Gonioscopy.org

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Glaucoma & Thyroid disease

The prevalence of self-reported glaucoma was significantly higher among [respondents] who reported a history of thyroid problems [6.5%] compared with those who did not [4.4%]

Hypothyroidism "may lead to the deposition of mucopolysaccharides in the trabecular meshwork, which increases IOP as well as aqueous outflow resistance"

Work up for Optic Neuropathy

Lab tests to r/o nfectious, inflammatory or nutritional problems:

• CBC
• C-reactive protein (GCA)
  
• ESR (GCA)
  
• Platelet count
• Lyme titer (infectious)
  
• ANA with reflex titer (rheumatologic)
• ACE (sarcoid)
  
• RPR (syphillis/infectious)
• FTA-ABS (syphillis/infectious)
• Vitamin B₁₂ (nutritional)
• Folic acid (nutritional)
• Methylmalonic acid (occult vitamin B₁₂ deficiency)

Neuroimaging:

• MRI (preferred) or CT scan
  

Differentials:

• a young patient complaining of sudden vision loss will more likely have an optic neuritis (ON)
• a middle-aged person would more likely have nonarteritic anterior ischemic optic neuropathy (NAION).
• an older patient with the same complaint would more likely have arteritic anterior ischemic optic neuropathy (AAION) associated with giant cell arteritis (GCA).
• NAION: no pain, “disk-at-risk” appearance in the fellow eye (small, crowded optic disc with little or no cupping that is predisposed to the ischemic process of NAION), less pale nerve
  
• AAION: pain with eye movements, optic nerve dema usually associated with hemorrhages during the acute phase, more pale nerve
  
• AAION and GCA symptoms: jaw claudication, scalp tenderness, fatigue, loss of appetite and fever.
• ON: pain on eye movement; you will see either a normal optic disc (retrobulbar optic neuritis) or disc swelling without hemorrhages (papillitis).
• Multiple sclerosis (MS) symptoms: weakness, numbness, pares-thesias or any other neurologic symptoms.
  
• Traumatic optic neuropathy: pallor of the neuroretinal rim suggests a longstanding or chronic process
  
• Structural abnormality or mass: non-acute, nonglaucomatous optic neuropathy; patient is in need of neuro-imaging to look for either a structural abnormality such as a mass or abnormal enhancement indicating an inflammatory process, or some form of disruption of the blood-brain barrier.
• GCA: A CBC, ESR, C-reactive protein and platelet count must be performed on patients over the age of 50
  

Ocular Side Effects Of Systemic Medications

http://www.revoptom.com/index.asp?ArticleType=SiteSpec&page=osc/105682/lesson.htm

Sinusitis

Clinical Features
- stuffy nose, followed by the slow onset of increased sinus pressure

- malaise, toxicity, headache, possibly a slightly elevated temperature, and usually a normal WBC count.

- as the disease progresses over two to three days, symptoms become more pronounced and severe.

- associated pain to the eye and orbit is a constant, dull ache with no throbbing. It may worsen if the patient bends over, coughs or strains.

- patients with chronic sinusitis usually have: allergic rhinitis, which is signaled by itchy/watery eyes, seasonal variation in symptoms and a family history of the disorder.

- acute sinusitis symptoms: facial pain or tenderness, colored nasal discharge, headache, decreased sense of smell, maxillary toothache, cough (usually daytime), fever, malodorous breath and occasional periorbital swelling. Less common findings include middle ear effusion, swelling of the face and nasal bleeding.²⁴

- ethmoid sinusitis: headache is a prominent symptom, located either behind or between the eyes with radiation to the temporal region. The eyes may be tender to pressure, and extreme tenderness on palpation of the medial and superior aspects of the orbit may be present. The patient may experience discomfort with eye movement.

- frontal sinusitis: may cause a frontal headache, which radiates behind the eyes to the vertex of the skull. The pain is generally constant and tends to feel like a pressure sensation. There is also point tenderness on the undersurface of the medial aspect of the superior orbital rim, which is the floor of the frontal sinus. Often, the pain is not present in the early morning after a night of rest. It usually appears one or two hours after waking, increases for three or four hours and becomes less severe in the late afternoon or evening. Apply finger pressure upward toward the floor of the sinus, where the sinus wall is thin, or perform palpation directly over the frontal sinus. Swelling caused by tumors or retained secretions (mucoceles) may cause a downward bulge in the floor of the frontal sinus. Transillumination of the frontal sinuses is done by placing a light source below the supraorbital rim, under the floor of the frontal sinus, at the upper inner angle of the orbit. This technique helps assess light transmission into the lower forehead.

- sphenoid sinusitis: causes pain at the occiput or vertex, yet frontotemporal, retro-orbital or facial pain is more common. It may also travel from the orbit to the mastoid area. The pain is described as constant, and if it occurs retrobulbarly, quite severe. This type of severe retro-orbital pain can cause photophobia and tearing.

- maxillary sinusitis: 10% of maxillary sinusitis is generally secondary to dental root infection. Simultaneous finger pressure over both maxillae exemplifies differences in tenderness.Perform transillumination by placing the light source over the middle of the infraorbital rim.

Examination and Testing
- thorough patient history and physical examination to establish either acute or chronic sinusitis
- an evaluation of vision, pupils, extraocular muscle function, exophthalmometry, slit lamp and funduscopy helps identify any secondary periorbital, orbital or ocular complications
- evaluation of the head and neck should be performed.

Amaurosis Fugax

-Most commonly caused by emboli thrown from the carotid artery or the heart; this eventually causes occlusion of the retinal arteriole system and/or an occlusive event anywhere else in the body.

-Patients usually have a history of hypertension, diabetes or hypercholesterolemia; danger of cerebral vascular accident (CVA) in addition to ocular sequelae.

-patients must be referred to the emergency room to rule out emboli actively being thrown from the carotid artery, cardiac valves or aortic arch.

-If a patient with these symptoms is 56 or older, one must consider giant cell arteritis (GCA)

-Other conditions, such as antiphospholipid antibody syndrome and systemic lupus erythematous, may also result in arteriole occlusion

-A central artery occlusion of less than 24 hours might be aided by intervention, including lowering IOP, performing ocular massage and attempting vasodilation by increasing carbon dioxide levels in the blood (this is accomplished by having the patient breathe into a paper bag).

-r/o weakness, numbness, headache or speech difficulty

-lab w/u:

• emergent complete blood count (CBC) with differential
• prothrombin time (PT)
• partial thromboplastin time (PTT) tests
• platelets
• carotid duplex
• echocardiogram

-start on ASA

-educate to report immediately to the ER if any non-recovering vision loss or peripheral weakness or numbness

Oral medical therapies

Oral Antibiotics

• Penicillins
• Augmentin (amoxocillin + clavulanic acid)
  
• 500mg, 875mg, or 1,000mg b.i.d. x 1 week (depending on severity)
  
• The dosage is determined by the severity of the clinical condition.

• Cephalosporins --5% to 10% cross-sensitivity with PCN
  
• Keflex (Cephalexin)
• 500mg b.i.d. x 1 week
  
  

• Macrolides -- only for pregnancy or chlamydia
  
• erythromycin
• 500mg t.i.d. x 1 week
• safe for pregnancy
  
• azithromycin
• 250mg tablets, 500mg tablets, 1,000mg oral suspension
• Zmax, a 2,000mg extended-release oral suspension
• chlamydial infection: one dose of either 1,000mg or 2,000mg azithromycin
  

• Fluoroquinolones (usually reserved for PCN allergies)
  
• Levaquin (Levofloxacin)
  
• 500mg q.d. x 1 week
  

Oral Corticosteroids

• best taken with meals to minimize the risk of GI upset
• caution: diabetes or peptic ulcer disease
• oral steroids exacerbating peptic ulcers
• a proton (hydrogen) pump inhibitor (PPI) can be prescribed, which will either fully protect or greatly diminish any expression of gastric ulceration
• PIs simply and safely reduce gastric acid secretion
• Prilosec (OTC, 20mg capsules, swallowed whole before a meal once daily), Nexium, Prevacid for the duration of the steroid therapy and for one additional week.

• patients with diabetes are prone to lose glycemic control while on oral steroids
• type II may well have increased blood glucose levels for a few days, which is rarely a problem; glycemic control returns after cessation of the steroid
• type I diabetes, they should be instructed to adjust their insulin dosagethe duration of their therapy
  

Acute optic neuritis and giant cell (cranial/temporal) arteritis

• 1,000mg of methylprednisolone (500mg q12 hours) IV daily for three days

Episcleritis

• Lotemax or FML q.i.d. x 1 week, then b.i.d. x 1 week, and that’s it
• For stubborn cases, add 40mg of p.o. prednisone x 2 days, then 30mg x 2 days, then 20mg x 2 days (up to six days), then 10mg x 2 to 4 more days
• rarely are systematic laboratory studies indicated
• if there are multiple recurrences or if the presentation is difficult to suppress. Lab work-up:
• Rheumatoid arthritis: Rheumatoid factor (RF) and antinuclear antibody (ANA)
• Systemic lupus erythematosus: Antinuclear antibody (ANA) and anti-DNA antibody
• Gout: Serum uric acid
• Syphilis: FTA-ABS, VDRL, MHA-TP or RPR
• Wegener’s granulomatosis: Antineutrophil cytoplasmic antibody (ANCA).
• Acne rosacea: None. This is a clinical diagnosis.
  

Orbital pseudotumor/orbitalmyositis/dacryoadenitis

• idiopathic white blood cell infiltration resulting in chemosis (without itching, therefore not allergic), proptosis, eyelid edema, and occasionally diplopia (because of orbital congestion)
• send patients for a CT scan to rule out any other orbital process, and to confirm our clinical diagnosis
  
• unusual or atypical eyelid or orbital presentation, order a CT scan
• if strongly feel the condition is infectious, start Augmentin 875mg b.i.d. or, if penicillin-allergic, Levaquin 500mg q.d.,
• Orbital pseudotumor is treated with 60mg p.o. prednisone x 3 to 4 days, then 40mg x 3 to 4 days, then 20mg x 1 to 2 weeks, then 10mg x 1 to 2 weeks

Marked or stubborn iridocyclitis

• If, after a few days of aggressive use of Pred Forte and a therapeutic cycloplegic (with perhaps FML ointment h.s.), the iritis appears unyielding (and the patient is compliant with the medications), try augmenting the topical medications with oral prednisone
• consider starting at 40mg a day x 2 or 3 days, 30mg x 2 or 3 days, and then reevaluate the patient. Assuming good improvement, continue the topical assault and continue to reduce the p.o. prednisone to 20mg x 1 week and recheck the patient. Assuming continued progress, stay the course topically, and reduce the p.o. prednisone to 10mg q.d.x 1 week and recheck the patient. This iritis should be very well controlled.
• Now the topical taper can begin. Reduce the Pred Forte to q2 hours x 1 week, and stop the FML ointment now, or after one more week. If the condition continues to improve, then continue q.i.d. x 1 week and recheck the patient. At this point, there should be little or no anterior chamber evidence of iritis. Keep this patient at b.i.d. for another 1 to 2 weeks.
• Regarding the cycloplegic agent, stop it when the cells and flare are reduced to Grade I or less
• If the IOP becomes elevated 10mm Hg or more from baseline, consider adding beta-blocker once daily if there are no contraindications, or brimonidine 0.2% q12 hours
• Once the inflammation is controlled and the patient is a steroid responder, switch the medication to Lotemax to finish the corticosteroid component of the therapy.
• If the iritis rebounds when the oral steroid is reduced below 20mg q.d., add a COX-2 inhibitor such as Celebrex (celecoxib, Pfizer) 100mg or 200mg b.i.d., or ibuprofen 400mg q.i.d. can be beneficial. In this scenario
• add one of these non-steroidals to the 20mg of oral prednisone q.d. x 1 week and then begin tapering the oral prednisone to 10mg q.d. x 1 week (or two) while concurrently using the oral NSAID.
  
• Many times, the use of NSAIDs in such instances enables the completion of the oral prednisone taper as planned. Once off the oral prednisone, continue the patient on the NSAID for a couple more weeks.
  

Bell's Palsy

• prednisolone 60mg a day for a few days, then tapering to 40mg, 20mg, and 10mg, depending upon the clinical response
• acyclovir 400mg five times a day for one week, or valacyclovir (Valtrex, GlaxoSmithKline) 500mg three times a day for one week, or famciclovir (Famvir, Novartis) 250mg three times daily for one week
• there is indecision regarding the need for such oral antiviral therapy in the setting of Bell’s palsy, however
• the current thinking is to prescribe an antiviral if the condition is severe or complete.
• preserve and maintain ocular surface integrity with frequent lubrication with a preservativefree artificial tear such as TheraTears Liquid Gel, or a gel formulation such as GenTeal Gel
• If more aggressive lubrication is required, an ointment such as Refresh P.M. can be employed
• modypatients fully recover in three to nine months.
  

MGD/posterior blepharitis

• no effective topical therapy to enhance meibomian gland function beyond warm soaks, lid scrubs and glandular massage.
• Doxycycline can exert a beneficial effect on the secretory function of these glands
• two 50mg capsules daily for two weeks (as a loading dose), then just one 50mg capsule daily x 3 to 6 months or longer, depending upon the clinical response. (read “Meibomian Gland Dysfunction,” by P.J. Driver, et al., in Survey of Ophthalmology, March-April 1996)
• side effects: occasional vaginal candidiasis
• OCuSOFT: ALODOX™ Convenience Kit
  

Allergic Blepharodermatitis

• usually just cold compresses and/or 0.1% triamcinolone cream applied b.i.d. to q.i.d.
• add oral prednisone p.r.n., or, depending upon your clinical judgment, prescribe oral prednisone as initial therapy, with or without concurrent topical steroid cream.
• the more severe the blepharodermatitis (or greater surface area involvement), the more we lean toward oral therapy.
• Fortunately, these conditions tend to resolve with only two to four days of therapy. We generally prescribe 40mg q.d. x 2 days, then 20mg q.d. x 2 to 4 more days, and then stop. There is no reason to taper such a low dose or short course of oral prednisone any further

Recurrent epithelial errosion

• Tetracyclines and corticosteroids can improve tissue adhesion of the basal epithelium/Bowman’s membrane/anterior stromal complex
• 50mg tablets of doxycycline to be taken by mouth as one 50mg tablet p.o. b.i.d. x 2 weeks, then q.d. x 6 to 8 weeks
• concurrently prescribe Lotemax q.i.d. x 1 month, then b.i.d. x 1 month

Oral Antivirals

• Acyclovir is available in 200mg capsules, 400mg and 800mg tablets, and in a 200mg-per-teaspoon (5ml) banana-flavored oral suspension

• Valtrex comes in 500mg and 1,000mg tablets
• Famvir is available in 125mg, 250mg and 500mg tablets.
• Acyclovir and Valtrex arePregnancy Category C; Famvir is Category B.
• precautions: kidney function, as all of the antiviral drugs are eliminated via the urine; ask patients about any known renal disease.

Herpes Zoster

• herpes zoster ophthalmicus 50% of the time
• keratitis, inflammatory anterior uveitis (or both), and less commonly as episcleritis and trabeculitis (which can result in high IOP).
• treated aggressively with topical corticosteroids such as Lotemax or Pred Forte.
• Oral antivirals can be used to treat childhood chickenpox, if indicated. The FDA/CDC recommended dosage for treating chicken pox in children over age 2 weighing at least 40 pounds can be as much as acyclovir 800mg q.i.d. x 5 days (the dosage for shingles is 800mg 5 times a day for 7 days).
• patient presenting with ophthalmic division shingles: standard dosage is acyclovir 800mg p.o. 5 times a day x 7 days, and potentially up to 10 to 14 days p.r.n. The clinically equivalent dosage for Valtrex is 1,000mg p.o. t.i.d. x 7 days. For Famvir, the dosage is 500mg p.o. t.i.d. x 7 days.

Herpes Simplex

• primary herpetic dermatitis to the face and/or eyelids. The cornea is not usually involved, but can be. In either case,
  
• 400mg of acyclovir 5 times per day x 7 days, Valtrex 500mg t.i.d. x 7 days, or Famvir 250mg t.i.d. x 7 days.
• HSV keratitis: supplement the oral antiviral with preservative-free artificial tears.
  
• Concurrent topical trifluridine is rarely ever needed
• Certainly, if in a few days the ocular dermatitis is resolved and the keratitis is unchanged, then adding topical Viroptic q2 hours x 4 days, then q.i.d. x 4 days may be needed, but this would be highly unusual.

Analgesics

• eye-related pain, which can certainly be intense, is invariably short-lived
• ask patients what they generally use for pain (extra-strength acetaminophen and ibuprofen)
• Acetaminophen (Extra Strength Tylenol) is indeed an excellent analgesic, which also has antipyretic (fever-reducing) properties
• is synergistic with oral narcotic analgesics
• Non-steroidal anti-inflammatory drugs (NSAIDs) such as ibuprofen are likewise very broadly used and are generically available.
• Ibuprofen is available over-the-counter as 200mg tablets or capsules.
• The optimum dosage of ibuprofen is 1,600mg per day. It is most often dosed as two 200mg tablets taken every four hours. This dosage is generally sufficient and approximates that of a Schedule III opioid.
• Tylenol #3 (30mg of codeine and 300mg of acetaminophen.)