TIPS FOR A BETTER EYE EXAM Emily Schmidt COT I have no relevant - PowerPoint PPT Presentation

TIPS FOR A BETTER EYE EXAM Emily Schmidt COT I have no relevant financial or nonfinancial relationships in the products or services described, evaluated or compared in this presentation.

HOW COMMON IS NYSTAGMUS? • A. 1 in 1,000 • B. 1 in 3,000 • C. 1 in 5,000 • D. 1 in 10,000 The answer may surprise you…

A. 1 in 1,000 According to the 2010 census the Minneapolis, St Paul metropolitan area population was 3,759,978 and 7.139 billion in the world. This means there are 3,760 people in the twin cities with nystagmus and 7,139,000 worldwide.

NYSTAGMUS GROUPS  Sensory  Neurological KINDS OF NYSTAGMUS  Congenital  Acquired NYSTAGMUS FORMS  Manifest  Latent  Manifest-Latent NYSTAGMUS SUBTYPES  49 different subtypes

Duration  Congenital=lifelong  1 exception Spasmus Natans  Acquired=??? ASSOCIATED CONDITIONS: CONGENITAL  Congenital Cataract  Optic nerve hypoplasia  Aniridia  Severe refractive error  Retina coloboma  Other optic nerve and retina disorders  Albinism (both regular and ocular)  Fetal alcohol syndrome  Idiopathic…

ASSOCIATED CONDITIONS: ACQUIRED  Medication use  Vitamin deficiency  Trauma  Inner ear (vestibular) problems  Stroke (most common cause in older people with acquired nystagmus  Brain tumor (rare cause of acquired nystagmus)  Multiple sclerosis  Chiari Malformation  NEVER IDIOPATHIC!!!

H OW DOES SOMEONE WITH CONGENITAL NYSTAGMUS SEE THE WORLD???

TYPES OF NYSTAGMUS MOVEMENTS 1. Vertical

1a.Upbeat

1b.Downbeat

1c.Seesaw

2.Torsional/ Rotary

3.Horizontal

3a. Horizontal jerk

Spasmus Natans

WAYS TO CAUSE TEMPORARY NYSTAGMUS Rapid head shaking or spinning Optokinetic drum or the railroad effect

NYSTAGMUS MANAGEMENT METHODS  Correct vision with Rx if needed  Glasses  Contacts  Prisms  Convergence  Null point  Surgery  Null point  Strabismus  Muscle/nerve disruption

 High minus contacts with high plus glasses  Botox  Retrobulbar vs individual muscles  Acquired: MS, stroke, tumors  Side affects: ptosis, diplopia, reduced accommodation  Temporary 3-6 months/2-3 months  Medications  Azopt (Brinzolamide) CN/INS  Oral medications-acquired

Management Approach Examples Gabapentin Barbiturates Oral Medications Memantine Alcohol 4-aminopyridine Acetazolamide 3,4-diaminopyridine Brinzolamide (topical) Baclofen Cannabis Clonazepam Valproate Trihexyphenidyl Benztropine Scopolamine Isoniazid Carbamazepine

Nystagmus Type Medication Common Side-Effects Treatment of Not applicable Peripheral Vestibular underlying Nystagmus disorder 4-aminopyridine Dizziness, paresthesias, Downbeat incoordination Nystagmus 3,4-diaminopyridine Dizziness, paresthesias, Clonazepam incoordination Drowsiness, dizziness, incoordination Memantine Lethargy, dizziness, headache Upbeat Nystagmus 4-aminopyridine Dizziness, paresthesias, incoordination Baclofen Drowsiness, dizziness, lethargy

Nystagmus Type Medication Common Side-Effects Torsional Nystagmus Gabapentin Dizziness, incoordination, drowsiness Alcohol Drowsiness, incoordination, vomiting Seesaw Nystagmus Clonazepam Drowsiness, dizziness, incoordination Memantine Lethargy, dizziness, headache Baclofen Drowsiness, dizziness, lethargy Periodic Alternating Nystagmus Memantine Lethargy, dizziness, headache Gabapentin Dizziness, incoordination, drowsiness Acquired Pendular Nystagmus in MS Memantine Lethargy, dizziness, headache Gabapentin Dizziness, incoordination, drowsiness Acquired Pendular Nystagmus in OPT Memantine Lethargy, dizziness, headache Trihexyphenidy Dry mouth, blurred vision, dizziness

MANAGEMENT METHODS SUMMARY  All methods can yield similar results  Nystagmus may be lessoned but never gone  Vision may be improve by up to 4 lines, 1 to 2 is more common, or it may not improved at all  Drugs for acquired are mainly used to reduce or stop oscillopsia

THE EXAM…  ***LISTEN TO YOUR PATIENT!!!***  Slow down, Slow down, SLOW DOWN!!!!!!!!!  Let them use their null point

THE EXAM  Always check binocular vision  Let them hold the near card where they want  Low vision does not equal low IQ  Watch out for memorization  Not everyone with nystagmus has a latent component

OCCLUDERS Single vs double occluder??? Null point=single occluder Large movement=single occluder

OCCLUDERS Black vs Translucent Translucent patch occluder Clip on occluders Handheld pinhole Clip on pinhole

PHOROPTER VS TRIAL FRAMES Null point=Trial frames Large movement=Trial frames Latent component=Trial frames*** Black occluder lens Pinhole lens Plus lens

SPECIALIZED TESTS OCT, fundus photos, visual field, topography, IOL master, etc… Breath, don’t panic Adjust the machine to the patient Don’t get frustrated Accept that you may not get a perfect test Use comment boxes

THE UNNECESSARY “NECESSARY TESTS ” Ø Non Contact Tonometry Ø Autorefractors 2 Common Patient Surgery Questions ? Can I have LASIK ? Can I have cataract surgery

REFERENES http://www.allaboutvision.com/conditions/nystagmus.htm http://www.ncbi.nlm.nih.gov/pmc/articles/PMC1279675/ http://webeye.ophth.uiowa.edu/eyeforum/tutorials/Nystagmus/ http://www.ncbi.nlm.nih.gov/pmc/articles/PMC1279676/ http://content.lib.utah.edu/utils/getfile/collection/ehsl- nam/id/47/filename/image http://www.aapos.org/terms/conditions/80 http://emedicine.medscape.com/article/1199177-overview#a0101 http://en.wikipedia.org/wiki/Nystagmus RESOURCES FOR PATIENTS American Nystagmus Network (ANN): http://nystagmus.org/new/index.php ANN Facebook Group Nystagmus Network (NN) UK based: http://www.nystagmusnet.org/cms/ Nystagmus United Facebook group