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UCSF Family Medicine Board Review Chiu

1

Common Eye Conditions Every Primary Care

Clinician Should Know

Cynthia S. Chiu, MD, FACSAssociate Professor

Director, Comprehensive Ophthalmology & OptometryUCSF Department of Ophthalmology

UCSF Family Medicine Board ReviewMarch 18, 2015

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


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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

Penlight Exam

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

LidsLashes

Conjunctiva/Sclera

CorneaIris/Pupil

Lens Puncta

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


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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

Viral Conjunctivitis

� URI� Clear or mucous discharge� Lymphadenopathy� Contagious!� Treat for comfort


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Bacterial Conjunctivitis

� Purulent discharge� Culture� Staph, Strep, Hflu

– Polymixin/Trimethoprim– Fluoroquinolones– NOT Tobra or Gent

� GC, chlamydia– Systemic Rx

Allergic Conjunctivitis

� History of atopy� Conjunctival edema� Itchy!

� Topical antihistamines– Elestat– Zaditor– Patanol

� Visine tachyphylaxis

Blepharitis

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

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

Herpes Simplex

� When to refer:V1, V2red eyeeye painchange in vision

� Acyclovir


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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

Angle Closure Glaucoma

� Headache� Loss of vision� Firm eye

� IV Diamox, Mannitol� Glaucoma gtt’s� Surgical treatment

Subconjunctival Hemorrhage

� Valsalva, HTN, anticoagulants, eye rubbing, spontaneous� In the setting of trauma: refer


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Corneal Abrasion

� Pain!� Loss of epithelium� Not infected

� Erythromycin ung� 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


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Disorders of theEyelid and Orbit

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


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Disorders of the Retina

http://webphysics.davidson.edu/faculty/dmb/EdibleOpticalMaterials/index_files/cyclops.jpg

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


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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)

Retinal Vein Occlusion

� Hypertension� Glaucoma� Young patients: hypercoagulable

Neuro-Ophthalmology

http://www.capitalgainsmedia.com/images/Development%20News%20Photos/Dev-Ino-Issues%2002/Dev-Ino%20Issue%200244/DSC01869.jpg


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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 pressurehttp://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/PComaneurysm

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


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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

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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