Primary Care, Oc Dx, Pharm

Deepak Gupta, OD, FAAO

No financial disclosures

Anterior Blepharitis

Inflammation of the outside of the eyelids

Signs and symptoms include:

– Morning crusting of lids

– Collarettes - scales that encircle lash

– Loss of lashes

– Lid margin redness

Posterior Blepharitis

Inflammation of the inside of the eyelids

Signs and symptoms include:– Dilated & plugged meibomian gland orifices

with “toothpaste” like material– Thickened lid margin– Filmy vision with foam in tear film

Treatment Goals

Reduce Inflammation

Increase patient comfort

Decrease the Bacterial Load/Improve LidHygiene

Blepharitis:Short term management

Warm Compresses

Zylet or Tobradex– Tobramycin is great for any Staph component

– Steroid helps with redness, irritation

Side effects of Corticosteroids

Increased IOP

Cataracts

Decreased healing or re-emergence of certainviral, herpetic, and fungal infections

Most potent steroid

Difluprednate (Durezol)

Safest steroid

Loteprednol (Lotemax and Alrex)

Steroids and IOP spikes

Impacts 4 – 6% of the population

Usually takes over 2-4 weeks to get IOP spike

Steroids and IOP spikes

Mechanism: Inhibition of phagocytosis

Steroids and cataracts

If prescribing rarely for a given patient, not a bigdeal

If prescribing periodically, then educate thepatient on the risk and document this conversation

What about the risk of HSK?

You can never be 100% sure it’s not HSK

Document negative findings i.e. (no dendrites, no corneal staining)

See patient for follow up; educate patient to comeback ASAP if gets worse

If patient has herpetic infection

RX = Zirgan

ADV: Better dosing schedule than Viroptic

Also, more selective mechanism of action

Blepharitis:Long term management

THE KEY IS LYD HYGIENE

Patient education

Warm compresses

Lid Scrubs

Baby shampoo

My Approach

Have the patient use warm wash cloth in theshower every AM

Express glands in the shower, if needed

Call me ASAP for flare-ups

Corneal Foreign Body

Diagnostic Criteria:

– History related to accident

– Slit Lamp examination

Slit Lamp Exam - Abrasions

– See how close abrasion is to visual axis

– Check to see how deep the abrasion is

Management

Topical Antibiotics at least QID until resolution

Consider an antibiotic ointment at bedtime

Cycloplegic agent

Consider bandage CL

Topical

Topical NSAIDs

Key point to educate your patient on: Not usingtoo much!

MAX Dose of Acetaminophen

Two 325 mg tablets

Commonly used control substances

– Codeine Tylenol #3 (APAP 300 mg + Codeine 30 mg)

– Hydrocodone Lortab, 5, 7.5 (APAP 500 mg + Hydrocodone 2.5, 5, 7.5 mg) Vicodin (APAP 500 mg + Hydrocodone 5 mg)

Vicodin ES (APAP 500 mg + Hydrocodone 7.5 mg)

– Oxycodone

Percocet (APAP 326 mg + Oxycodone 5 mg)

Percodan (ASA 325 mg + Oxycodone 4.5 mg)

Tylox (APAP 500 mg + Oxycodone 5 mg)

Controlled Substances

– Schedule I: High abuse potential (heroin, marijuana, LSD)

– Schedule II: High abuse potential with severe dependence liability(narcotics, amphetamines

– Schedule III: Moderate dependence liability (certain narcotics,nonbarbiturate sedatives, etc)

– Schedule IV: Less abuse potential than S3; limited dependence lability(nonnarcotic analgesics, antianxiety agents, etc)

– Schedule V: Limited abuse potential (small amounts of narcotics inantitussives or antidiarrheals)

FDA Pregnancy CategoriesA - Controlled studies demonstrate no risk

B - No evidence in risk in humans. Either animal studies show risk and humansdo not OR if no human studies, animal studies negative

C - Risk cannot be ruled out. Human studies lacking but animal studies arepositive for fetal risk or lacking

D - Positive Evidence of riskInvestigational or post-marketing data show risk to fetus. If needed in life-

threatening situation or serious situation or serious disease, drug may beacceptable

X –Contraindicated in pregnancyFetal risk clearly outweighs any benefit to patient

For central abrasions

Or, you and instill loading dose of topicalantibiotics and then Rx both the antibiotic andtopical steroid

Document to the patient the potential for loss ofBCVA even if everything goes 100% as planned

My protocol for central abrasions

Instill antibiotic drop q 5 min for 30 min while patient isstill in office

Then I send patient home with: Hourly topical antibiotics TID topical steroid Cycloplegic agent Antibiotic ung QHS Oral OTC pain medications RTO 24 hours follow up

Patient may have RCE

What are risk factors for RCE?

Manage with Muro 128– Drops during the day

– Ointment at bedtime

Epithelial Debridement

Loosely adherent epithelium is debrided using a surgical sponge,spatula, or surgical blade

Anterior Stromal Puncture

Numerous small punctures through the epithelium andBowman’s layer into the anterior stroma.

Excimer Laser Phototherapeutic Keratectomy

The objective of PTK is simply to remove enough of thesuperficial Bowman layer to permit formation of a new basementmembrane with adhesion structures

The ablated anterior corneal stromal surface appears to be highlysupportive of stable reepithelialization

Doxycycline

DRUG CLASS: Systemic tetracylines

– MMP is upregulated in epithelial specimens of pts with recurrenterosion

– MMPs alter the epithelial basement membrane during wound healing

Doxycycline

Systemic tetracylines and topical steriods to reduce matrixmetalloproteinase (MMP) activity

– MMP is upregulated in epithelial specimens of pts with recurrenterosion

– MMPs alter the epithelial basement membrane during wound healing

Cataract surgery and keratoconus

Wound position a little more critical

Post op refraction more variable

Things to avoid: Toric and Multifocal IOL

ACG – classic signs

Increased IOP

VA hazy

Pt has headache and/or nausea

Mid fixed pupil

Steamy cornea

How do we rule out ACG on this patient?

SLE: Angles appear open

? Gonioscopy – probably not on this eye

IOP 23

Pupils: NL

If it was ACG what would you do on thispatient?

Lower IOP

Add Alphagan in office

?Add two tablets Diamox 250 - why not Diamox500 sequels?

Send to ER/Glaucoma Specialist?

Acute hydrops

Acute corneal hydrops is caused by the acutedisruption of Descemet's membrane in the settingof corneal ectasia.

Hydrops denotes the abnormal accumulation offluid

Management

Most cases of acute corneal hydropsspontaneously resolve over 2-4 months

Do we Rx anything?

Acute hydrops

Hypertonic sodium chloride to reduce epithelial edema

Cycloplegic for patient comfort.

Topical steroids to help reduce the inflammation and subsequentneovascularization that can accompany these episodes.

A large diameter bandage contact lens can be placed for comfort.

What about Corneal Cross-linking?

Uses Riboflavin as photosensitizer toincrease bonds between collagen fibers

Oral vs Topical

Can generally get better penetration intosuperficial ocular tissues with topical route

Only need orals for those tissues with poor ocularpenetration

If you have a topographer Initial Diagnosis

If you don’t a have topographer…

Refraction

Retinoscopy

Slit Lamp Findings

Corneal Pachmetry

Quick GP refraction

Refraction

Large changes in cylinder

Shifts in axis

BCVA not 20/20

Retinoscopy findings for keratoconus

Scissors motion

Keratometry findings for keratoconus

Distorted mires

Oval mires

Non superimposable central rings

Pachmetry findings for keratoconus

Normal cornea 540 Microns but that is centralcornea

You want thinnest point of cornea

Slit Lamp Findings Quick GP VA Check

Put in a drop of anesthetic

Apply GP roughly equivalent to BC

Do VA and OR

When does a keratoconus patient needsurgery

Risk of perforating

Scarring preventing adequate vision

???? Progression of disease ????

How often does the cornea perforate?

Almost never

Scarring of cornea

Mostly due to CL abuse and/or improperly fit lens

As scarring progresses, CL refit can often stop theprocess. Patients only need surgery if you waittoo long to refit them

When does a keratoconus patient NOTneed surgery

GP Intolerance

Poorly fitting contact lenses

???? Progression of disease ????

GP Intolerance/Poor fit

The percentage of patients who are truly GPintolerant is WAY over-rated

The vast majority of them have not been properlyfit or prepared for the process

Ways to avoid GP intolerance

New shoe analogy

Wait for vision to be bad enough to motivate thepatient to work through the discomfort

Astigmatism after PKP

The vast majority of patients are left with residualastigmatism

Refraction may be difficult or imprecise in these patients

Glasses may not work to correct this astigmatism. GPare often needed to fully restore vision

Complications

Delayed corneal reepithelization

Infection

Corneal endothelium cell damage – in thin corneas

Keratouveitis

Severe corneal haze

Is a patient better of getting refitmultiple times or surgery?

Which is less risky?

Progression is usually a finite time period

3 most common conditionswe send to retinal specialist

Retinal detachment

Diabetic retinopathy

Macular degeneration

How do we monitor patients with dryAMD

Amsler Grid is an easy screening test for monitoring AMD

Visual field 10-2 Fundus Photography

OCT UV Protection

Vitamins Stop Smoking

Dietary Changes Increase exercise

Genetic testing

Can we do these ourselves?

Absolutely !!!

So why do you need to send out?

Lucentis

Used for wet AMD, macular edema due to CRVOor diabetic macular edema

Typical protocol: once a month for at least 3months, then “every couple of months” dependingon clinical situation

When does a glaucoma patient needsurgery?

Selective Laser Trabeculoplasty Selective Laser Trabeculoplasty

Uses a “cold” laser

No thermal damage to tissues

Efficacy of SLT

90% successful after 3 years

Many still at target IOP at 5 years

SLT

Not best choice for adjunctive or alternativetherapy

Best use: Truly non compliant patients

Conventional Surgery OptionsTrabeculectomy

Conventional Surgery Options

Conventional Surgery Options

Tube Shunts

Stents and Microstents

Conventional Surgery Options

Cyclodestructive Procedures

Most common reasons why patients haveLASIK

Discomfort from CL wear

They are tired of having to deal with taking CL inand out every day

They want to be able to see during the night

By offering your patient a fitting with aCONTINUOUS WEAR CONTACT LENS

You will either solve the patient’s problem

OR

You will reinforce his or her decision to haveLASIK

When do we send a patient forcataract surgery?

When do you send a patient for cataractsurgery?

No magic number – it is based on a patient’s visual needs

Before you send them…

Talk to them about IOL optons – spherical, toric,bifocal

Talk to them about post op goal for refractiveerror

Talk to them about costs

Common Surgeries

Pterygium

PKP

Intacs

Corneal Crosslinking

SLT

Trab & Tube Shunts

Cataract Surgery

RD surgeries

Lid Surgeries

Refractive Surgery Procedures