HE SAID, SHE SAID

Jill Autry, OD, RPh

Eye Center of Texas, Houston

drjillautry@tropicalce.com

FUCH’S DYSTROPHY

• Endothelial corneal disorder• Women > Men, 3:1 and more severely• Progresses with age• Stages

– Guttata

– Stromal and epithelial edema

– Corneal scarring

• Muro-128 5% solution/ung• DSAEK

Who Gets Dry Eye?

• Women>Men

• Older>Younger

• Patients with autoimmune diseases

• Lupus, rheumatoid arthritis, sarcoid, Sjogren’s, thyroid disease, rosacea, etc.

• Post-menopausal

• Medication induced• Hormonal therapy, antidepressants, anxiolytics

Inflammation and Dry Eye

• Research clearly shows corneal, conjunctival and lacrimal gland inflammation as a major cause of dry eye syndrome.

• Ongoing inflammation results in the increase production of cytokines and activated T-Cells that mediate the inflammatory process

• Inflammation acts to shut down the components of good tears

SJOGREN’S

• Autoimmune disease that attacks the exocrine glands

• Associated with rheumatoid arthritis• Specifically lacrimal and salivary glands• Women>Men• Increases with age• Diagnosis often made with signs/symptoms• Positive SSA and SSB serum autoantibodies

Restasis® Proven To:

• Decreases inflammation in the cornea, conjunctiva, and lacrimal gland

• Increases tear production• Increases goblet cell density• Decreases SPK• Decrease dependence on artificial tears• Excellent safety profile

– Cyclosporine undetectable in blood

Restasis® Recommendations

• BID dosing in most cases-not PRN• Severe cases use QID with a steroid initially• Continue artificial tear use initially• Burning initially or later as ocular surface heals• Use before and after contact lenses (15 minutes)• Persistence with therapy

– Results are 2-3 months away

• Discuss long-term therapy– May attempt once daily dosing when controlled

• Mail order (90 day supply);2 boxes=1 month supply

Edward Wade, M.D. Ting Fang-Suarez, M.D. Mark Mayo, M.D. Chris Allee, O.D. Jill Autry, O.D. Randy Reichle, O.D.

6565 West Loop South 4415 Crenshaw Rd. 15400 SW FrwyBellaire, TX 77401 Pasadena, TX 77504 Sugar Land, TX 77478Phone (713)797-1010 Phone (281)998-3333 (281)277-1010

450 Medical Ctr Blvd, #305 11914 Astoria Boulevard, #325 21700 Kingsland Blvd. Webster, TX 77598 Houston, TX 77089 Katy, TX 77450 (281) 332-1397 (281) 484-2030 (281) 578-4815

NAME Jill Autry AGE ______________

ADDRESS_____________________________________________________DATE 3-3-11

Rx Restasis 1 gtt bid OUOne month supply (2 boxes=one month supply)Three month supply (6 boxes=three month supply)

Pharmacist please note: 1 month supply=2 boxes per PPI

REFILLS-- one year Jill Autry, O.D.

Estrogens vs. Androgens• Androgens important in the quality/quantity of oily

secretions• Androgen levels decrease with age resulting in

– Increased meibomian gland dysfunction• Results in evaporative dry eye

– Lacrimal gland inflammation• Results in aqueous deficiency

• May explain post-menopausal dry eye• Sjogren’s patients show decreased androgen levels

ACNE ROSACEA

• Redness/telangiectasia/papules on the cheeks, nose, and forehead

• More common in women• More severe in men• Fair or light skinned patients more common

and more severe• Increased meibomian dysfunction and

blepharitis with ocular rosacea

DOXYCYCLINE• 50mg bid• No with children < 8 years old/pregnant/nursing.• qd to bid dosing• Can take with food• Can take with dairy products• Cannot take with antacids• Can cause photosensitivity• Cannot take before lying down

– Must wait 2 hours to avoid esophageal ulceration

VERNAL KERATOCONJUNCTIVITIS

• Young Males > Young Females, 3:1• Seasonal pattern during warmer weather• Bilateral, severe itching with thick, ropy discharge• Exam

– Giant papillae under upper lid– SPK– Trantas’ dots– Shield ulcers (severe cases)– Thickened eyelids

VERNAL KERATOCONJUNCTIVITIS

• Mast cell stabilizers• Topical and oral antihistamines• Topical and oral NSAIDS• Restasis• Topical steroids for severe exacerbations• Shield ulcer

– Antibiotics– Cycloplegic– Bandage CL

EPISCLERITIS

• Women > Men and more severely

• Sectoral injection on bulbar conjunctiva

• Mild tenderness to area

• Superficial conjunctival vessels and deeper episcleral vessels involved

• Treat with PF/Durezol q2h to start

• Taper as usual with response

MANAGEMENT

• Refer for bloodwork with multiple recurrences/bilateral involvement

• Nodular episcleritis more typical of systemic disease

• Refer if severe pain and/or bluish color to conjunctiva– Typical of scleritis

• Refer if unresponsive to topical steroid treatment

IRITIS

• Women > Men• Unilateral pain, circumcorneal injection,

photophobia, decreased VA• C/F in AC, KP on corneal endothelium,

posterior synechiae, decreased/increased IOP• Traumatic, postoperative, idiopathic, systemic

associations• PF/Durezol q1-2h, cycloplegic, glaucoma

drops PRN

MANAGEMENT

• Most cases easily managed without referral

• Need to taper steroid over 1-2 weeks

• Refer for bloodwork/x-rays if repeat episodes or bilateral

• Refer if unresponsive to topical therapy– May need subconjunctival steroid injection

• Refer if posterior uveitis present

GENDER & INFLAMMATION

• Lupus (W)

• Sarcoid (W)

• Rheumatoid arthritis (W)

• Ankylosing spondylitis (M)

• Reiter’s (M)

• Juvenile rheumatoid arthritis (W)

• Psoriatic arthritis (W = M)

INFLAMMATORY LABS

• Lupus (ANA)• Sarcoid (ACE, Chest X-ray)• Rheumatoid arthritis (RF)• Ankylosing spondylitis (HLA-B27, sacroiliac

spinal films)• Reiter’s (HLA-B27, joint x-rays)• Pars planitis (HLA-B27)• Psoriatic arthritis (ESR-Sed rate)

MACULAR HOLE

• Progress from Stage 1 to Stage 4• Women>Men• Older>Younger• Idiopathic mostly, occasionally traumatic• Best diagnosed with OCT• Full-thickness holes generally 20/200 VA • Round, dark red colored area in the center of the

macula• Often with yellow, lipofuscin granules

MACULAR HOLE

• Distinguish from ERM pseudohole– Macular hole perfectly round– Poor vision with macular hole– Positive Watzke-Allen with macular hole– Pseudohole with tortuous surrounding vessels

• Can follow Stage 1 and 2 holes but get macular OCT for follow-up

• Amsler grid

MACULAR HOLE SURGERY

• Vitrectomy with membrane peel (ILM)• Gas fluid exchange• Face-down positioning for 2 weeks until gas

bubble absorbs• Watch IOP closely with gas bubble• No flying until gas bubble completely resorbs• Can use silicone oil but need second surgery

EXPECTED OUTCOMES

• 90% expected closure

• Expected visual outcomes dependent on length of time macular hole present– Best outcomes within one year– Prognosis decreases with each year

• Average gain is 2 lines VA

CENTRAL SEROUS RETINOPATHY

• Mostly in young (20-50yo), male patients• Recently being reported more in women,

especially during pregnancy• Mildly reduced VA, metamorphopsia• Round, serous RPE detachment• Usually resolves in 2-3 months without tx• Controversial treatment with Diamox

MANAGEMENT

• Need baseline fluorescein to rule-out other causes of serous detachments– Pinpoint leakage followed by smokestack

• Can follow thereafter by monitoring VA and macular appearance

• Watch for recurrences over time

• Rare CNV or PED in future secondary to RPE disturbances

PIGMENTARY GLAUCOMA

• Flacid, peripheral iris bows posteriorly

• Believed to rub against lens zonules

• Releases iris pigment

• Decreases trabecular meshwork function

• One-third of pigmentary dispersion patients will develop pigmentary glaucoma

• Bilateral

CHARACTERISTICS• Demographics

– Young Male– Myopic Caucasian

• Mid-peripheral iris transilluminating defects (TID)

• Krukenberg spindle (K spindle)• Heavy pigment in trabecular meshwork on

gonioscopy• Acute IOP rise after exercising

POSSNER-SCHLOSSMAN

• More common in middle-aged males• Open angle with high IOP (40-60)• Patient not in pain, eye is white, cornea

without edema• Mild C/F in AC, KP on cornea, mildly

decreased VA• PF/Durezol q2h and glaucoma drops; avoid

prostaglandins if possible

MANAGEMENT

• Can be easily managed without referral • HOWEVER…• Watch for exacerbations• Requires close and frequent follow-up• Trabecular meshwork often weakened and

IOP is hard to control even when uveitis subsides

• Patient often without symptoms and IOP could be very high causing VF loss

OPTIC NEURITIS

• Decreased vision over days• Unilateral• Pain on eye movements• Decreased color vision (red cap test)• + RAPD• Visual field defects vary• Swollen disc or retrobulbar• MRI of Brain and Orbits with Flair sequencing

OPTIC NEURITIS TREATMENT TRIAL (ONTT)

• Recommends treatment with IV methylprednisolone x 3 days

• Avoid prednisone orally until AFTER treatment with IV (10-14 days)

• Hastens visual recovery but not final visual outcome

• Prolongs time to development of MS• Do not use oral steroids alone

MULTIPLE SCLEROSIS• Female > Male• 18-45 years old• Intermittent diplopia• Optic neuritis• Nystagmus• Tingling or numbness in extremities• Uhtoff’s sign

– Worsening vision with increased body temperature

• Lhermitte’s sign– Shock-like sensation with neck flexion

PSEUDOTUMOR CEREBRI

• Papilledema• Negative MRI of Brain• Negative MRV of Brain• Increased opening pressure on lumbar puncture• Normal CSF composition• Obese females (Diamox and weight loss)• Pregnancy (Diamox after 20 weeks gestation)• Medication induced (remove offending agent)

PAPILLEDEMA SIGNS

• Bilateral ONH swelling caused by increased intracranial pressure

• Peripapillary swollen NFL

• Blurring of disc margins

• Blurring of ONH vasculature

• Peripapillary flame shaped hemorrhages

• Enlarged blind spots on VF testing

• No RAPD

PAPILLEDEMA SYMPTOMS

• Transient obscurations of vision lasting seconds (usually bilateral)

• Headaches worse upon wakening

• Diplopia secondary to 6th nerve palsy

• Little or no vision loss*unless chronic

• Color vision intact*unless chronic

FLOMAX®

• Alpha-1 blocker used in men for BPH• Benign Prostatic Hypertrophy (BPH)• Initial study; 15/16 patients exhibited floppy iris

syndrome• Can cause miosis, prolapse, excessive movement,

PC rupture during cataract surgery• Pre-op atropine or intraoperative alpha agonists

may help

FLOMAX®

• Notice how pupil dilates in office• Discontinue before referral; however, may

not stop the syndrome• Other alpha agonists are not as selective and

have not consistently shown syndrome– prazosin-Minipress®

– terazosin-Hytrin®

– doxazosin-Cardura®

TAMOXIFEN®

• Breast cancer oral treatment/prophylaxis• Most commonly after one year of therapy• Macular refractile bodies and RPE changes

– Does not warrant discontinuation

• Color vision decreases or CME develops– STOP MED

RETINAL CHANGES

• Chloroquine/Hydroxychloroquine (Plaquenil)– Early changes

• Retinal parafoveal granularity of RPE

– Late changes• Bull’s eye appearance of the macula

• Choroidal filling defects on FA

• Distorted color vision

PLAQUENIL MONITORING

• Baseline (or within one year of initiation)• Routine monitoring

– Dose and risk factor dependent– More frequent

• Dose > 6.5 mg/kg/day for greater than 5 years• Age > 60, kidney/liver disease, coexisting retinal disease

• Dilated fundus examination• Amsler grid• 10-2 Visual field• Color vision testing

ERECTILE DYSFUNCTION

Viagra®

• Bluish color vision defects reported especially with increased dosage amounts

• Concomitant nitrate use causes hypotension• Avoid in Retinitis Pigmentosa patients• Association with ischemic optic neuropathy

Cialis ®

Levitra ®

• Sildenafil (Viagra®)– Used in the treatment of erectile dysfunction– WHO classification: Possible– Anterior Ischemic Optic Neuropathy

• Painless, immediate loss of vision

• Swollen optic nerve with APD

• Altitudinal defect

– Users are older with vasculopathic conditions– Consider not using med with history of AION or

small optic nerve cupping

OPTIC NEUROPATHY

TOPAMAX

– Acute myopia; up to 6-8 diopters– Most cases within one month of initiation– Secondary angle closure– Choroidal effusion and ciliary body edema– Can lead to anterior displacement of lens and

acute angle closure with increased IOP

TOPAMAX INDUCED ANGLE CLOSURE

• Secondary angle closure– Shallow AC– Red eye, pain, high IOP, mydriasis– Superchoroidal effusion, not related to pupillary block– Ciliary body edema, not relieved by peripheral

iridotomy (PI)– Need to DC med as quick as possible– Must be tapered;cannot stop abruptly

• Hyperosmotic therapy, cycloplegic, topical antiglaucoma agents

MIGRAINES

• Women>Men; 3:1• Generally starts before 20 years of age• Often have family history• May have nausea and vomiting, fatigue,

photophobia• Headaches predominantly on same side;may

occasionally switch sides• Headache triggers

-Stress -Chocolate -BC pills-Bright lights -Alcohol -Pregnancy

MIGRAINE RELATED AURA

• Flashing lights, heat waves, jagged objects, tunnel vision, colored spots

• Lasting 15 to 30 minutes

• May or may not be accompanied by HA

• Acephalic migraine– History of migraine is common

CLUSTER HEADACHES

• Unilateral• Very painful• Typically affects men• Lasts minutes to hours; typically occurs at

same time each day• May disappear as easily as they appeared• May see ipsilateral tearing, rhinorrhea,

Horner’s

ADIE’S TONIC PUPIL

• Usually female

• Poor reaction to light

• Slow constriction to near

• Slow redilation following near constriction

• Vermiform movement

• Constricts to 0.125% pilocarpine

• Long standing can result in small pupil