Eyecare Review—
For Primary Care
Practitioners
Primary Care Practitioners
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See variety of eye problems
Discuss treatment options
Facilitate referrals
Positioned to explain
optometry's role as
primary eye care providers
Outline
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Anatomy
Optics
Turned Eyes
Lazy Eye
External Conditions
Internal Conditions
Diabetic Retinopathy
ANATOMY
Basic Anatomy
Sclera
Choroid
Retina
Cornea
Fovea
Pupil
Lens
Iris
Ciliary Body
Optic Nerve
Lids

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Lashes—protection
from foreign material
Glands—lubricate
anterior surface
o Meibomian glands
o Glands of Zeis
o Glands of Moll
Conjunctiva

Thin, transparent,
vascular layer lining
o Backs of eyelids
o Fornices
o Anterior sclera
Sclera
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Tough outer shell
Composed of
collagen bundles
Protects from
penetration
Cornea
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Composed of regularly
oriented collagen fibers
5 layers
Anterior Chamber
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Space between
cornea and iris
Filled with aqueous
humor produced by
ciliary body
Iris
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Iris gives eye color
2 muscles:
o Dilator—opens
o Sphincter—constricts
Pupil
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Allows light to enter
Enables view to back
of eye and eye health
evaluation
Lens
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Located behind iris
Focuses light on
retina
Allows for
accommodation
Normally transparent
Where cataracts form
Ciliary Body
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Primary functions
o Pulls on lens for
accommodation
o Epithelium secretes
aqueous fluid that
fills anterior chamber
Red Reflex
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Light reflection off
retina
Useful for assessing
media clarity
Affected by any
opacity of cornea, lens,
vitreous
White reflex = leukocoria
Refer immediately!
Vitreous Humor
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Gel-like fluid that
fills back cavity
Serves as support
structure for blood
vessels while eye
formed—before birth
After birth, just
‘hangs out’ in there
Where floaters are located
Fundus
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Interior surface
of eye
Includes
o Optic nerve
o Retina
o Vasculature
Optic Nerve Head
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Collection of nerve
fibers and blood
vessels from retina
Transfers info to
brain’s visual cortex
Slightly yellow-pink
when healthy
White ‘full moon’
appearance can
mean trouble!
Optic Nerve Head
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Cup is natural
depression in center
of nerve
Cup size varies
between people
Very large cup, or
change in appearance
over time, can
indicate glaucoma
Physiologic Cup
Optic Nerve
Optic Disc
Macula
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Dense collection
of cone photoreceptors
Fine detail and
color vision
Macular degeneration
affects this area
Retinal Vessels
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Include arteries and veins
Only place in body
where you can directly
visualize blood vessels
Excellent indicators
of systemic diseases
o
o
o
o
HTN
Diabetes
High cholesterol
Carotid disease
Peripheral Retina
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Can only be evaluated
with dilated pupil
Important to evaluate
periodically to fully
assess eye health
OPTICS
Optics Review
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Myopia
Hyperopia
Astigmatism
Presbyopia
Myopia
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Nearsightedness
See well up close
but blurry in distance
Eye is too long
Light focuses in
front of retina
Hyperopia
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Farsightedness
See well in distance
Eye is too short
Focus point is
behind retina
Hyperopia
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Blurry image on retina
Lens focuses to compensate
Hyperopes often
asymptomatic much
their of lives
Can cause headaches or
eyestrain with extended
reading
These problems can
get worse after age 40
Astigmatism
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Surface of cornea is
irregular or misshapen
Light focuses at
various points causing
distorted vision
Often combined with
nearsightedness and
farsightedness
Presbyopia
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Normal, age-related
change
Near vision becomes
difficult
Mid-40s lens becomes
less elastic and loses
ability to change focus
Time for bifocals…
MISALIGNED
EYES
Turned Eyes - Strabismus
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Eye misalignment
o One or both turn
in, out, up or down
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Caused by muscle
imbalance
3 Kinds of Strabismus
o Esotropia
o Exotropia
o Hypertropia
1. Esotropia
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Eye turns in
towards nose
3 Types of Esotropia
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Infantile (congenital)
o Develops in first 3 months of life
o Surgery usually recommended—
along with vision therapy and glasses
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Accommodative
o Usually noted around age 2
o Child typically farsighted
o Focusing to make images clear can
cause eyes to turn inward
o Treated with glasses but
vision therapy may also be needed
3 Types of Esotropia
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Partially Accommodative
o Combination of
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accommodative dysfunction and
muscle imbalance
o Glasses and vision therapy
won’t completely correct
eye turn
o Surgery may be required
for best binocularity
If you see Esotropia
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Refer to pediatric
optometrist or
ophthalmologist
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Sooner the better for
best chance of good
vision
2. Exotropia
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Eye turns outward
Congenital—present
at birth
Surgery usually needed
to re-align
Many exotropias are
intermittent
o May occur when patient is tired or not paying attention
o Concentration can force eyes to re-align
o Vision therapy and/or glasses can help
2. Exotropia

When intermittent
o Brain sometimes receives
info from both eyes
(binocular)
o Less chance of amblyopia
o However, important to be
seen by eyecare provider
when deviation noted
3. Hypertropia
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One eye vertically
misaligned
Usually from paresis
of an extra-ocular
muscle
Typically much more
subtle for patient to
describe and provider
to diagnose
2 Types

Congenital
o Most common type
o Patients can compensate for
years by tilting head
o Can be discovered by looking at
childhood photos
2 Types
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Acquired
o Trauma—
Extra-ocular muscle ‘trapped’
by orbital fracture
o Vascular infarct—
Systemic diseases that affect
blood supply to nerves can
cause temporary nerve palsy
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Diabetes and HTN most
common
Palsies tend to resolve over
weeks or months
o Neurological—
In rare cases a tumor or
aneurysm can cause symptoms
LAZY EYE
Lazy Eye - Amblyopia
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Decreased vision
uncorrectable by glasses
or contacts—not due to
eye disease
For some reason, brain
doesn’t fully acknowledge
images seen
Lazy Eye - Amblyopia
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3 Types of Amblyopia
o Strabismic
o Anisometropic
o Stimulus deprivation
1. Strabismic Amblyopia
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One eye deviates from other and
sends conflicting info to brain
Brain doesn’t like to see double—
so “turns off ” info from deviated
eye
Results in under developed visual
cortex for that eye
Can usually be reversed or
decreased if treated during first
9 years
Need to visit eyecare provider
ASAP to determine cause
Treatment
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If caught early,
treatment can teach
brain how to see better
o Vision therapy/patching
o Glasses
o Surgical re-alignment
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Early vision screenings
are critical!
2. Anisometropic Amblyopia
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Anisometropia—significant
difference in Rx between eyes
Commonly one eye more
farsighted
Farsighted eye works hard to
see clearly—and sometimes
gives up
Brain relies on info from
other eye
2. Anisometropic Amblyopia
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If not caught, one eye
won’t learn to see as well
as other
Vision therapy and glasses
are both beneficial
Sooner the better
3. Deprivational Amblyopia
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Any opacity in visual
pathway can be devastating
to developing visual system
o Congenital cataracts
o Corneal opacities
o Ptosis (droopy eyelid)
o Other media opacities
EXTERNAL
CONDITIONS
Common External Ocular
Conditions
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Blepharitis
Hordeolum—stye
Preseptal cellulitis
Orbital cellulitis
Pterygium
Corneal ulcer
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Conjunctivitis
o
o
o
o
o
o
Viral “pink eye”
Adenovirus
Bacterial
Allergic
Hyperacute
Chlamydial
Blepharitis
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Inflammation of
eyelids (anterior or
posterior)
Symptoms
o
o
o
o
o
Itching
Burning
Crusting
Dry eye sensation
Foreign body
sensation
Blepharitis
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Signs
o Crusts on lid margins
o Thickened, reddened
eyelids
o Plugged or inspisated
meibomian glands
along eyelid
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Treatment
o Warm compresses,
10 minutes 1-2 x/day
o Lid scrubs with
diluted baby
shampoo
o Artificial tears
o Erythromycin
ointment at night
Hordeolum (stye)
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Abscessed
meibomian gland
Raised, tender
nodule
Often gets larger
over days to a week
Hordeolum
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Signs
o Raised nodule
protruding out from
or under lid
o Red, swollen lid
o Capped glands at
site of infection
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Treatment
o Warm compresses,
BID-TID for 10 mins
o Topical meds don’t
penetrate abscess
o Oral antibiotics if no
response to traditional
treatment
Preseptal Cellulitis
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Bacterial infection of
eyelid anterior to
orbital septum
Can arise from
o concurrent sinus
infection
o penetrating lid trauma
o dental infection
o hordeolum
o insect bite
Preseptal Cellulitis
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Signs
o Painful, swollen lid
extending past
orbital rim
o May be unable to
open eye
o No decreased vision,
restricted ocular
motility or proptosis
o White conjunctiva
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Treatment
o Amoxicillin
(augmentin) 500 mg
PO TID
o Treat infection
quickly to minimize
risk of orbital
cellulitis
Orbital Cellulitis
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Serious infection of soft
tissues behind orbital
septum
Can be life-threatening
Causes
o Sinus infection
o Extension of preseptal
cellulitis
o Dental infection
o Penetrating lid injury
o After ocular surgery
Orbital Cellulitis
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Signs
o Tender, warm
periorbital lid edema
o Proptosis
o Painful
ophthalmoplegia
o Decreased vision
o Severe malaise, fever
and pain
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Treatment
o Medical emergency
o Hospitalization with
IV antibiotics
o Consider orbit/head
CT to look for
abscess
o Consult pediatrician
or infectious disease
specialist
Preseptal vs. Orbital Cellulitis
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Preseptal
o Painful, swollen lid
extending beyond
orbital rim
o Normal vision
o Full EOMs
o White conjunctiva
o No proptosis
o No fever
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Orbital
o Painful, swollen lid
that stops at orbital
rim
o Decreased vision
o Restricted ocular
motilities
o Proptosis
o Fever/malaise
Pterygium
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Triangular-shaped
growth of conjunctival
tissue onto cornea
Causes
o UV exposure
o Dryness
o Irritants
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Smoke
Dust
Pterygium
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Signs
o
o
o
o
Dry eye
Irritation
Redness
Blurred vision
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Management and
Treatment
o UV tint on glasses
o Avoid irritating
environments
o Artificial tears
o Topical vasoconstrictor
or mild steroid
o Surgery
Corneal Ulcer
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Infection of cornea
o Bacterial
o Fungal
o Acanthamoeba
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Causes
o SCL wearer
o Trauma
o Compromised
cornea from preexisting condition
Corneal Ulcer
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Signs
o
o
o
o
o
Pain
Photophobia
Blurred vision
Discharge
Hypopyon
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Treatment:
o Start immediately
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Fortified antibiotics
Fluoroquinolones
o Culture may not be
necessary if ulcer is
small
o Must be monitored
daily!
Conjunctivitis (red eye)
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Various Causes
1. Viral/Adenovirus
2. Bacterial
3. Allergic
4. Chlamydial
5. Herpetic
6. Toxic
Conjunctivitis
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Signs
o
o
o
o
o
Irritation
Burning/stinging
Watering
Photophobia
Pain or foreign body
sensation
o Itching
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Discharge
o
o
o
o
Watery
Mucoid
Mucopurulent
Purulent
1. Viral Conjunctivitis (pink eye)
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Most viral infections are fairly mild
and self-limiting
Signs & Symptoms
o Watering
o Redness
o Photophobia
o Discomfort/foreign body sensation
o Palpable preauricular node
1. Viral Conjunctivitis
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Patients often have recent history of URI
Treat symptoms
o Cool compresses
o Artificial tears
o Topical vasoconstrictors or mild antiinflammatory
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Frequent handwashing
Usually runs course in
1-3 weeks
2. Adenoviral Conjunctivitis
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Highly contagious
Most common types
o Pharyngoconjunctival fever (PCF)—
can be caused by adenovirus
types 3, 4 & 7
o Epidemic keratoconjunctivitis (EKC)—
caused most commonly by adenovirus
types 8 & 19
2. Adenoviral Conjunctivitis

Signs
o Watering
o Conjunctival follicles
o Subconjunctival
hemorrhages
o Chemosis
o Pseudomembranes
o Lymphadenopathy
o Keratitis
3. Bacterial Conjunctivitis
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Common, especially in
children
Usually self-limiting
Signs/symptoms
o Acute redness
o Burning/grittiness
o Mucopurulent
discharge
o Lids stuck shut in
morning
3. Bacterial Conjunctivitis
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Common organisms: S. aureus, S. epidermidis,
S. pneumonia, H. influenza (esp. peds)
Usually self-limiting
But important to use broad-spectrum antibiotic
until discharge cleared (5-7 days)
Antibiotics
o Tobramycin
o Polytrim—polymyxin + trimethoprim
o Fluoroquinolones like
Ocuflox or Ciloxan
5. Hyperacute Conjunctivitis
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Cause
o Sexually transmitted
o Neisseria gonorrhoeae

Signs
o Swollen, tender lids
o Copious purulent
discharge
o Significant conjunctival
redness and swelling
o Lymphadenopathy
5. Hyperacute Conjunctivitis

Treatment
o Lavage
o Take scrapings for culture and sensitivity
testing
o Patients usually hospitalized and started on
IM Ceftriaxone
o Topical antibiotics not effective
6. Chlamydial Conjunctivitis

Cause
o Sexually transmitted ocular infection

Signs
o Patients typically have mild but persistent
follicular conjunctivitis non respondent to
topical antibiotics
o Any conjunctivitis lasting longer than 3
weeks despite therapy should be suspect
6. Chlamydial Conjunctivitis

Patients can have concomitant genital
infection (could be asymptomatic)
o Refer for work-up if necessary
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Treatment
o Oral—Azithromycin 1g, doxycycline 100mg
bid x 7 days, erythromycin 500mg qid x 7
days. Also need to tx partners!
o Topical—erythromycin, tetracycline, or
sulfacetamide ung bid-tid x 2-3 weeks
4. Allergic Conjunctivitis
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Can be seasonal or
acute
Signs/symptoms
o
o
o
o
o
o
Itching is hallmark
Conjunctival redness
Chemosis
Lid edema
Thin, watery discharge
No palpable preauricular
nodes
4. Allergic Conjunctivitis
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Treatment
o Eliminate offending agent
o If mild
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Cool compresses
Artificial tears/vasoconstrictors
o If moderate or severe
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Topical antihistamine/mast-cell stabilizer (ie. Patanol)
Topical NSAID
Topical steroid
Oral antihistamine
INTERNAL
CONDITIONS
Internal Ocular Conditions
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Glaucoma
Cataracts
Macular
Degeneration
Retinal detachment
Glaucoma
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Progressive loss of Nerve
fiber layer at ONH
(increased cupping)
Can lead to peripheral
visual field loss
Sometimes caused by
elevated intraocular
pressure
Glaucoma
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Pathophysiology of progression not well
understood
Increased IOP
o Damages nerves as they leave eye, causing cell death
o Reduces blood supply to ONH, indirectly destroying
cells by starving them of oxygen and nutrients

Abnormal levels of neurotransmitter (glutamate)
cause cells to die off
Glaucoma
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Monitoring
o
o
o
o
IOP
ONH appearance
Visual field testing
Newer methods include
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HRT (Heidelberg Retinal
Tomograph II)
GDx Nerve Fiber Analyzer
Genetic testing
Glaucoma
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IOP reduction is mainstay
of treatment
Decrease aqueous production
o B-blockers
o Alpha-agonists
o Carbonic anhydrase inhibitors

Increase uveoscleral outflow
o prostaglandin analogs
Cataract


Clouding of natural
lens
Patients experience
o Blurred/dim vision
o Glare, especially
at night
o Halos around lights
o Doubling or ghost
images of objects
Etiology


Everyone develops them if
they live long enough!
Types of cataracts
o Age-related—senile
o Trauma—blunt or perforating
injury
o Systemic conditions—diabetes
o Medications—steroids
Main Types

Age-related
o Nuclear sclerotic
o Cortical spokes
o Posterior subcapsular
o Mature cataract
Treatment


Surgery
When loss of vision interferes
with daily activities
o Driving
o Reading
o Hobbies
Outpatient Surgery

5-10 minutes with skilled
surgeon
o Incision through cornea
or sclera under upper lid
o Circular tear in anterior
capsule
o Lens broken up with ultra
sound instrument
o Fragments suctioned out
o Lens implant inserted
Secondary Cataract
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Cloudiness forms on
posterior capsule after
cataract surgery
30-50% of patients
YAG laser used to
create opening
Vision quickly restored
Macular Degeneration

#1 cause of blindness in
Americans over
age 65
Pathophysiology
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
Causes not well understood
Theorized link to
o UV light exposure
o subsequent release of free
radicals
o oxidation within retinal tissues

Another theory—areas of
decreased vascular perfusion
in retina, lead to cell death
Two Types

Dry (atrophic)
o 90% of those diagnosed

Wet (exudative)
o 10% of those diagnosed
o But accounts for 90% of
blindness caused by
disease
Symptoms
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None
Blurred vision
Metamorphopsia—
straight lines appear
wavy or distorted
Scotomas—missing
areas in vision
Dry Form
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
Slow, progressive loss of
central vision
Breakdown of underlying
retinal tissues, resulting in
mottling or clumping of
normal pigment
Drusen begin to accumulate
Geographic atrophy can also
occur
Wet Form



Can quickly degrade
central vision
Break in underlying
tissues allows new blood
vessels or fluid to come
through
New blood vessels are
weak so frequently break
and bleed
Treatment for Dry Form



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Regular eye exams
Careful discussion regarding
family history
Education
UV protection
Antioxidants
o AREDS
o PreserVision

Stop smoking
Treatment for Wet Form



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

Refer to retinal specialist
Photocoagulation
Photo-dynamic therapy
(PDT)
Submacular surgery
Macular translocation
Anti-angiogenic drug
therapy
Retinal Detachment

Several types
o Rhegmatogenous—
caused by break in retina
o Exudative—caused by
fluid accumulation
beneath retina
o Tractional—proliferative
fibrovascular vitreal
strands
Signs & Symptoms



Flashing lights in peripheral vision
New floaters—black spots or ‘cobwebs’
Peripheral scotoma—dark shadow or
“curtain” blocking vision
Emergency


Patients with these
symptoms must see eyecare
provider immediately
Additional risk factors
o Highly nearsighted
o Diabetic
o Recent trauma/injury
Treatment




Laser photocoagulation
or cryotherapy
Pneumatic retinopexy—
gas bubble to
tamponade retina back
into place
Scleral buckle
Silicone oil
DIABETIC
RETINOPATHY
Diabetic Retinopathy


Diabetes affects
retinal microvasculature
One of leading
causes of blindness
among ages 20-64
Progression



Over time, elevated and fluctuating blood sugar
damages vessel walls
Vessels leak fluid, lipids or blood into retina
New vessels grow to bring more oxygen to
retina
Symptoms




Fluctuating vision
Blurred vision
Distortion
Sudden loss of vision
Treatment


Control blood sugar
Refer to retinal specialist
when vision threatened
PRP (pan-retinal
photocoagulation)
 Focal laser
 Vitrectomy
 Retinal detachment repair

Working Together



Together we can catch
vision threatening
conditions earlier
Glad to answer questions
Always happy to take
your calls
Questions?