AzaSite "pink eye" drop

AzaSite 1% ophth soln (azithromycin)

recommended dosage: BID x 2 days, QD x 5 days (total of 9 drops vs. 21 other brands)

demonstrated prolonged high levels in ocular tissue

good for bleph/bacterial conjunctivitis/dry eye patients (exerts anti-inflammatory activity along with antibacterial activity)

Acetaminophen dosages

Age:
>2 mo. (5kg): 80mg per dose
>4 mo. (6.5 kg): 100mg per dose
>6mo. (8kg): 120mg per dose
>12mo. (10kg): 160 mg per dose
>2 years (13kg): 200mg per dose
>3 years (15kg): 240mg per dose
>5 years (19kg): 280mg per dose

well-hydrated child: 15 mg/kg q4-6hrs
dehydration risk: 10 mg/kg q4-6hrs
maximum: 90 mg/kg/day (up to 4 grams daily)

Pyogenic granuloma

• benign vascular lesion of the skin and mucosa
• appear as a fleshy red mass with relatively rapid growth
• Histology: mixed acute and chronic inflammatory cells, with capillary proliferation in a lobular pattern (capillary hemangioma)
• occurs most often in children and pregnant women and may occur close to the site of a minor injury
• causes: usually associated with some inflammatory process such as a chalazion, severe blepharitis and meibomianitis, as a foreign body reaction or trauma such as surgery (pterygium excision, chalazia incision and drainage, placement of orbital implants, nasolacrimal duct probing with silicone tube placement, insertion of silicone punctal plugs, blepharoplasty, and eye muscle surgery).
• in most cases, these lesions will resolve with topical steroid administration x2-3 weeks
• surgical excision may be required for those lesions that fail to resolve after topical treatment
• in rare cases malignant neoplasms such as Kaposi’s sarcoma may mimic pyogenic granuloma
• recurrence following excision is extremely rare

CRAO

Symptoms:

• abrubt, painless vision loss (pain = OIS)
• amaurosis fugax precedes visual loss in 10% of patients
• men:woman = 2:1; mean age = 60; bilateral involvement = 1-2%

Findings:

• VA 20/800 to LP (NLP = ophthalmic artery obstruction or temporal arteritis)
• +APD
• anterior segment normal (except if OIS, can have NVI)
• ischemic whitening of the retina
• cherry red spot at macula
• ONH pallor with splinter retinal hemorrhages
• 20-25% demonstrate visible emboli

Differential diagnoses:

• mild, nonischemic CRVO
• neuroretinitis
• hypertensive retinoathy

Sequelae:

• after 4-6 weeks, retinal whitening dissipates, leaving optic nerve pallor
• arterial collaterals
• absent foveal reflex
• RPE hyperplasia from stress to the RPE
• NVI/NVG = 18% (make referal for panretinal laser photocoagulation)
• after >100 minutes, complete irreversible loss

Causes:

• Blood conditions: coagulopathies or poor blood flow, antiphospholipid antibody syndrome, protein S deficiency, protein C deficiency, antithrombin III deficiency
• Systemic disease: 60% of patients have HTN, 25% have DM, 50% no cause identified
• Heart disease: 30% have carotid artery disease; Refer patients (especially those <50> 50 y/o
• Optic neuritis
• Local trauma producing damage to the optic nerve
• Radiation exposure
• Behcet disease
• Migraine
• Syphilis
• Optic disc drusen
• Prepapillary arterial loops

Management:

• 350mg ASA, agressive digital ocular massage, topical beta blocker, oral Diamox 2 x 250mg (attempt to lower IOP to decrease resistance to nerve and retinal blood flow), breath into brown paper bag (stimulate rtinal arterials)
• Labs:
• CBC w/ differential and platelets
• blood pressure
• fasting BS
• lipid panel
• cholesterol
• ESR (if yes, requires high-dose corticosteroid treatment)
• CRP
• HLA-B27
• FTA-Abs
• HIV
• electrocardiogram with 2-D echo
• transesophageal electrocardiogram
• carotid doppler
• MRI

msd Mini-Scleral Design (from Blanchard CL company)

• designed to vault the cornea and fit on the sclera/conjunctiva, reducing the net-vault of the contact lens over the cornea
• reduction in the chance of irritation and better centering
• keratoconus fits that dont center or dislodge with eye mvmt
• irregular cornea fits
• GP-intollerant patients (chronic awareness)
• sagital depth of the CL
• trial fit progressively deeper vaults until corneal clearance achieved
• compression ring on conjunctiva after full day wear is ok
• if mid-peripheral or limpal touch exists, increase the mid-peripheral zone of the lens to move the surface of the lens off the cornea
• if mid-peripheral space b/w lens and cornea is too great (causing an air bubble), which may cause epithelial desiccation, decreasing the mid-peripheral zone will minimize these issues
• small air bubbles in periphery that move during lens wear don't interfere with vision or cause epithelial surface drying

Tears Again Hydrate

• for dry eye, blepharitis, MGD
• Rx only
• omega-3 fatty acid, flaxseed oil, evening primrose oil, omega-6, bilberry extract
• anti-inflammatory properties
• 4 soft gels daily, directly or during meals/snacks
• avoid taking at the same time with other medications or supplements, or if pregnant/nursing
• possible side effects: intestinal blockage, thyroid problems, may reduce blood vessel platelet aggregation (if you're taking ASA or blood thinners have your clotting time checked, may lower the seizure threshold in patients taking seizure meds

Visual Fields - documenting progression

Glaucoma Progression Analysis (GPA)

• change in the total deviation values over time may be due to factors other than glaucoma such as advancing cataract or decreased pupillary size.
• by using the pattern deviation values, the GPA software specifically targets the localized change associated with glaucoma
• If there were a diffuse component to the glaucomatous change, it would not be reflected in the GPA result, but the more likely localized component due to the formation of new glaucomatous defects or the expansion and deepening of existing defects would be characterized
• change needs to be present in 3 consecutive visual fields before progression can be confirmed
• if progression has occurred and there is a resultant change in therapy, the clinician should
  establish a new baseline so that any additional progression can be found
• if the patient undergoes ocular surgery or develops another ocular condition, new baseline
  tests after he stabilizes should be selected for use in evaluating subsequent examinations

Mean deviation plot

• gives the slope associated with change in the mean deviation
• this change will include anything that affects the subject’s visual sensitivity, including advancing cataract, and that it may not reflect change due to glaucoma.

• The GPA software will automatically assess the next visual field (and the next) to determine if that change is repeatable.
• If it is present on two consecutive tests, a half-filled triangle will appear at the location
• For repeatable change on three consecutive tests, a closed triangle will appear.
• The GPA software then assesses the repeatability of three or more points and gives a plain-language report of “possible progression” if two consecutive fields show that
• the same three or more points changed from baseline or “likely progression” if three consecutive fields show change at the same three or more points.