Every Primary Care Clinician Should Know Cynthia S. Chiu, MD, FACS - - PowerPoint PPT Presentation

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Every Primary Care Clinician Should Know Cynthia S. Chiu, MD, FACS - - PowerPoint PPT Presentation

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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

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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

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SLIDE 2

Disclosure

I have no financial interest in any of the products mentioned in this presentation

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SLIDE 3

The Eye Exam

 Eye Vital Sign  Near Vision Card  Held at 14 inches  Glasses as needed

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

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SLIDE 4

Pupils

 Look for afferent

pupillary defect

 Swinging flashlight

test

 +APD indicates

  • ptic nerve or large

retinal lesion

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

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Motility

 Six extraocular

muscles

 Test cardinal fields

  • f gaze

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

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SLIDE 6

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

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SLIDE 7

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

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SLIDE 8

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

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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

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Primary Care Ophthalmology

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

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SLIDE 11

The Red Eye

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

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Viral Conjunctivitis

 URI  Clear or mucous

discharge

 Lymphadenopathy  Contagious!  Treat for comfort

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Bacterial Conjunctivitis

 Purulent discharge  Culture  Staph, Strep, Hflu

– Polymixin/Trimethoprim – Fluoroquinolones – NOT Tobra or Gent

 GC, chlamydia

– Systemic Rx

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SLIDE 14

Allergic Conjunctivitis

 History of atopy  Conjunctival edema  Itchy!  Topical antihistamines

– Elestat – Zaditor – Patanol

 Visine tachyphylaxis

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SLIDE 15

Blepharitis

 Redness, itching, “grit”, dry eyes  Rosacea, Staph, Demadex  Warm compresses, baby shampoo, artificial tears  Doxycycline, Azithromycin

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

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SLIDE 16

Herpes Simplex

 When to refer:

V1, V2 red eye eye pain change in vision

 Acyclovir

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SLIDE 17

Herpes Zoster

 Hutchinson’s sign: nasociliary nerve  Treat Post-Herpetic Neuralgia:

Lyrica, Neurontin, TCA’s

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SLIDE 18

Uveitis

 Inflammation of

vascular tissue

 Auto-immune  Infectious  Toxic  Masquerade  May require

immunosuppression

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SLIDE 19

Angle Closure Glaucoma

 Headache  Loss of vision  Firm eye  IV Diamox, Mannitol  Glaucoma gtt’s  Surgical treatment

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Subconjunctival Hemorrhage

 Valsalva, HTN, anticoagulants, eye rubbing,

spontaneous

 In the setting of trauma: refer

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Corneal Abrasion

 Pain!  Loss of epithelium  Not infected  Erythromycin ung  Artificial Tears  Patching

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Corneal Foreign Body

 Iron is toxic  Surgical treatment

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SLIDE 23

Hyphema

 Severe eye trauma  Risk of rebleed  Risk of glaucoma

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SLIDE 24

Ruptured Globe

 Peaked pupil  Brown tissue

  • utside the eye

 CT scan NOT MRI  Fox shield, NPO

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SLIDE 25

Common Diseases of Aging

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

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Cataract

 Painless progressive loss of vision with age  Also caused by DM, XRT, trauma, medications  Difficulty reading, driving, glare  Outpatient surgery

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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

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Macular Degeneration

 Risk factors: age, UV, tobacco, Family Hx  Loss of central vision  Dry form: AREDS vitamins, stop smoking  Wet form: anti-VEGF injections

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SLIDE 29

Disorders of the Eyelid and Orbit

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

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Chalazion

 Blocked oil gland  Inflammation  Warm compresses  Incision/curettage

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Cellulitis

 Preseptal vs Orbital  Preseptal: full EOM,

no proptosis, quiet eye

 Treat PO Abx  Orbital: proptosis,

strabismus, inflamed eye

 Treat IV ABx

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SLIDE 32

Thyroid Orbitopathy

 Proptosis  Strabismus/Diplopia  Corneal exposure  Optic nerve

compression

 131-I may aggravate  Surgical treatment

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Disorders of the Retina

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

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Retinal Detachment

 Flashes/Floaters  Loss of vision/field  Sudden, painless  Surgical treatment

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

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Diabetic Retinopathy

 Microvascular disease  Bleeding  Macular edema  Neovascularization  Glucose/BP control  Laser ablation  Anti-VEGF

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SLIDE 36

Hypertensive Retinopathy

 Mild: arteriolar narrowing  Mod: cotton wool spots,

hemorrhages

 Severe: disc edema,

vessel leakage, infarcts

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SLIDE 37

HIV/CMV Retinopathy

 Microvascular

disease

 Annual exam if

CD4>200

 CMV retinitis

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

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SLIDE 38

Retinal Artery Occlusion

 Embolic: cardiac echo,

carotid doppler

 Vasculitic (GCA)

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SLIDE 39

Retinal Vein Occlusion

 Hypertension  Glaucoma  Young patients:

hypercoagulable

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SLIDE 40

Neuro-Ophthalmology

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

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SLIDE 41

Stroke

 Homonymous

field defect

 Location of

lesion is contralateral + upside-down

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SLIDE 42

Pituitary Adenoma

 Compression of nasal

fibers at optic chiasm

 Bitemporal hemianopia

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

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SLIDE 43

Temporal Arteritis

 Acute vision loss  Headache, jaw claudication,

scalp tenderness, proximal myalgias, constitutional symptoms

 ESR and CRP  Prednisone 100mg QD  Temporal artery biopsy

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SLIDE 44

Optic Neuritis

 Loss of vision  Pain with EOM  +/- disc edema  Multiple Sclerosis  Steroids

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

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SLIDE 45

Pseudotumor Cerebri

 Headache, tinnitus  Papilledema  Vision loss  Female, overweight  Medication-induced  LP: opening pressure

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

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SLIDE 46

Horner Syndrome

 Anisocoria in the dark  Mild ptosis  Acute and painful:

R/O carotid dissection

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

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SLIDE 47

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

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SLIDE 48

Thank You!

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

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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

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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