Loading presentation...

Present Remotely

Send the link below via email or IM

Copy

Present to your audience

Start remote presentation

  • Invited audience members will follow you as you navigate and present
  • People invited to a presentation do not need a Prezi account
  • This link expires 10 minutes after you close the presentation
  • A maximum of 30 users can follow your presentation
  • Learn more about this feature in our knowledge base article

Do you really want to delete this prezi?

Neither you, nor the coeditors you shared it with will be able to recover it again.

DeleteCancel

Make your likes visible on Facebook?

Connect your Facebook account to Prezi and let your likes appear on your timeline.
You can change this under Settings & Account at any time.

No, thanks

Eyes4PCPs

No description
by

eye MD

on 29 December 2015

Comments (0)

Please log in to add your comment.

Report abuse

Transcript of Eyes4PCPs

Practical Ophthalmology: An Algorithmic Approach Blur <24 Hours >24 Hours Seconds Minutes Hours Papilledema
(Postural) TIA (Unilateral) Vertebrobasilar Insufficiency (Bilateral) Migraine Uncommon Central retinal vein occlusion Ischemic optic neuropathy Ocular ischemic syndrome Glaucoma Transient hypotension Optic disc drusen Giant cell arteritis Sudden Gradual Post-Traumatic Retinal artery occlusion Ischemic ptic neuropathy Cherry red spot Vitreous hemorrhage Retinal detachment Optic neuritis Sudden Discovery Cataract Refractive Error Chronic glaucoma Macular Degeneration Diabetic retinopathy Acute glaucoma Optic neuritis Uveitis Endophthalmitis Corneal Hydrops Eyelids swollen shut Corneal scar Hyphema Open globe Traumatic cataract Lens dislocation Retinal Hemorrhage Retinal detachment Traumatic optic neuropathy Non-Physiologic Matthew D. Neale, MD Diagnosis of exclusion Partial Complete Unilateral Bilateral Tricky Tricky Easy Fun! Sunglasses Sign Blink to threat Bumping into objects on purpose Unable to sign own name Try dropping a $100 bill Sensitivity 46.0%
Specificity 99.5% Fellow Travellers Positive review of systems
Workers' compensation claim
Disability
Lawsuit Watery Red Chronic Acute Lids Globe Trichiasis Floppy Eyelid Syndrome Entropion Blepharitis Lubrication Surgery Associations: Obstructive Sleep Apnea
Obesity
Male
Collagen or Elastin Disorders Temporal Arteritis Diabetes Plaquenil Screening Toxicity Risk Management Diagnosis Presentation The Solution The Problem Timely intervention, despite good vision *Gestational Diabetes doesn't need exam Risk of toxicity was traditionally 0.5% But this risk rises sharply, especially among certain groups: Short Stature Prolonged exposure A 68-year-old female with rheumatoid arthritis was treated with hydroxychloroquine 200 mg PO bid for almost five years. She complained of bilateral visual disturbances and discontinued the medication. On examination, best-corrected visual acuity was 20/50 in each eye A Case Report Fundus Examination Fluorescein Angiography Automated Visual Field Optical Coherence Tomography Newer data suggests risk is 1% overall, >7 years Cumulative Dose (400 mg x 365 days x 7 years = 1022 g A baseline examination within the first year Annual screening recommended after five years If risk factors present: Small stature Liver or kidney disease Macular disease Advanced age Annual screening from INITIATION of therapy Frequency Technique High Definition Optical Coherence Tomography Automated Visual Field Macular pigmentary alterations, such as bull's-eye changes, are generally late manifestations Dilated Fundus Examination Color Vision Fluorescein Angiography Multifocal Electroretinogram Amsler Grid Electroretinogram Electrooculogram Sources http://www.retinalphysician.com/printarticle.aspx?article=105383
http://www.laretina.com/Our-Services/Visual-Function-Laboratory.aspx
http://en.wikipedia.org/wiki/Electroretinography
http://upload.wikimedia.org/wikipedia/commons/0/01/Normalamslergrid.gif
http://www.opt.indiana.edu/ce/plaq/mgmt.htm
http://www.youtube.com/watch?v=BEE19bpyLEc
http://www.youtube.com/watch?v=abIyQCJg8CU
http://www.youtube.com/watch?v=Ku3W8pcrUbA&feature=related

Klein R, Knudtson MD, Lee KE, Gangnon R, Klein BE. The Wisconsin Epidemiologic Study of Diabetic Retinopathy XXIII: the twenty-five-year incidence of macular edema in persons with type 1 diabetes. Ophthalmology. Mar 2009;116(3):497-503.
http://www.youtube.com/results?search_type=search_videos&search_query=diabetic+retinopathy&search_sort=relevance&search_category=0&page=
http://www.youtube.com/watch?v=838qb9v7wR4
http://www.youtube.com/watch?v=9OJbm4BnLB0&feature=related
http://www.youtube.com/watch?v=rALSIg6Os8g&feature=related
http://www.youtube.com/watch?v=U40_38yoGxI&feature=related
http://www.youtube.com/watch?NR=1&v=9_yZBFYrb-8
http://www.youtube.com/watch?v=R5pLFjmtisk&feature=related
http://www.youtube.com/watch?v=YlvzjxxQ9Yc&feature=related
http://www.youtube.com/watch?v=vtkUz95NKmk&feature=related
http://www.youtube.com/watch?NR=1&v=FbtimyH1BhU
http://www.endotext.org/diabetes/diabetes29/diabetes29.htm
http://emedicine.medscape.com/article/1225122-overview#a0156
http://www.eyesurgeryinberkshire.co.uk/information_fj/p7hg_img_1/fullsize/se_fs_fs.jpg
http://www.ophmanagement.com/article.aspx?article=105515
http://www.sciencephoto.com/image/256687/large/M1550357-Close-up_of_eye_of_patient_with_rubeosis_iridis-SPL.jpg
http://www.oculist.net/downaton502/prof/ebook/duanes/graphics/figures/v1/0730/030f.jpg
http://3.s3.envato.com/files/189117.jpg
Sources Diabetes is the leading cause of blindness in younger people. Spots Double This can happen in a multitude of ways : Cataract Neurotrophic Keratitis Rubeosis Iridis Glaucoma But--Feared above all these is: Diabetic Retinopathy Nonproliferative Proliferative Tractional Detachment Macular Edema Prevalence: 700 000 Americans Annual Incidence: 65 000 8000 Patients Blinded Every Year Tip: If spontaneous venous pulsations are seen, increased ICP is ruled out. MRI/MRV/LP DDX: Intracranial mass
Hydrocephalus
Pseudotumor
Subdural/Epidural Hematoma
Subarachnoid Heme
AV Malformation
Brain Abscess
Meningitis/Encephalitis
Cerebral venous sinus thrombosis Work-Up Work-Up: ESR/CRP/CBC/A1C
Ophthalmic exam
Auscultation of heart and carotids
Image carotids and heart
HPI: Typical aura:
Flickering, spots, lines, rainbows, etc
Fully reversible
5-60 mins
Unilateral sensory symptoms
pins and needles
NO Motor symptoms
Work-Up: Atypical migraine
Consistent laterality
Headache precedes aura
Complicated migraine
Permanent neurologic deficit http://www.osnsupersite.com/images/content/tutorials/29815/slide15.jpg
http://www.kellogg.umich.edu/theeyeshaveit/acquired/images/hollenhorst.jpg
http://www.dizziness-and-balance.com/disorders/central/images/dissection%20va.jpg
http://www.migraine-aura.org/site/content/e24966/e25413/e25619/e47479/Mogridge_Senses_Under_Assault_small_400_en.jpg
http://www.migraine-aura.org/site/content/e24966/e25413/e25429/e25446/Sir_William_Richard_Gowers_1895_en.jpg Arteritic Post-Op Non-
Arteritic Features:
Elderly
Severe loss
Symptoms Features:
Younger
Less severe
Vascular risk
Nocturnal hypotension Features:
Prolonged surgery
Blood loss
Hypotension
Anemia Plan:
Prevention
Perfusion
Oxygen
Transfusion Plan:
Treat
Diagnose Plan:
Suspect GCA
Treat HTN, DM
Avoid QHS anti-hypertensives
Work-Up: ESR/CRP/CBC/A1C
Ophthalmic exam
Auscultation of heart and carotids
Image carotids and heart
Features:
May be subtle or profound
Hours to days
Typically unilateral
Younger patients
Pain on eye movement (90%)
Pulfrich phenomenon
Uthoff sign Work-Up
MRI with contrast and fat suppression
Ophthalmic eval
Bloodwork for atypical cases Treatment
Negative MRI:10 YR risk of MS 22% Observe.
Positive MRI: 10 YR risk of MS 56%. Treat with 1g methylprednisolone IV. *Never use oral prednisone as primary treatment due to increased risk of recurrence. *See section on Pain Uncomforable Painful Sources
http://img.medscape.com/fullsize/migrated/584/197/ijir584197.fig1.gif
http://farm4.static.flickr.com/3386/4641954634_db789edb00_z.jpg
http://www.youtube.com/watch?v=ETExs_Nrxas&feature=related
http://radpod.org/wp-content/uploads/2007/04/optic_neuritis.JPG
http://t2.gstatic.com/images?q=tbn:ANd9GcQizMLPCw70x4HQh4jREomUj03QslcPG7VOUbb7fdvXfporaGhiGQ
http://dro.hs.columbia.edu/lc1/psc1b.jpg Etiology:
Involutional
Cicatricial
Spastic
Congenital Treatment options:
Protect the cornea
Quickert suture
Botox
Lid reconstruction
Etiology:
Involutional
Paralytic
Cicatricial
Congenital
Harlequin Fetus Euryblepharon Ectropion Other Options:
Lubrication
Cryotherapy
Electrolysis
Surgery
Sources:
http://www.oculist.net/downaton502/prof/ebook/duanes/graphics/figures/v5/0730/014f.gif
http://www.lensinkmd.com/uploads/images/medical_condition/eyelid_malposition/Entropion_3168_1.jpg Sources:
http://www.nature.com/eye/journal/v18/n4/images/6700686f1.jpg
http://www.oogartsenpraktijkschoten.be/userfiles/images/glaucoom/ectropion.jpg&w=368&h=263&ei=P3-5TuaoG8OtiALV2bThBA&zoom=1
http://static2.thrivesmart.com/uploaded_images/business_images/0005/8685/2008_07-16_Mel_cam_252_slide_show.jpg?1222718880
http://www.ispub.com/journal/the-internet-journal-of-pediatrics-and-neonatology/volume-2-number-1/a-case-of-harlequin-fetus-with-psoriasis-in-his-family-1.article-g01.fs.jpg
http://www.pumch.net/downaton502/prof/ebook/duanes/graphics/figures/v6/1100/020f.gif "Itchy" "Burning" "Stinging" "Watery" "Sore" "Aching" Hot Compresses and Tears Topical Antibiotic/Steroid Matrix Metalloproteinase Inhibition Conservative Acute Chronic Pharmacologic Pterygium Contact lens Conjunctival Hemorrhage Episcleritis Carotid-Cavernous Fistula Monocular Binocular "Does it go away if you cover one eye? Dry eye Cataract Glasses problem Lens dislocation Polycoria Myasthenia Constant Intermittent Decompensated phoria Cranial nerve palsy Orbital inflammation CNS lesion INO Epidemiology
Most common systemic vasculitis affecting older patients
Female:Male::3.7:1
Median age: 75
Symptoms
Headache (72%)
PMR (58%)
Jaw Claudication (40%)
Fever (35%)
Amaurosis Fugax (10%)
Permanent visual loss (8%) Sudden, Bilateral, Permanent Blindness Labs: ESR (97% sensitivity)
CRP (98.6% sensitivity)
Platelets usually elevated
Imaging: Biopsy: Sensitivity 30-40%
Specificity 100%
Risk scalp necrosis Color doppler
MRI 69% sensitive
82% specific Similar sensitivity and specificity In Practice: TA biopsy necessary if imaging is unhelpful or contradictory Shoot first... Methylpred-nisolone 250 mg i.v., q6h for 12 doses ...ask questions later Maintain Prednisone 80-100 mg PO QD Until symptoms resolve and ESR normalizes Think Positive Negative ? Taper Decrease dosage monthly
Follow ESR
6-12 months Yes No Graves Disease* Orbital Pseudotumor Sources:
CN3 video www.youtube.com/watch?v=NAUl-A4qsxs&feature=related
CN4 video www.youtube.com/watch?v=AWJg3Juuhvw&feature=related
CN6 video www.youtube.com/watch?v=3M1GhgV8px0&feature=related
Orbital pseudotumor www.youtube.com/watch?v=UD1lb-3mlRk
Eye popping www.youtube.com/watch?v=HX_5zIXxKEU
Complete ophthalmoplegia www.youtube.com/watch?v=ZBzTz0gHpgk
bilateral INO www.youtube.com/watch?v=gj81SNtQVsM&feature=related Transient Constant Migraine Disclosure: No financial relationships to disclose Caveat: This presentation is neither comprehensive nor authoritative "Floaters" Vitreous Condensations Posterior Uveitis Vitreous Hemorrhage Vitreous Detachment Scleritis Iritis Trauma Conjunctivitis Angle Closure Endophthalmitis Sources:
http://www.sarawakeyecare.com/Atlasofophthalmology/posteriorsegment/1sarcoidosis3.jpg
http://img.medscape.com/fullsize/migrated/513/226/cou513226.fig3.gif
http://www.vrmny.com/images/crp_pdr2.jpg
http://www.youtube.com/watch?v=LwU9_v86A78
http://www.youtube.com/watch?v=sxroMCVgpPk&feature=related
migraine http://www.youtube.com/watch?v=qVFIcF9lyk8
Nasolacrimal Duct Obstruction Congenital glaucoma NO Discharge NO Discharge Discharge Hyperpurulent Watery Scant

Purulent Non-GC Bacterial Allergic Infectious Keratitis Ceftriaxone 1g IM
Ciloxan ung QID
Azithromycin 1g PO
Treat partners Gonoccal Polytrim or cipro gtt QID Eliminate offending agent
Topical antihistamine gtt
PO antihistamines Artificial tears
Sunglasses
Surgery Discontinue lenses
Rule out ulcer Try drug holiday Sources:
http://www.hkapi.hk/images/drugs_images/Tobradex%20Drops%202.JPG
http://masterofmedicine.com/wp-content/uploads/2011/05/Pterygium_from_Michigan_Uni_site_CC-BY.jpg
http://upload.wikimedia.org/wikipedia/commons/thumb/e/e8/Doxycycline_100mg_capsules.jpg/653px-Doxycycline_100mg_capsules.jpg
http://www.sciencephoto.com/image/256531/large/M1550083-Macrophoto_of_human_eye_with_blepharitis-SPL.jpg
http://www.tomokaeye.com/photos/condition-blepharitis.jpg
Sources:
http://www.nature.com/eye/journal/v21/n10/images/6702841f2.jpg
http://www.pacificu.edu/optometry/ce/courses/13036/images/Fig2020.jpg
http://img.webmd.com/dtmcms/live/webmd/consumer_assets/site_images/articles/health_tools/pinkeye_slideshow/PRinc_rm_photo_of_conjunctivits_eye_pus.jpg
http://www.eczematreatmentremedies.com/wp-content/uploads/2011/08/Severe-Allergic-Conjunctivitis.jpg
http://26.media.tumblr.com/tumblr_lo8zd4ZWfE1qjcf0do1_500.jpg
http://odlarmed.com/wp-content/uploads/2009/05/hyphema.jpg
http://www.revoptom.com/CMSImagesContent/2011/8/089_RO0811_GGR.gif
http://theglaucomaguide.com/images/pupil_block.jpg
http://www.vision-and-eye-health.com/images/AngleClosureASOCT1.jpg
http://arapaho.nsuok.edu/~fulk/Images/Img0025.JPG
http://eso-cdn.bestpractice.bmj.com/best-practice/images/bp/en-gb/496-11_default.jpg Glycemic control (AKA Doxycycline) Painful *OK...that wasn't really graves disease--it was spontaneous globe luxation...but you get the idea. Artificial tears
Time Management Unilaterally blind? Less Effective More Effective
Full transcript