ON CALL with Melton-Thomas Ron Melton, OD, FAAO Randall Thomas, OD, MPH, FAAO www.eyeupdate.com Financial Disclosure Dr. Ron Melton and Dr. Randall Thomas are consultants to, on the speakers bureau of, on the advisory committee of, or involved in research for the following companies: ICARE, Valeant. The Eye and the ED Why people go to the ED with Eye problems Most common ICD Diagnosis
Conjunctivitis 33% Corneal injury 13% Corneal F.B. 8% Hordeolum 4% Mean ED charge $989.30 for eye visit Eye visits: 1.5% of all visits Vazini K, et al. Ophthalmology 2016;123(4):917-19 About 400,000 patients per year present to U.S. emergency departments with eye injuries, and children represent up to onethird of those injured. JAMA Ophthal, August, 2018 Acute Conjunctivitis and Antibiotic Use
Conjunctivitis is the most common cause of red or pink eye, but most (up to 80%) are viral. Topical antibiotics (for bacterial infection) provide only a very modest beneficial effect on clinical remission. Antibiotic Rx Combo Rx - ODs 44% ODs 30% - MDs 36% MDs 23% - Non-Eye Drs 60% Non-Eye Drs 8% One-fifth of all Rxs were for a combination antibioticsteroid which are contra-indicated in acute cases of conjunctivitis. (Not True!) Use of AdenoPlus may reduce diagnostic uncertainty and increase comfort with deferring antibiotic therapy. Ophthalmology, August, 2017
Povidone - Iodine 5% ophthalmic solution Broad spectrum microbicide Indicated for irrigation of the ocular surface Off label use: Tx adenoviral keratoconjunctivitis - Anesthetize with proparacaine - Instill 1 or 2 drops of NSAID - Instill several drops Betadine 5% in eye(s), close eye(s) - Swab or rub excess over eyelid margin - After 1 minute, irrigate with sterile saline - Instill 1 or 2 drops of NSAID - Rx steroid qid x 4 days No reports in clinical trials of adverse reactions. Avoid use if patient is allergic to iodine Marketed as Betadine 5% ophthalmic prep solution (30 ml opaque bottle) by Alcon surgical
CPT 99070 supply code Adenoviral Infections Common cause of red eyes Assume adenovirus until proven otherwise Often have pre-auricular node Non-purulent watery discharge Usually starts in one eye and spreads to fellow eye in a few days Always evert lids to survey tarsal conjunctiva With EKC, spotty sub-epithelial infiltration in 50 to
75% of untreated cases Corneal Foreign Body Take good Hx to help rule out penetration Remove foreign body and corneal rust deposits Cycloplege to prevent or treat secondary iritis Do thorough intraocular exam with BIO Cycloplege if any secondary iritis Prophylactic antibiotic drops +/- NSAID drops
F/U until epithelial integrity re-established Differential Diagnosis of Corneal Ulcers vs. Infiltrates Ulcer (Infection) Infiltrate (Inflammation) Rare Common Usually painful Mild pain Tend to be central
Tend to be peripheral 1 to 1 staining defect to Staining defect size relatively lesion ratio Cells in anterior small Rare cells in anterior chamber chamber Generalized conjunctival Sector skewed injection injection
pattern Usually solitary lesion Can be multiple lesions Possible tear lake debris Clear tear lake Perspective on Posterior Vitreous Detachment Occurs mostly between ages 50 and 70 (peak incidence 62) No association with refractive error, except patients with -3.00D or more
go to P.V.D. 5-10 years earlier 80-90% of breaks associated with P.V.D. are in the superior quadrants Acute PVD and Retinal Tears The rate of an acute retinal tear associated with an acute symptomatic PVD is about 8% at the initial visit, and 1.5% of eyes without a tear on the initial visit are found to have a tear on follow-up examination. Ophthalmology, January 2018 What About Scleral Depression An examination using a 28 diopter lens with scleral depression did not provide any additional benefit to an examination without depression during indirect ophthalmoscopy.
In many areas around the world ophthalmologists have progressively shifted from indirect ophthalmoscopy with 28 diopter-type lenses to new fundus lenses at the slit lamp to improve the comfort of the patient without scleral depression. Am J Ophthalmol. November 2018 Treatment of Vitreous Floaters Treatment options: Live with them Vitrectomy Vitreolysis YAG laser angle of focus can be changed to reach floaters; special vitreous lenses allow the laser beam to focus on floater
Advantages: simple, noninvasive, no pain or discomfort Disadvantages: healthy eyes getting elective surgery, risk of retinal detachment, possibly worsening of symptoms Clear visualization of floaters key to successful treatment Treatment may require more than one laser session; symptomatic vitreous opacifications (SVO); only SVOs > 4mm from retina treated Patient decision on benefits vs risks CRST, May 2016 (Stonecipher) Timing and RD Repair: Is there a hurry? Preoperative VA is the strongest predictor of postoperative VA When control vision is affected, about 30% of patients ultimately achieve 20/40 or better There is no difference in VA outcomes among patients who underwent within the first week of onset. VA can improve for months to years after surgical repair There was no association between duration of macular
detachment and postoperative VA Clinical evidence suggests that the duration of macular detachment has a minor, if any, effect on visual outcome when repair is performed within about one week. Similarly, many fovea-sparing RDs can likely be deferred for a short period without affecting visual outcomes. JAMA Oph. November 2013 Alternative Oral Anticoagulants to Coumadin Direct thrombin inhibitor Pradaxa (dabigatran) Oral factor Xa inhibitor Xarelto (rivaroxaban) Eliquis (apixaban) Savaysa (edoxaban)
Reversal Agents for Anticoagulants Vitamin K quickly reverses warfarin, a vitamin K antagonist Newer anticoagulants: Pradaxa, Xarelto, Eliquis, and Savaysa Praxbind reverses Pradaxa The Xa-inhibitors; Xarelto, Eliquis, and Savaysa are inhibited by Andexanet within minutes Andexanet is a major enhancement to the clinical usefulness of these newer anticoagulants! Reference: NEJM. November 2015 Iris Vascular Tufts
AKA capillary hemangioma or microhemangioma Single or multiple usually bilateral Most always at pupillary border Most patients are over age 50 Can lead to spontaneous hyphema Natural course is benign (self-limited) Recurrence is unusual (can Tx with argon ablation) Tx with cycloplegia and steroids (similar to traumatic hyphema)
Herpes Zoster Ophthalmicus Acute vesicular eruption of ophthalmic division of 5th cranial nerve Etiology: varicella-zoster virus; more common after 50 or in the immuno-compromised Symptoms: skin pain most common Ocular involvement in 50% more common - zoster epithelial lesions, anterior uveitis, stromal keratitis, episcleritis Tx: valacyclovir 1000mg tid for 1 wk; famciclovir 500 mg tid for 1 wk; acyclovir 800mg 5x d for 1 wk If ocular involvement, treat with topical steroids Retrobulbar Optic Neuritis
Commonly ages 30-50; most common ages 30-35 Females more likely affected Unilateral, rapid vision loss main symptom Afferent papillary defect most always present Most patients experience diffuse blurred vision Positive scotoma as phosphenes/sparks may occur VF defects vary; central scotoma most common Varying degrees of optic atrophy may develop Retrobulbar Optic Neuritis
Normal ophthalmoscopic picture Color vision first to be affected; last restored R/O macular disease w Photostress Recovery test VA prognosis good; most recover 20/40 or better Visual recovery several days to a few weeks Even 20/20 is less crisp after recovery Recurrence rate approximately 20% Multiple Sclerosis can be associated
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