NC2011-12 Opthalmology for Internist - Dr Mehtani

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Ophthalmology for the Internist:

Ophthalmology for the Internist Mohit Mehtani MD Ophthalmology PGY3, Georgetown University Ex-Highland Intern 2009-10


Objectives… Eye Anatomy/Exam DDX of a Red Eye Chronic Vision Loss Glaucoma, Cataracts, AMD Acute Vision Loss Retinal, Vascular, Optic Nerve Ocular Manifestations of Systemic Disease DM, HTN, Thyroid, Sarcoid, HIV/AIDS How to Spell Op H thalmology

Basic Eye Anatomy:

Basic Eye Anatomy

Visual Acuity:

Visual Acuity Visual Acuity What does 20/20 mean? 1 st number is distance (ft) between pt and chart 2 nd is distance at which letters can be read by a person with normal vision Presbyopia Starts in age 40s-50s

The “RED EYE”:

The “ RED EYE ” Conjunctivitis (viral, allergic, chemical, thermal, etc ) Keratitis (HSV, contact lens, etc ) Scleritis / Episcleritis Corneal abrasion Uveitis Dry eye Subconjunctival hemorrhage Angle closure glaucoma Ocular foreign body HGH Resident on Nightfloat

The “RED EYE”:

The “ RED EYE ” Basic Approach: Is the vision significantly decreased?  not just conjunctivitis Is there significant pain/photophobia?  think corneal problem or uveitis Both eyes?  think dry eyes or allergic conjunctivitis Unreactive Pupil?  think uveitis or angle closure glaucoma Any other history?

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Dr. Indulkar goes to the movies with a hot date and soon after the lights go down, she notices that her left eye hurts. She bites her lip and doesn ’ t complain as to not mess up her perfect date. Soon however, the pain becomes unbearable and she vomits into the popcorn bag and she sees halos around the movie screen. Should she: Suck it up and wait it out Go to the HGH ER Go to an optometrist the next morning Find a new date, because she is allergic to this one Flush her eyes with saline solution Angle Closure Glaucoma Most common in far-sighted, Asian eyes shallow chamber Induced by any adrenergic drug Treatment: topical glaucoma drops, po diamox , IV mannitol Definitive treatment: Laser iridotomy

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Dr. Chow wakes up one morning and leans in to kiss Dr. Wang who sees her and says “ Oh my God! Whats wrong with your eye! ” Dr. Chow says “ What? Nothing is wrong! ” and goes to the mirror and sees this: What most likely contributed to this lesion: The fact that Dr. Chow has been sick with flu-like symptoms The fact that Dr. Chow has been very constipated Dr. Chow sleeping in her contact lenses Dr. Chow ’ s seasonal allergies The fact that Dr. Chow has been possessed Subconjunctival hemorrhage Common in ventilated patients, hypertensive patients, ocular trauma Tx : Reassurance Recurrent: Think about VWD other other bleeding problem

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Dr. Dirocco is playing with his daughter who unexpectedly kicks him in the left eye on Friday. His eye is a little red but not really painful until Sunday when he cant stand the light at all with either eye. His eye under the slit lamp is shown. Uveitis/ Iritis , Traumatic AKA intraocular inflammation: DDX is large including trauma, infectious ( toxo , lyme , syphillis ), rheumatic (JRA, reactive arthritis, Sarcoid ) Treatment: topical and sometimes systemic steroids What is the diagnosis?

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Dr. Lahsaeizadeh is showing an intern how to put in a subclavian line into an intubated and sedated patient. The patient wakes up and smacks Dr Lahsaeizadeh in the eye. His eye is pictured. What is his diagnosis? a) Hypopyon b) Hyphema c) Imperforate Hymen d) HyStrung Hyphema  Ophthalmology Eval

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Dr Jafari has recurrent bouts of redness localized to one area of her right eye. Physical exam reveals a small lump in one are of the sclera with redness around it. This has happened about 5 times over the last few months, each lasting a few days. She ’ s a trooper so never saw anyone about it. Next step? a) reassurance b) artificial tears c) Topical antibiotics d) Oral antibiotics e) ophthalmologist for systemic workup Scleritis This can be a indicator of a systemic inflammatory disease like Sarcoid, rheumatoid arthritis, Wegeners, SLE, PAN

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Dr. Tran awakens one Sunday with some mild pain and tearing in her right eye. She also notes some sore throat and congestion. By Tuesday her other eye starts getting red too. What was she most likely doing on Friday? a) Smoking Ganja b) Drinking heavily c) Surfing d) Seeing patients in clinic with the flu Viral Conjunctivitis Treat with cold compresses, contagious precautions Usually resolves over 1-2 weeks, can infect the other eye Preauricular adenopathy

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Dr. Do has a patient in the ICU who he is so concerned about that he has been forgetting to take out his contact lenses before going to bed. He wakes up one day in tears because his left eye is in so much pain. He cant stand to go outside because of the sunlight. He needs an ophthalmologist ASAP He may need a corneal transplant He will have to be out of contact lenses for months He has learned his lesson the hard way All of the above Corneal Ulcer Most often secondary to contact lens wear or trauma Treatment: topical antibiotics ( moxifloxacin / Vigamox 1gtt OS q2h), ophtho eval Can develop a hypopyon Do not patch painful eyes!

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A 28 year old model walks into Dr. Villanueva ’ s clinic. She had LASIK a few years ago and notes that at the end of the day while she is at the computer, she feels a little foreign body sensation when blinking. Her vision also gets a little blurry at these times. On examination, both her eyes are slightly red. Next Step? Urgent ophtho referral Topical artificial tears Topical antibiotics Oral antibiotics and follow-up exam at romantic restaurant in 1 week


“ RED EYE ” Ask about symptoms!


CHRONIC VISUAL LOSS Glaucoma Cataract AMD: Age-related macular degeneration


GLAUCOMA High Eye Pressure Normal is 8-21 mmHg Chronic Open Angle Glaucoma Most common cause of blindness in Blacks Most patients with early glaucoma ASYMPTOMATIC Insidious disease visual field defects occur late Early detection is important because it is preventable Screening Q2-4yrs after age 40 or Q3-5yrs at age 20-39 if Black Family History Cup to Disc Ratio Acute Angle Closure Glaucoma Painful, Red eye, Halos, Nausea, vomiting, Fixed pupil


CATARACTS 70% of patients have over the age of 70 Types Age related (most common) Congenital or genetic Disease related Inflammatory, metabolic, nutritional, radiation, steroid-induced Traumatic Cataract Surgery When interferes with ADLs Glare at night, cloudy vision, etc NOT a laser surgery Most common surgery in the US Intraocular lens placed in eye


AMD: AGE-RELATED MACULAR DEGENERATION MCC of irreversible central vision loss (20/200 or worse) among people 52 or older. Types: “ Dry ” : no neovascularization, 90%, 10% Wet AREDS vitamins “ Wet ” – + neovascularization Avastin/Lucentis


ACUTE VISUAL LOSS Retinal Retinal Detachment Flashes & Floaters Vascular CRAO CRVO Amaurosis Fugax (transient) EKG, Echo, Carotid U/S Optic Nerve Optic Neuritis MS, Sarcoid, Lyme, Syphillis Papilledema Ischemic optic neuropathy Arteritic (Giant Cell Arteritis) Age>50, Elevated ESR, CRP Temporal HA, Jaw claudication Start Steroids! Nonarteritic HTN, DM, HLD


THE EYE AND SYSTEMIC DISEASE Diabetes mellitus Hypertension Thyroid disease Sarcoidosis AIDS


THE EYE AND SYSTEMIC DISEASE Diabetes mellitus Leading cause of blindness in working age Americans Type 1: After 5 years – 23% have retinopathy After 15 years – 80% have retinopathy Type 2: May have diabetic retinopathy at diagnosis Lower incidence of retinopathy than type I Non-proliferative retinopathy Cotton wool spots, dot-blot hemorrhages, hard exudates Macular edema Proliferative retinopathy Ischemia  neovascularization Vitreous hemorrhage, Tractional retinal detachments


THE EYE AND SYSTEMIC DISEASE Diabetes mellitus Treatment Non-proliferative Macular edema Focal laser therapy Proliferative Pan retinal photocoagulation Vitrectomy Hemorrhage Traction retinal detachment DCCT Study (1993) Intensive glycemic control reduces the risk of new diabetic retinopathy (76%) and progression of existing Type 1 DM UKPDS Study (1997) Reduction in new retinopathy (56% )


THE EYE AND SYSTEMIC DISEASE Hypertension Findings Exudates Cotton-wool spots Flame shaped hemorrhages Edema Vessel attenuation and sclerosis Copper/Silver wiring AV-Nicking Malignant hypertension Optic disc swelling


THE EYE AND SYSTEMIC DISEASE Grave ’ s disease Eye findings Lid Retraction MCC of proptosis Complications Corneal exposure Diplopia Compression of optic nerve Treatment Lubrication Steroids Surgical decompression


THE EYE AND SYSTEMIC DISEASE Sarcoidosis Eye findings: Uveitis with Keratic precipitates Iris nodules Retinitis If present, likelihood of CNS involvement increases to 20-30 % Lacrimal gland involvement


THE EYE AND SYSTEMIC DISEASE HIV/ AIDS Eye findings: Cotton-wool spots CMV retinitis Leading cause of visual loss in patients with AIDS CD4 <50 Treated with Ganciclovir intravitreal injection or implant

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The End Hope you learned something! QUESTIONS?? Mohit Mehtani MD

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LASIK Laser Assisted in-Situ Keratomileusis

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