Ino-Issues%2002/Dev-Ino%20Issue%200244/DSC01869.jpg

Stroke

Homonymous field defect

Location of lesion is contralateral + upside-down

Pituitary Adenoma

Compression of nasal fibers at optic chiasm

Bitemporal hemianopia

http://www.lfhk.cuni.cz/patfyz/intranet/Figures/58/18.13.jpg

Temporal Arteritis

Acute vision loss

Headache, jaw claudication, scalp tenderness, proximal myalgias, constitutional symptoms

ESR and CRP

Prednisone 100mg QD

Temporal artery biopsy

Optic Neuritis

Loss of vision

Pain with EOM

+/- disc edema

Multiple Sclerosis

Steroids

http://www.djo.harvard.edu/files/2982_355.jpg

Pseudotumor Cerebri

Headache, tinnitus

Papilledema

Vision loss

Female, overweight

Medication-induced

LP: opening pressure

http://www.caleyes.com/images/papilledema-image.jpg

Horner Syndrome

Anisocoria in the dark

Mild ptosis

Acute and painful:

R/O carotid dissection

http://www.mrcophth.com/oculoplasticgallery/traumatichorner/horner.jpg

Third Nerve Palsy

Aniscoria in the light

Severe Ptosis

EOM paresis

Microvascular

PCA/PCom

aneurysm

http://www.nature.com/eye/journal/v18/n3/images/6700625f1.jpg

http://www.revophth.com/Images//2008/10/083_RPJ8_F6.gif

Thank You!

http://blog.omy.sg/dingan/files/2009/05/bob.jpg

References

http://www.drgreene.com/21_1254.html http://www.bobzyeruncle.com/archives/images/conjunctivitis-GC.html http://www.ueseyecare.com/images/photos/allergic_conjunctivitis_l.jpg http://www.ueseyecare.com/images/photos/viral_conjunctivitis_l.jpg http://www.vigamox.com/images/packaging.jpg http://dro.hs.columbia.edu/ced3/conjhemb.jpg http://www.aafp.org/afp/20030401/1481_f3.jpg http://eyemicrobiology.upmc.com/Images/Sub/PhotoEyeDendrite.jpg http://www.hkmj.org.hk/skin/images/108-1.jpg http://www.medicalskincare.be/images/content/herpes03.jpg http://www.tusalud.com.mx/images/herpes_zoster.jpg http://eyelearn.med.utoronto.ca/Lectures04-05/RedEye/images/11Kera2.jpg http://www.nova.edu/~albert/ScleritisWeb.jpg http://www.mrcophth.com/externaleyediseases/sp.JPG http://e-learning.studmed.unibe.ch/augenheilkunde/systematik/aderhaut/images/iritis2.jpg http://www.emedicine.com/oph/images/456cmv7.jpg http://www.revoptom.com/handbook/images/62a.jpg http://images.google.com/imgres?imgurl=http://www.asoprs.org/Graphics/gravesct.jpg&imgrefurl=http://www.asoprs.org/Pages/thyroid.html&h=250&w=

429&sz=9&tbnid=ul6zL-4JdFYJ:&tbnh=71&tbnw=122&start=1&prev=/images%3Fq%3Dthyroid%2Beye%2Bmuscles%26hl%3Den%26lr%3D http://www.medscape.com/content/2002/00/44/63/446304/art-mop446304.coat.fig3.jpg http://www.jeremydiamond.co.uk/graphics/cataract_eye.jpg http://technology.kingston.ac.uk/dirc/medical/images/catara2.jpg http://www.drloden.com/Pages/Pics/cataract.gif http://www.eri.harvard.edu/faculty/peli/Opthalm_Mngt_0803_files/xNat.beauty.jpg http://www.avclinic.com/images/tonometry.jpg http://www.avclinic.com/Glaucoma.htm http://www.lasikinstitute.org/Glaucoma_whatis.html http://www.neec.com/images/photos/mitrev5.jpg http://www.rvscny.com/images/Diabetic%20retinopathy.jpg http://www.tedmontgomery.com/the_eye/eyephotos/pics/DiabeticRetinopathyProliferative.jpg http://www.neec.com/images/photos/diabetic%20retinopathy%20figure%203.jpg

References

http://www.gaileyeyeclinic.com/images/dr3.gif http://www.foxeyecare.com/canon/large/diabetic_retinopathy.jpg http://hubnet.buffalo.edu/ophthalmology/site/Home/Eye_Disorders/Hypertensive_retinopathy.jpg http://www.mrcophth.com/retinacases/CMV.gif http://www.opt.indiana.edu/ce/antseg/graphics/cwsaids.jpg http://www.ohiovalleyeye.com/images/macdegen_K45_dry.jpg http://www.opt.pacificu.edu/ce/catalog/10701-PS/4hemorr.jpg http://www.ttuhsc.edu/eye/Faculty%20Presentations/Visual%20Field%20Testing%20Tech%20Seminar_files/slide0036_image002.jpg http://webeye.ophth.uiowa.edu/dept/GCA/images/GCAfig1b_.jpg http://www.ophthalmic.hyperguides.com/tutorials/oculoplastics/temporal_arteritis/slides/Slide1.jpg http://www.mrcophth.com/pathology/gca2.jpg http://content.lib.utah.edu/EHSL-WFH/image/icon124.jpg http://www.atlasophthalmology.com/atlasimg/1396_6_low_thumb.jpg http://www.tedmontgomery.com/the_eye/eyephotos/pics/CentralRetinalArteryOcclusion.jpg http://www.omnieyespecialists.com/images/eye_brao.jpg http://dro.hs.columbia.edu/vr3/crvob.jpg http://www.scielo.br/img/revistas/abo/v66n6/18991f1.jpg http://www.drugdigest.org/images/pillimages/A0315100.JPG http://ec1.images-amazon.com/images/I/31ITYXvQYpL._AA200_.jpg http://www.aafa.org/images/eye.jpg http://www.aclens.com/accessoryphotos/visine-advanced-relief-eye-drops-15-6683-v3b.jpg http://content.answers.com/main/content/wp/en-commons/thumb/6/69/420px-Gray784.png http://eyelearn.med.utoronto.ca/Lectures02-03/RedEye/images/RedEye_033.jpg http://www.varga.org/corneal_foreign_body_2.jpg http://www.permanente.net/homepage/kaiser/pictures/7945.gif http://www.medscape.com/pi/editorial/conferences/2001/747/art-aad-02.fig1.jpg http://www.opt.pacificu.edu/ce/catalog/10310-SD/Trauma%20Pictures/Hyphema.jpg http://www.revoptom.com/handbook/images/25aa.jpg http://www.tedmontgomery.com/the_eye/eyephotos/pics/Chalazion.jpg http://medicine.ucsd.edu/clinicalimg/eye-periorbital-cellulitis1.jpg http://eyelearn.med.utoronto.ca/Lectures05-06/RedEye/images/RedEye_010.jpg