Ophthalmology: Current Topics in Questions and Answers - - PDF document

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Current Topics in Ophthalmology

Jacque Duncan, MD Professor, Clinical Ophthalmology UCSF Primary Care Medicine: Principles and Practice October 30, 2013

Ophthalmology: Questions and Answers

With help from: Stephen D. McLeod, Professor and Chair, UCSF Department of Ophthalmology Ayman Naseri, Professor and Vice Chair for Graduate Medical Education, UCSF Department of Ophthalmology

Disclosures:

 I have nothing to disclose

Common Questions:

• 1. What does my patient need before

undergoing cataract surgery?

• 2. Are vitamins really helpful in preventing

vision loss?

• 3. What do I need to do for patients on

Plaquenil?

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Common Questions:

• 1. What does my patient need before

undergoing cataract surgery?

• 2. Are vitamins really helpful in preventing

vision loss?

• 3. What do I need to do for patients on

Plaquenil?

Cataract Surgery

 Most commonly performed ambulatory

surgery in the US

 Numbers will increase as population ages  Should I do an extensive medical evaluation

to ensure my patient is safe to undergo surgery?

– True – False

Should I do routine medical testing (EKG, CBC, renal panel) to ensure my patient is safe to undergo surgery?

• 1. Yes
• 2. No

No: Cochrane Review

 Routine pre-operative testing does not

increase the safety of cataract surgery

– Intraoperative events (OR 1.02, 95% CI 0.85 to 1.22) – Postoperative adverse events (OR 0.96, 95% CI 0.74 to

1.24).

– Costs estimated to be 2.55 times higher in those with

preoperative medical testing compared to those without preoperative medical testing.

 91.4% one year survival rate among VA pts

with high disease burden

Keay L, et al. Cochrane Database of Systematic Reviews 2012, Issue 3. Art. No.: CD007392 Schein O et al. NEJM 2000; 342:168-75 Greenberg PB et al. J Cataract Refract Surg 2011; 37:970-71

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Should I discontinue my patient’s anticoagulant or antiplatelet medications before cataract surgery?

• 1. Yes
• 2. No

Answer: NO

 Most cataract surgery is done without any

injections

 May increase medical morbidity  Ophthalmologists need to communicate

with primary care providers for patients with severe systemic disease, or when more invasive ocular surgery is planned.

American Academy of Ophthalmology Cataract in the Adult Eye. Preferred Practice Patterns, 2006. Chen CK, Tseng VL, Wu W-C, Greenberg PB. J Cataract Refract Surg 2010; 36:1239-40. Ong-Tone L, Paluck EC, Hart-Mitchell RD. J Cataract Refract Surg 2005;31:991-6.

Common Questions:

• 1. What does my patient need before

undergoing cataract surgery?

• 2. Are vitamins really helpful in preventing

vision loss?

• 3. What do I need to do for patients on

Plaquenil?

Age-Related Macular Degeneration

 Leading Cause of Severe Central Vision Loss among

people over 50 in U.S.

– 6 million cases in U.S. – 1.75 million over age 50 have advanced AMD  Prevalence increasing as population ages

 Population >60 will double by 2030  Number with advanced AMD will increase 50% to 2.95 M by

2020 Eye Diseases Prevalence Research Group, Arch Ophthalmol 2004;122:564-72

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AMD Normal

Normal Retina

Milam AH, John SK. The Human Retina in Heath and Disease CD-ROM. 2001

Drusen

Milam AH, John SK. The Human Retina in Heath and Disease CD-ROM. 2001

Geographic Atrophy

Milam AH, John SK. The Human Retina in Heath and Disease CD-ROM. 2001

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Choroidal Neovascularization

10% of patients, 90% of severe vision loss

Milam AH, John SK. The Human Retina in Heath and Disease CD-ROM. 2001

Disciform Scar

Milam AH, John SK. The Human Retina in Heath and Disease CD-ROM. 2001

Nutritional Supplements in AMD



Age Related Eye Disease Study (AREDS)

–

Double-masked, placebo-controlled, multicenter, randomized clinical trial

–

3,640 patients, followed at least 5 years (average 6.3 years)

–

Randomly assigned to high doses of:

• 1. Antioxidants
• Vit C 500mg, Vit E 400 IU, -carotene 15mg
• 2. Zinc=80mg Zn oxide + 2mg cupric oxide
• 3. Antioxidants + Zinc
• 4. Placebo

AREDS Research Group, Arch Ophthalmol 2001;119:1417-36

Risk of Developing Advanced AMD

Placebo Antioxidants Zinc Antioxidants+Zinc

Years

Percent with Advanced AMD

50 40 30 20 10 1 2 3 4 5 6 7

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Age Related Eye Disease Study (AREDS)

 Recommend: – All people > 55 years old should have dilated eye

examinations

– If patients have medium to high-risk AMD in either

eye, or advanced AMD in 1 eye:

 Consider supplemental vitamin C, E, zinc +copper  Add -carotene if not a smoker  Quit smoking if a smoker!

 AREDS 2

 No additional benefit to adding lutein and omega-3

fatty acid supplementation

AREDS Research Group, Arch Ophthalmol 2001;119:1417-36 AREDS Study 2 Research Group, JAMA 2013:309:2005-15

Common Questions:

• 1. What does my patient need before

undergoing cataract surgery?

• 2. Are vitamins really helpful in preventing

vision loss?

• 3. What do I need to do for patients on

Plaquenil?

63 year old woman

 PMH: Lupus with Sjogren’s syndrome  Meds: Treated with hydroxychloroquine 400 mg

daily for 25 years (lifetime dose of 3,650 grams). Weight of 135 lbs = 6.52 mg/kg/d

 Complained of vision loss, but her ophthalmologist

records visual acuity of 20/20 OU.

 She was told her vision was fine and not to worry.  Stopped taking hydroxychloroquine in 2005  Monitored with serial Humphrey visual field tests:

Visual fields: 2003

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Visual fields: 2007 Visual fields: 2009 Fundus Photos: 2009 Retinal Toxicity and Hydroxychloroquine

 Rare relative to the many thousands/millions of individuals

treated

 Of concern because even after drug cessation there is little if

any visual recovery and sometimes progression of vision loss

 Mechanism not clearly understood  Early symptoms: paracentral vision loss with foveal sparing  Moderate: bull’s eye maculopathy  Late: loss of peripheral visual field, night vision, widespread

fundus changes

 Toxicity can be prevented if the drug is discontinued

before advanced macular outer retinal damage has

• ccurred

Marmor MF et al, Ophthalmology 2002; 109: 1377-82

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Retinal Toxicity and Hydroxychloroquine

 Risk factors:

– Daily dose greater than 6.5 mg/kg/d IBW – Obesity: drug is not retained in fat – Duration of therapy greater than 5 years

 After 7 years: risk increases to 1%

– Cumulative dose > 1000 g – Renal or hepatic dysfunction – Age greater than 60 years – Macular or retinal disease at baseline (AMD)

Ideal body weight: women = 100 lbs + 5 lbs for each inch over 5 feet men = 110 lbs + 5 lbs for each inch over 5 feet

Screening Protocol

 Patient counseling re: risk of permanent vision loss and

need for periodic exams

 Baseline exam, then annually after 5 years  Visual field testing: Sensitivity losses 2-6 degrees from

fixation

– White: red is sensitive but not specific – Even the most subtle change should prompt objective

testing and referral to an ophthalmologist!

Marmor MF et al, Ophthalmology 2011; 118: 415-22

Hydroxychloroquine/Chloroquine Screening recommendations

 Baseline:

– Dilated Eye Exam and Visual Field Testing

– Look for pre-existing disease that could contraindicate use

• r complicate interpretation of screening tests

– Consider baseline referral to optometry or ophthalmology  Routinely check for toxic daily dosing: > 6.5 mg/kg

ideal body weight

 No additional ophthalmic testing for the first 5 years

for routine patients in absence of visual symptoms, renal or hepatic disease

Browning DJ, Am J Ophthalmol 2013: 155: 418-28 Marmor MF, Am J Ophthalmol 2013; 155: 413-14

Hydroxychloroquine/Chloroquine Screening recommendations

 Follow up:

– Consider annual undilated visual fields and where

available, SDOCT photos: sensitive and widely available

– Take any visual field changes seriously and evaluate

with objective tests

– Refer to ophthalmology with any subjective or visual

field changes for more advanced objective testing

– Require at least 2 methods (1 objective) to confirm

toxicity before recommending drug discontinuation

Marmor MF, Am J Ophthalmol 2013; 155: 413-14 Browning DJ, Am J Ophthalmol 2013: 155: 418-28

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Common Questions (and Answers):

• 1. What does my patient need before undergoing

cataract surgery?

–

Excellent medical care by you and communication with ophthalmology!

• 2. Are vitamins really helpful in preventing vision

loss?

–

YES: AREDS for AMD

• 3. What do I need to do for patients on Plaquenil?

–

Baseline and regular evaluations with visual fields and eye exams by opthalmology or optometry

References



Keay L, Lindsley K, Tielsch J, Katz J, Schein O. Routine preoperative medical testing for cataract surgery. Cochrane Database of Systematic Reviews 2012, Issue 3. Art. No.: CD007392. DOI: 10.1002/14651858.CD007293.pub3



Schein OD, Katz J, Bass EB, Tielsch JM, Lubomski LH, Feldman MA, Petty BG, Steinberg EP. The value of routine preoperative medical testing before cataract surgery. N Engl J Med 2000;342:168-75.



Greenberg PB, Tseng VL, Jiang L, Wu W-C. Cataract surgery in the very ill. J Cataract Refract Surg 2011;37:970- 971



American Academy of Ophthalmology Cataract in the Adult Eye. Preferred Practice Patterns. San Francisco, CA(2006). Available at www.aao.ppp



Chen CK, Tseng VL, Wu W-C, Greenberg PB. Survey of the management of antithrombotic therapy in cataract surgery patients. J Cataract Refract Surg 2010; 36:1239-40.



Ong-Tone L, Paluck EC, Hart-Mitchell RD. Perioperative use of warfarin and aspirin in cataract surgery by Canadian Society of Cataract and Refractive Surgery members: Survey. J Cataract Refract Surg 2005;31:991-6.



Milam AH, John SK. The Human Retina in Heath and Disease CD-ROM. Phiadelphia, PA, Scheie Eye Institute, 2001.



Eye Diseases Prevalence Research Group, Arch Ophthalmol 2004;122:564-72.



AREDS Research Group. A randomized, placebo-controlled, clinical trial of high-dose supplementation with vitamins C and E, beta carotene, and zinc for age-related macular degeneration and vision loss: AREDS report no. 8. Arch Ophthalmol 2001;119:1417-36.



AREDS Study 2 Research Group. Lutein + zeaxanthin and omega-3 fatty acids for age-related macular degeneration: the Age-Related Eye Disease Study 2 (AREDS2) randomized clinical trial. JAMA 2013:309:2005-15.



Marmor MF et al, Ophthalmology 2002;109: 1377-82.



Marmor MF et al, Ophthalmology 2011; 118: 415-22.



Lyons and Severns, Am J Ophthalmol 143:801-9, 2007.



Browning DJ, Am J Ophthalmol 2013: 155: 418-28