nicholas j. volpe, md tarry professor and chairman department of ophthalmology

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Nicholas J. Volpe, MDTarry Professor and ChairmanDepartment of OphthalmologyFeinberg School of Medicine

Northwestern University

Vision and Eye Problems: How to recognize them and what we

can do about them

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Goals

• common visual symptoms in elderly people

• followed by a discussion of what we do to make the diagnosis

• how we treat common problems including dry eye, glaucoma, cataract, eyelid problems, diabetic retinopathy, macular degeneration and double vision"

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Strategies to Preserve Your Vision

• Choose your parents well and stop aging!!! OR

• Don’t Smoke

• Wear Glasses that are UV protective– Safety glasses for high risk activities

• Pay Attention to Nutrition and Vitamins

• Don’t Ignore Symptoms

• Get Regular Eye Examinations

• Prevention is our most potent tool in the quest to reduce disease (and healthcare costs)

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Major Causes of Chronic Visual Loss

Preventable and Treatable

• Cataracts• Glaucoma• Macular degeneration• Diabetic retinopathy

• Other Issues– Dry eye– Double Vision– Eyelid Abnormalities– Presbyopia near vision blurring

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Stop Smoking

• Clearly a risk factor for cataracts– 3X the risk

• Clearly a risk factor for macular degeneration and its response to treatment

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Nutrition

• Healthy tear film• Macular degeneration

• Fruits and Green Leafy Vegetables– Carotenoid pigments (lutein) accumulate in macula and

prevent light damage• Omega fatty acids• Lutein and Zeaxanthin

– Studied in AREDS 2• Vitamins A,C, E

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Regular Check Ups

• Many diseases can be detected• Every 2-3 years from age 40-65• Every 1-2 years after age 65• More frequently with diabetes or family history of

glaucoma or macula degeneration• Young adults, in the absence of symptoms, do not

require routine examinations

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Common Eye Symptoms

• Foreign body sensation• Itching and burning

• Blurred vision• flashes and floaters

• Distortion of shape

• Blind spots• Loss of peripheral vision

• Double vision• Eyelid position changes

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Foreign Body Sensation,Itching and Burning• Dry eye• Blepharitis• Allergy• Eyelid malposition

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Dry Eye

• Tears• Cyclosporine• Punctal plugs

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Ptosis, Entropion, Ectropion

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Flashes and Floaters

(ahujaeyecenter.com)

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Cataracts

• Expected if ≥ 60 years old50% - 65 - 75 years

old70% > 75 years old

• Most common cause of decreased vision

• Symptoms– Loss of acuity– Difficulty with colors– Glare at night– Trouble reading small print

AgeSteroids (PSC)TraumaInflammationDiabetesOther drugs

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Subcapsular cataract

Anterior Posterior

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Nuclear cataract

• Exaggeration of normal nuclear ageing change• Causes increasing myopia

• Increasing nuclear opacification

• Initially yellow then brown

Progression

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Cataract Surgery

• Outpatient• Very successful > 95%• Almost all with intraocular lenses• Most common surgical procedure

in U.S.• >1.4 million/year• Most successful surgical

intervention • Complications• uncommon• sight threatening• IOL technology continues to evolve

for astigmatic correction and presbyopia

• Newest modality is femtosecond laser

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Cataract Prevention

• Smoking cessation– Reduces Vitamin C in the eye– Vitamin C levels are high in the eye and this helps

remove prooxidants• Ultraviolet light• Fruits and vegetables

– 5 fold decrease at 3-4 servings per day

• Regular alcohol consumption increases risk of cataract

• Steroids and inflammatory conditions are risks for cataracts

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Age- Related Macular Degeneration• Age-related macular degeneration (AMD) is the most

common cause of severe, irreversible vision loss in older Americans and Europeans

• Worldwide, AMD disease affects 25-30 million people.• Etiology is complex and poorly understood

– Free-radical mediated damage to the photoreceptors and the RPE

– Angiogenesis is a feature of neovascular AMD– AMD may be associated with a systemic vascular

disorder– Genetic and environmental factors– Variation in the complement factor H gene

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AMD Risk Factors

• Gender ♀ > ♂• Race/Ethnicity• Smoking• Family History• Atherosclerosis• Hypertension

• Symptoms• early = None, mild distortion• late = acute loss of vision

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Atrophic AMD

Initially drusen and non-specific RPE changes

Late RPE (geographic) atrophy

Progression

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Atrophic AMD

Hyperfluorescence from RPE window defectLow-vision aids if appropriate

ManagementFluorescein angiogram

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Choroidal Neovascularization (CNV)• Metamorphopsia is initial symptom

• Many lesions are not visible clinically

Suspicious clinical signs

Gray-yellow subretinal lesion with fluid

Subretinal blood or lipid

• Less common than atrophic AMD but more serious

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Current Status of Therapiesfor CNV

• Antiangiogenic therapy

• Lucentis, Avastin, Eylea– CATT trial (Avastin vs

Lucentis)

• Photodynamic therapy with verteporfin

• Steroids

• Thermal Laser

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Treatment w/Anti VEGF

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Treatment for Dry AMD

-Age-related Eye Disease Study (AREDS) –role of antioxidants

• vitamin E, 400 IU• vitamin C, 500 mg• beta carotene, 15 mg (approximately 25,000 IU Vitamin A)• zinc 80 mg as zinc oxide• copper, 2 mg, as cupric oxide

– Copper should be taken with zinc, because high-dose zinc is associated with copper deficiency.

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Established Age Related Macular Degeneration• Use Amsler Grid to monitor central vision

• AREDS-Occuvite Preservision• B carotene vs. Lutein and Zeaxanthin (AREDS 2)• Vitamin C• Vitamin E• Zinc Oxide (?necessary and ? Stomach upset)• Copper

• NB: No beta carotene for smokers and others at risk for lung cancer

• Others??? Lutein Eyes, PhoVision, Perspective, Ocu-force

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AREDS Results Recommendations • Evaluation: • Persons over 55 years old receive a dilated eye exam to

assess risk of advanced AMD.

• Contraindications to Treatment: • Smokers and ex-smokers should not use beta carotene,

because previous studies have suggested an association with lung cancer and beta carotene in smokers.

• There were no benefits from treatment shown in the AREDS for patients with no AMD (Category 1) and early AMD (Category 2).

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AREDS 2

• Adding omega 3’s did not help

• Taking away B Carotene did not hurt and lutein and zexanthine may have been a bit more protective

• Reducing zinc dose did not hurt and less side effects

• No prevention of cataracts

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Diabetic Retinopathy

•most common cause of • new blindness among adults 20-64 yo• Blindness in working adults

•affects over 5.3 million Americans age >18 (2.5% of this population)

• Prevention- worse in HTN, obesity, renal failure, hyperlipidema, smoking, anemia, pregnancy and POOR glycemic control

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Clinical Findings in NPDR

• Microaneurysms• Earliest clinical sign of diabetic

retinopathy • Appear as small red dots in the

superficial retinal layers • Rupture produces blot/flame

hemorrhages

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Macular Edema (CSME)

• Leading cause of visual impairment in patients with diabetes

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Macular Edema Treatments

• ETDRS – focal laser surgery for CSME reduces the incidence of moderate

visual loss (doubling of visual angle or roughly a 2-line visual loss) from 30% to 15% over a 3-year period

• Steroids-peri-ocular-intraocular

Anti-VEGF agents

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Ischemic diabetic maculopathy

• Macula appears relatively normal • Capillary non-perfusion on FA• Poor visual acuity • Treatment not appropriate

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PDR

• Proliferation of new blood vessels due to ischemia

• NVD Disc• NVE Elsewhere• NVI Iris• NVA Angle

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PDR - cont.

• Treatment Options• Pan-retinal photocoagulation • Peripheral Retinal Cryotherapy • Vitrectomy• Anti-VEGF

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Retinopathy Screening

• Type 1 diabetes - screen within 3-5 years of diagnosis after age 101

• Type 2 diabetes - screen at time of diagnosis1

• Pregnancy - women with preexisting diabetes should be screened prior to conception and during first trimester1

• Follow-up depends on severity of disease

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Diabetic Eye Care

• Like glaucoma, you will NOT HAVE SYMPTOMS UNTIL IT IS TOO LATE!

• 95-100% treatable with early detection• Regular eye exams at 6 or 12 month interval depending

on what MD sees• Bleeding, swelling and growth of blood vessels• Diabetes control (Hemoglobin A1c) is the most important

way to reduce your risk• High blood pressure is a risk• Diet and exercise

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Glaucoma

• Optic nerve• 1.2 million nerve fibers• Ganglion cells in retina

exit to brain as optic nerve

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Definition of Glaucoma• A group of optic neuropathies in which retinal ganglion

cells die by apoptosis with resultant optic disc cupping and characteristic visual field deficits– Optic neuropathy– Retinal ganglion cell apoptosis– Optic disc cupping or excavation– Loss of visual function

-IOP is too high for the nerve???

• Most common cause blindness:• African-AmericansCOMPLETE/TOTAL BLINDNESS

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Glaucoma

• Loss of visual field• Site of visual field loss

corresponds to area of damage on optic disc,e.g., “cupping”

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Angle Closure Glaucoma

• Acute pain, redness, tearing• Associated with dilation of

pupil• Natural (e.g., movie theater)• Pharmacologic• Nausea & vomitingoften in ER with “acute abdomen”

Risk factor of narrow angle can be detected on screening exam (esp hyperope) and prophylactic iridotomy is preventative of attack in 100%

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Acute angle-closure glaucoma

• Severe corneal edema • Complete angle closure

• Dilated, unreactive, vertically oval pupil

• Shallow anterior chamber

• Ciliary injection

Signs

Medical rx to lower IOP, followed by laser (Yag) iridotomy

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Primary Open-Angle Glaucoma

• The most prevalent type of glaucoma in the United States• Elevated intraocular pressure is not part of the diagnostic

criteria– 25% of patients with primary open-angle glaucoma in

the US have normal intraocular pressure• Asymptomatic

– Some loss of visual field– Most common type– Familial, bilateral– “Sneak thief of sight”

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Primary Open-Angle Glaucoma

• Evidence that IOP reduction is beneficial• Collaborative Normal-Tension Glaucoma Study (CNTGS)• Advanced Glaucoma Intervention Study (AGIS)• Early Manifest Glaucoma Study (EMGT)

– 25% IOP reduction RoP 62% to 45% at a median of 6 years.

• Ocular Hypertension Treatment Study (OHTS)

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Treatment for POAG• Lower the IOP• Medical therapy• Prostaglandin , B-

blockers,Sypathomimetics, Carbonic-anyhrase inhibitors

• Laser surgery (ALT, SLT)• Incisional surgery (Trab,

shunt)

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Tube Shunts

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Double Vision

• Monocular vs binocular

• Eye misalignment

• Stroke, tumor, cranial nerve palsy

• However most are benign

• Thyroid Eye Disease

• Patch, prism, surgery

Utsavaeyelinic.com

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Summary

• FBS, itching burning• Floaters and flashes• Diabetic Retinopathy•Prevention, treatment• Cataract–Surgical treatment continues to improve• Double Vision

– Most benign-eye misalignment– Must be evaluated

• Glaucoma–Silent blindness, family history–Medical and surgical rx• ARMD–New age of available prevention strategies and treatments exudative varietyFBS

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Strategies to Preserve Your Vision

• Choose your parents well and stop aging!!! OR

• Don’t Smoke

• Wear Glasses that are UV protective– Safety glasses for high risk activities

• Pay Attention to Nutrition and Vitamins

• Don’t Ignore Symptoms

• Get Regular Eye Examinations

• Prevention is our most potent tool in the quest to reduce disease (and healthcare costs)