Chiu FamilyMedicine 2018 - fcm.ucsf.edufcm.ucsf.edu/sites/fcm.ucsf.edu/files/026 Chiu-Common...

UCSF Family Medicine Board Review Chiu

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Common Eye Conditions Every Primary Care

Clinician Should Know

Cynthia S. Chiu, MD, FACSProfessor

UCSF Department of Ophthalmology

UCSF Family Medicine Board ReviewMarch 21, 2018

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 extraocularmuscles

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


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Penlight Exam

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

Lids

LashesConjunctiva/Sclera

Cornea

Iris/Pupil

LensPuncta

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.jpghttp://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

Infectious Conjunctivitis

VIRAL: Clear/mucoid discharge Lymphadenopathy Contagious! Treat for comfort

BACTERIAL: Purulent discharge Culture: Staph, Strep, Hflu

– PolyTrim or Vigamox– NOT Tobra or Gent

GC, chlamydia (IM/PO)


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Allergic Conjunctivitis

History of atopy Conjunctival edema Itchy!

Topical antihistamines– Zaditor– Patanol/Pataday/Pazeo

Visine tachyphylaxis

Blepharitis

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

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

Dry Eye Syndrome

Burning, stinging, excess tearing (wind or cold) Blurry vision that improves with blinking Artificial tears, immunologics (Restasis, Xiidra)

http://steptohealth.com/wp-content/uploads/2015/07/dry-eye.png

Herpes Simplex

When to refer:V1, V2red eyeeye painchange 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


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Angle Closure Glaucoma

Headache Loss of vision Firm eye

IV Diamox, Mannitol Glaucoma gtt’s Surgical treatment

Subconjunctival Hemorrhage

Coughing/sneezing, HTN, anti-coagulation, eye rubbing, spontaneous

Not dangerous unless vision has changed In the setting of trauma: refer

http://sixfishes.com/_cache/assets/img/441-r-w320-q75-m1445457194.jpg

Corneal Abrasion

Pain! Loss of epithelium Not infected

Erythromycin ung PolyTrim gtt 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


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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.gifhttp://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 theEyelid and Orbit

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

Ptosis

Loosening of eyelid muscle, extra skin Surgical repair

http://www.drduerksen.com/public/images/gallery/1366466717-1366466717-111052-(Small).jpg


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Trichiasis

Eyelash growing inward toward the eye

Epilation Electrolysis

http://healthfixit.com/wp-content/uploads/2016/01/Trichiasis-or-Ingrown-Eyelash-1.jpg

Ectropion/Entropion

Ectropion: rotation of eyelid outward Entropion: rotation of eyelid inward Irritation of the ocular surface Surgical repair

http://www.shropshireeyecare.co.uk/sites/default/files/Bilateral%20LL%20ectropion_2_0.jpeghttp://www.lancashireeyeclinic.co.uk/wp-content/uploads/2014/09/lower-lid-entropion-6.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


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Posterior Vitreous Detachment

Separation of vitreous from optic nerve and retina Sudden appearance of floaters (ring/lines) Small risk of retinal tear when first occurs,

otherwise benign

http://www.retinacarecenternj.com/images/p-pvd_diagram_100.jpghttp://theretinagroup.com/wp-content/uploads/2015/06/Screen-Shot-2015-06-14-at-8.08.41-PM.png

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

Microvasculardisease

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)


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Retinal Vein Occlusion

HTN/hyperlipidemia 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


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

Thank You!

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

Cynthia S. Chiu, MD, FACS(510) 836-2122 Oakland, [email protected]

http://www.tylin.com/system/uploads/gallery_image/image/681/080714_demo_Burbank-2 3 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


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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

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