Eyecare Review—

For Primary Care

Practitioners
Primary Care Practitioners
 See variety of eye problems
 Discuss treatment options
 Facilitate referrals
 Positioned to explain
optometry's role as
primary eye care providers
Outline
 Anatomy
 Optics
 Turned Eyes
 Lazy Eye
 External Conditions
 Internal Conditions
 Diabetic Retinopathy
ANATOMY
Basic Anatomy
Choroid
Sclera
Retina

Cornea

Fovea

Pupil

Lens
Optic Nerve
Iris

Ciliary Body
Lids
 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
 Tough outer shell
 Composed of
collagen bundles
 Protects from
penetration
Cornea
 Composed of regularly
oriented collagen fibers
 5 layers
Anterior Chamber
 Space between
cornea and iris
 Filled with aqueous
humor produced by
ciliary body
Iris
 Iris gives eye color
 2 muscles:
o Dilator—opens
o Sphincter—constricts
Pupil
 Allows light to enter
 Enables view to back
of eye and eye health
evaluation
Lens
 Located behind iris
 Focuses light on
retina
 Allows for
accommodation
 Normally transparent
 Where cataracts form
Ciliary Body
 Primary functions
o Pulls on lens for
accommodation
o Epithelium secretes
aqueous fluid that
fills anterior chamber
Red Reflex
 Light reflection off
retina
 Useful for assessing
media clarity
 Affected by any
opacity of cornea, lens,
vitreous
 White reflex = leukocoria
Refer immediately!
Vitreous Humor
 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
 Interior surface
of eye
 Includes
o Optic nerve
o Retina
o Vasculature
Optic Nerve Head
 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
 Cup is natural
depression in center Physiologic Cup
Optic Disc

of nerve
 Cup size varies
between people
 Very large cup, or
change in appearance
over time, can Optic Nerve

indicate glaucoma
Macula
 Dense collection
of cone photoreceptors
 Fine detail and
color vision
 Macular degeneration
affects this area
Retinal Vessels
 Include arteries and veins
 Only place in body
where you can directly
visualize blood vessels
 Excellent indicators
of systemic diseases
o HTN
o Diabetes
o High cholesterol
o Carotid disease
Peripheral Retina
 Can only be evaluated
with dilated pupil
 Important to evaluate
periodically to fully
assess eye health
OPTICS
Optics Review
 Myopia
 Hyperopia
 Astigmatism
 Presbyopia
Myopia
 Nearsightedness
 See well up close
but blurry in distance
 Eye is too long
 Light focuses in
front of retina
Hyperopia
 Farsightedness
 See well in distance
 Eye is too short
 Focus point is
behind retina
Hyperopia
 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
 Surface of cornea is
irregular or misshapen
 Light focuses at
various points causing
distorted vision
 Often combined with
nearsightedness and
farsightedness
Presbyopia
 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
 Eye misalignment
o One or both turn
in, out, up or down
 Caused by muscle
imbalance
 3 Kinds of Strabismus
o Esotropia
o Exotropia
o Hypertropia
1. Esotropia
 Eye turns in
towards nose
3 Types of Esotropia
 Infantile (congenital)
o Develops in first 3 months of life
o Surgery usually recommended—
along with vision therapy and glasses
 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
 Partially Accommodative
o Combination of
 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
 Refer to pediatric
optometrist or
ophthalmologist
 Sooner the better for
best chance of good
vision
2. Exotropia
 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
 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
 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
 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
 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
 3 Types of Amblyopia
o Strabismic
o Anisometropic
o Stimulus deprivation
1. Strabismic Amblyopia
 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
 If caught early,
treatment can teach
brain how to see better
o Vision therapy/patching
o Glasses
o Surgical re-alignment

 Early vision screenings

are critical!
2. Anisometropic Amblyopia
 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
 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
 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

 Blepharitis  Conjunctivitis
 Hordeolum—stye o Viral “pink eye”
 Preseptal cellulitis o Adenovirus
o Bacterial
 Orbital cellulitis
o Allergic
 Pterygium o Hyperacute
 Corneal ulcer o Chlamydial
Blepharitis
 Inflammation of
eyelids (anterior or
posterior)
 Symptoms
o Itching
o Burning
o Crusting
o Dry eye sensation
o Foreign body
sensation
Blepharitis
 Signs  Treatment
o Crusts on lid margins o Warm compresses,
o Thickened, reddened 10 minutes 1-2 x/day
eyelids o Lid scrubs with
o Plugged or inspisated diluted baby
meibomian glands shampoo
along eyelid o Artificial tears
o Erythromycin
ointment at night
Hordeolum (stye)
 Abscessed
meibomian gland
 Raised, tender
nodule
 Often gets larger
over days to a week
Hordeolum
 Signs  Treatment
o Raised nodule o Warm compresses,
protruding out from BID-TID for 10 mins
or under lid o Topical meds don’t
o Red, swollen lid penetrate abscess
o Capped glands at o Oral antibiotics if no
site of infection response to traditional
treatment
Preseptal Cellulitis
 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
 Signs  Treatment
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
o Amoxicillin
(augmentin) 500 mg
PO TID
o Treat infection
quickly to minimize
risk of orbital
cellulitis
Orbital Cellulitis
 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
 Signs  Treatment
o Tender, warm o Medical emergency
periorbital lid edema o Hospitalization with
o Proptosis IV antibiotics
o Painful o Consider orbit/head
ophthalmoplegia CT to look for
o Decreased vision abscess
o Severe malaise, fever o Consult pediatrician
and pain or infectious disease
specialist
Preseptal vs. Orbital Cellulitis
 Preseptal  Orbital
o Painful, swollen lid o Painful, swollen lid
extending beyond that stops at orbital
orbital rim rim
o Normal vision o Decreased vision
o Full EOMs o Restricted ocular
o White conjunctiva motilities
o No proptosis o Proptosis
o No fever o Fever/malaise
Pterygium
 Triangular-shaped
growth of conjunctival
tissue onto cornea
 Causes
o UV exposure
o Dryness
o Irritants
 Smoke
 Dust
Pterygium
 Signs  Management and
o Dry eye Treatment
o Irritation o UV tint on glasses
o Redness o Avoid irritating
o Blurred vision environments
o Artificial tears
o Topical vasoconstrictor
or mild steroid
o Surgery
Corneal Ulcer
 Infection of cornea
o Bacterial
o Fungal
o Acanthamoeba
 Causes
o SCL wearer
o Trauma
o Compromised
cornea from pre-
existing condition
Corneal Ulcer
 Signs  Treatment:
o Pain o Start immediately
o Photophobia  Fortified antibiotics
 Fluoroquinolones
o Blurred vision
o Discharge o Culture may not be
necessary if ulcer is
o Hypopyon small
o Must be monitored
daily!
Conjunctivitis (red eye)
 Various Causes
1. Viral/Adenovirus
2. Bacterial
3. Allergic
4. Chlamydial
5. Herpetic
6. Toxic
Conjunctivitis
 Signs  Discharge
o Irritation o Watery
o Burning/stinging o Mucoid
o Watering o Mucopurulent
o Photophobia o Purulent
o Pain or foreign body
sensation
o Itching
1. Viral Conjunctivitis (pink eye)
 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
 Patients often have recent history of URI
 Treat symptoms
o Cool compresses
o Artificial tears
o Topical vasoconstrictors or mild anti-
inflammatory
 Frequent handwashing
 Usually runs course in
1-3 weeks
2. Adenoviral Conjunctivitis
 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
 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
 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
 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
 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
 Can be seasonal or
acute
 Signs/symptoms
o Itching is hallmark
o Conjunctival redness
o Chemosis
o Lid edema
o Thin, watery discharge
o No palpable preauricular
nodes
4. Allergic Conjunctivitis
 Treatment
o Eliminate offending agent
o If mild
 Cool compresses
 Artificial tears/vasoconstrictors
o If moderate or severe
 Topical antihistamine/mast-cell stabilizer (ie. Patanol)
 Topical NSAID
 Topical steroid
 Oral antihistamine
INTERNAL
CONDITIONS
Internal Ocular Conditions
 Glaucoma
 Cataracts
 Macular
Degeneration
 Retinal detachment
Glaucoma
 Progressive loss of Nerve
fiber layer at ONH
(increased cupping)
 Can lead to peripheral
visual field loss
 Sometimes caused by
elevated intraocular
pressure
Glaucoma
 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
 Monitoring
o IOP
o ONH appearance
o Visual field testing
o Newer methods include
 HRT (Heidelberg Retinal
Tomograph II)
 GDx Nerve Fiber Analyzer
 Genetic testing
Glaucoma
 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 sub-
capsular
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
 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
 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
 None
 Blurred vision
 Metamorphopsia—
straight lines appear
wavy or distorted
 Scotomas—missing
areas in vision
Dry Form
 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
 Regular eye exams
 Careful discussion regarding
family history
 Education
 UV protection
 Antioxidants
o AREDS
o PreserVision
 Stop smoking
Treatment for Wet Form
 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 micro-
vasculature
 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?