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Tahiti 2016 CE Handouts Hotel Sofitel Moorea Ia Ora InterContinental Bora Bora March 4-13, 2016 Lecturers: Paul C. Ajamian, O.D., F.A.A.O. Jill Autry, O.D., RPh Maynard L. Pohl, O.D., F. A.A.O. Stuart Autry 281-808-5763 SAutry@TropicalCE.com Josh Ogden 281-900-8493 Josh@TropicalCE.com Tahiti 2016 Sofitel Mo’orea Resort & Intercontinental Resort & Thalasso Spa PROGRAM AGENDA – COPE EVENT # 110736 Paul C. Ajamian, O.D. - Diplomate, American Board of Optometry Jill Autry, O.D., RPh Maynard L. Pohl, O.D., F.A.A.O. Sunday, March 6, 2016 7:30 am – 9:30 am Favorite Cases – COPE # 43916-SD Paul C. Ajamian, O.D., F.A.A.O. 9:30 am – 10:30 am Oral Meds for Anterior Segment Disease – COPE # 45883-OP Paul C. Ajamian, O.D., F.A.A.O. 10:30 am – 12:30 pm The Future of Cataract Surgery – COPE # 46635-OP Paul C. Ajamian, O.D., F.A.A.O. Monday, March 7, 2016 7:30 am – 8:30 am What a Pain – COPE # 43917-OP Paul C. Ajamian, O.D., F.A.A.O. 8:30 am – 10:30 am The Sneak Thief Cutting Through the Controversies – COPE # 40985-GL Paul C. Ajamian, O.D., F.A.A.O. 10:30 am – 12:30 am Anti-Infective Agents Making the Right Choice – COPE # 43893-PH Jill Autry, O.D., RPh Thursday, March 10, 2016 12:30 pm – 3:30 pm Practice Essentials in Posterior Segment Care – COPE # 43707-PS Maynard L. Pohl, O.D., F.A.A.O. 3:30 pm – 5:30 pm Retinal Vascular Occlusive Disease: See It, Know It, Manage It – COPE # 43687-SD Maynard L. Pohl, O.D., F.A.A.O. Friday, March 11, 2016 7:30 am – 9:30 am Essentials in Cataract Patient Care – COPE # 41811-PO Maynard L. Pohl, O.D., F.A.A.O. 9:30 am – 11:30 am Learn to Comanage the Complex and Unusual – COPE # 38487-PO Maynard L. Pohl, O.D., F.A.A.O. 11:30 am – 12:30 pm What’s New in Corneal Transplant Surgery – COPE # 39011-PO Maynard L. Pohl, O.D., F.A.A.O. 20 TOTAL HOURS OF CONTINUING EDUCATION The best continuing education courses available presented in the most exciting resort locations Tahiti 2016 Sofitel Mo’orea Resort & Intercontinental Resort & Thalasso Spa CONTINUING EDUCATION REQUIREMENTS The Council on Optometric Practioner Education (COPE) and individual state and provincial boards of optometry approve Tropical CE’s optometric education courses for optometric continuing education credit. Each optometrist must meet the following requirements in order to receive credit for each session. Registrants must SIGN IN no later than 5 minutes after the starting time. ATTENDANCE FORM MUST BE SIGNED by the monitor at the end of each session. An education monitor will be present at each session to verify CE attendance. Forms provided for this purpose can only be verified as you leave the session. Attendance forms cannot be verified at a later time. A Letter of Attendance Verification will be sent directly to each participant immediately following the meeting specifying the number of continuing education hours attended. Tropical CE maintains a permanent transcript for all participants. 2/17/2016 1 First, a few rules to live by… 1. Be observant and curious 2. Never panic before you examine 3. Don’t be afraid to tackle new things 4. Always explain VA loss less than 20/20 or have a plan to do so Rule 2: Don’t Panic! Even if others before you missed the dx doesn’t mean you will Calmly assess the eye, one medical finding at a time Rule 3: Don’t Be Afraid to Tackle New Things Glaucoma is still an area of untapped potential for optometrists! Lacrimal procedures If you are referring, always ask “what are they going to do that I cannot” Rule 4: Explain VA not correctable to 20/20 The Devil is in the Diagnosis Warm Up Cases •61 WM seen for “routine exam” •Complaining of reduced vision right eye •No family history of glaucoma •IOP 18/18 •“Arcuate” superior visual field loss OD noted by OD, sent for Gl Eval 2/17/2016 2 Workup •Vascular consult/endarterectomy Conquer Your Fears 22 HM with “swollen lid” Motility Restriction The Case of the Sleepy Senior •63 WM with history of ptosis, “has trouble keeping eyes open when tired” •Seen by MD, put on topical steroid, told “nothing wrong” •Family concerned 2/17/2016 3 • Sustained upgaze test as shown • Vertical diplopia also common • Tensilon testing is usually diagnostic • Look closely at our patient post‐tensilon as results can be subtle! Myasthenia Gravis 77 wm • c/o binocular diplopia (horizontal with slight vertical component) • Sent by OD to Neurophth, told he might have had a mild stroke but MRI negative • Patient as shown •MG may mimic any EOM palsy •75% of pts have ocular symptoms initially •This is a neurological disease •Treatment with anticholinesterase agents may not be effective>>>switch to steroids 2/17/2016 4 The Case of the Sticky Situation •53 WF •Itchy eyes for a few days •Reaches into the bathroom closet for an “allergy drop” •60 wf •Putting “artificial tears” into her dry eyes What to do? 1. Calmly assess prior to punting 2. Use force to pry lids open 3. If #2 does not work, use more 4. Use acetone to open lid 5. Warm soaks for three days, then see patient back 2/17/2016 5 3 yo girl exploring Mommy’s handbag! Superglue on the cornea..no problem! Take Home Point • Don’t be afraid to remove superglue from the eye and lids 2/17/2016 6 Functional Vision Loss •Tubular fields •VA initially not 20/20 •May be problems in child’s life, but also may be overachiever The Troubled Teen • 14 WF • Blurred distance vision OU x 1 year • Given low plus lenses for accommodative problem with no improvement VA 20/200 best corrected OD/OS Exam findings • Confrontation fields full to finger count but….. • Restricted to Hand Presentation at two distances • Pupils normal • Scopes plano to 20/200 Magic Drop Refraction • Eventually reads one letter at a time on 20/20 line • Fundus normal More history perhaps? •Father just left home •Younger sister bipolar •Grandmother died •Has changed schools 4 times in a year •Straight A student, avid reader, artist, writes poetry, etc etc etc. 2/17/2016 7 And another from the Omni Files 2 months ago………. •18 BF •Poor vision, 20/40 best, scopes plano, normal fundus •Tubular fields and magic drop refraction gets •Talk with the Dad reveals “all is great” until I get the Mom on the phone! The Case of the Running Eye •41 WF •Breast cancer survivor •Worried about itching and “tearing” OS > OD, worse when “out of contacts” 2/17/2016 8 Before and after AND HERE IS THE CULPRIT!! Pearl •Always ask about tearing…”do the tears run down your face?” Yes Tears Down Cheeks? No Check for punctal apposition & patency, blockage of canaliculus dry eye workup True epiphora • examine punctal openings (size and apposition to globe), then dilate/irrigate to determine site of blockage 2/17/2016 9 Irrigating Cannulas/Dilators •Shahinian Lacrimal Cannula, straight (bullet tip 23 ga) •$50 Amblersurgical.com or Bauschinstruments.com or Katena.com Burnstine cannula • Combination dilator/irrigator • Katena.com Irrigation Take Home Pearl • Always ask about tearing…”do the tears run down your face?” • Think about adding lacrimal procedures to your practice! In a nutshell………. •Be a good observer •Stay on the cutting edge •Give yourself a chance by seeing patients first •Know when to refer and to whom 2/17/2016 10 Iris Implants; The Price of Beauty? Initial Exam •45 yr old white female •Decreased vision, trouble navigating house, glare at night OU •Ocular, medical history •Colored iris implant surgery OU in Istanbul, Turkey 2011 •Multiple facial/cosmetic plastic surgeries •VAsc: OD 5/200 OS: 20/200‐1, PH NI OU •Pupils: Sluggish pupils, no reflex observed •Entrance testing unremarkable •Physical •2+ conjunctival injection OU, corneal stromal edema OU, endothelial pigment/striae OU, displaced colored iris implants bisecting pupil OU, lens iris touch OU, 3+ nuclear sclerosis OU Initial Exam •Pachymetry •OD: 630um OS: 618um •Specular microscopy •OD: 1157mm2 OS: 1198mm2 •Normal: 2700‐3000mm2 Initial exam 2/17/2016 11 Assessment/plan • Dense nuclear cataracts OU • Bullous keratopathy OU • Posterior and anterior synechiae OU Recommended cataract extraction OD then OS with synechiolysis and iris implant removal OU Post op 1‐day •VAsc: OD CF@3 FT, PH NI. •Patient reported greatly improved VA right after CE, however got progressively worse overnight. •3+ corneal edema, 2+ cells, 2+ conj injection OD •Pachymetry: OD: 720um Post op 1‐week •VAsc: OD 20/400, PH NI •Patient reports periods of clear vision, but usually fluctuating and notes mild FBS •2+ corneal edema, 1+ cells, trace injection OD, and PCIOL in good position •Schedule DSAEK OD DSAEK post op • 1‐ day • VAsc: OD 20/400, PH NI • Patient reports no pain • Attached graft with no fluid clefts, diffuse edema, 2+ injection OD, and PCIOL in good position • 1‐week • VAsc: OD 20/40, PH 20/30+2 • Patient reports greatly improved vision and mild FBS • Stable and attached graft, 1+ stromal edema, 2+ injection OD, and PCIOL in good position • 1‐month •VAsc: OD 20/25‐1, BCVA: 20/25+2 •Patient is ecstatic! •Stable and attached graft, trace edema, trace injection OD, and PCIOL in good position •Pachymetry: 659um •Plan – Continue Pred Forte and Muro128. Schedule CE/DSAEK OS 2/17/2016 12 Combined PCIOL/DSAEK OS • VAsc: • 1‐day post op: 20/400 • 1‐week post op: 20/30‐ PH 20/25‐ • 1‐month post op: 20/20‐ (removed stiches) • Exam findings • Irregular pupils OU • Small area of PAS remaining OU • Clear corneal grafts in place OU • PCIOLs clear and in place OU Medical Uses •Aniridia •OCA •Large scale iris atrophy •Iris colobomas •Dyscoria •Heterochromia •Colored iris implantation is not US FDA approved! •Dr. Kahn in Panama brought it to the forefront •Patients thus seek surgery from Turkey, Panama, Tunisia, India, Mexico, Jordan, and Lebanon •Costs can range up to $10,500 •Bright ocular, New Iris Complications • Implant can “bounce around” the anterior chamber • Chronic iritis • PAS/Posterior synechiae • Cataracts • Bullous keratopathy • Endothelial dysfunction ‐> Corneal decompensation • Increased IOP ‐> Closed angle glaucoma • Hyphema •With cosmetic procedures on the rise, many will do anything to achieve their ideal look •Intrigued with the vanity aspect…They don’t stop and think about possible consequences •Stay informed and know a good anterior segment surgeon! 2/17/2016 13 The Case of the Hurting Face 73 BF 1 week hx of severe mucopurulent drainage OS and a red eye Began noting “raw, irritated” skin above and below eye with itching • Was applying frequent hot soaks to area around OS • Awoke the morning we saw her with swelling below RLL Your diagnosis? Atopic Dermatitis • Think of it as a form of eczema triggered by a variety of irritants • Soaps, harsh chemicals, heat, stress, foods, and certain infections such as • Staph Aureus: a frequent cause of this condition with skin response in periorbital region 2/17/2016 14 Management • Ofloxacin drops OS QID • Tobradex ointment for eczema • Benadryl OTC 25mg tabs QID • Total resolution 4 days later with photos to prove it! 2/17/2016 1 Oral Meds for Anterior Segment Disease Paul C. Ajamian, O.D. Tropical CE Bora Bora What this talk is about….. •Its as much about what to prescribe, but more importantly what NOT to prescribe •Limit your treatment to eye and adnexa problems! •Introduction •Antibiotics •Antivirals Guiding Principles • Be sure you get the diagnosis right • Know the drugs in your tool kit • Use them judiciously AARP Website •http://www.aarp.org/health/drugs‐supplements/info‐ 2007/my_personal_medication_record.html •Or just google “aarp personal medication record” • Personal medication record • Drug log/ allergies 2/17/2016 2 KEEPING UP •Rxlist.com • Search for drug information • Top 200 List RXLIST.com Other Resources • Centerwatch.com • Clinical trials, drug information • Epocrates.com • Epocrates Rx: Free App • Epocrates essentials: $159.99/year Other Resources • Drugs.com • Pill identifier, interaction checker • EMR: most systems have interactions built in • FactsandComparisons.com 2/17/2016 3 Before you prescribe… • Allergic to anything? • What other meds are they taking? • Rx • OTC • Vitamins/Herbals • What systemic conditions do they have? • Especially note hepatic and renal problems. • “I am allergic to antibiotics” • What exactly happens when you take them? • “I get a bit nauseous for a few days with loose stool” DISTINGUISH SIDE EFFECTS FROM ALLERGY! TRUE ALLERGIC REACTIONS • Skin rash, hives, or itching • Wheezing or trouble breathing • Swelling of the face, lips, or throat/laryngeal edema • Discontinue use immediately • Consult doctor immediately • Severe reactions demand emergency care PRESCRIBING FOR WOMEN • Pregnant/nursing or thinking about it? • Consult OB‐GYN if necessary • OK in pregnancy •Tylenol 3, Vicodin/Lortab •Augmentin, erythromycin, Zpack, amoxicillin •Acyclovir and other antivirals Category A Controlled studies in women fail to demonstrate a risk to the fetus in the first trimester (and there is no evidence of a risk in later trimesters), and the possibility of fetal harm appears remote. Category B Either animal-reproduction studies have not demonstrated a fetal risk but there are no controlled studies in pregnant women, or animal-reproduction studies have shown an adverse effect (other than a decrease in fertility) that was not confirmed in controlled studies in women in the first trimester (and there is no evidence of a risk in later trimesters). Category C Either studies in animals have revealed adverse effects on the fetus (teratogenic or embryocidal or other) and there are no controlled studies in women, or studies in women and animals are not available. Drugs should be given only if the potential benefit justifies the potential risk to the fetus. Category D There is positive evidence of human fetal risk, but the benefits from use in pregnant women may be acceptable despite the risk (e.g., if the drug is needed in a life- threatening situation or for a serious disease for which safer drugs cannot be used or are ineffective). 2/17/2016 4 The FDA has a categorization of drug risks to the fetus that runs from: "Category A" (safest) to "Category X" (known danger--do not use!) Category X Studies in animals or human beings have demonstrated fetal abnormalities, or there is evidence of fetal risk based on human experience or both, and the risk of the use of the drug in pregnant women clearly outweighs any possible benefit. The drug is contraindicated in women who are or may become pregnant. ANTIBIOTICS •Is an oral antibiotic truly needed? •Check allergy information •Use less expensive antibiotics when possible •Take full course of therapy • Oral antibiotics can cause thrush, vaginal yeast infections •Take doses with yogurt •Diflucan may be prescribed but do it through OB GYN • Stop antibiotic if patient reports severe diarrhea/blood in stool •Concerns of pseudomembranous colitis On birth control pills? • Counsel and document for concomitant antibiotic therapy although definite interaction controversial Oral Antibiotics • Tetracyclines • Penicillins • Cephalosporins • Macrolides • Fluoroquinolones OCULAR USES •Posterior blepharitis •Chalazions •Acne rosacea •Dry eye •Preseptal cellulitis •Dacryocystitis •Dacryoadenitis •Canaliculitis •Chlamydia •Posterior toxoplasmosis activation 2/17/2016 5 Bacterial Conjunctivitis •Chronic Staph…very common Oral Antibiotics • Tetracyclines • Penicillins • Cephalosporins • Macrolides • Fluoroquinolones ‐CYCLINES • Inhibit bacterial protein synthesis • Cannot use in children younger than 8‐12 due to teeth discoloration • Cannot use in pregnancy/nursing • Causes photosensitivity and photophobia • Long‐term therapy associated with pseudotumor cerebri (rare) TETRACYCLINE •Good broad spectrum activity •Less use than Doxycycline •QID dosing (250‐500mg qid) •Must take on an empty stomach* •Cannot take with dairy products •Cannot take with antacids** •Cannot take with vitamins *food prevents absorption of drug into bloodstream **calcium/iron/aluminum/magnesium compounds also bind to TCN DOXYCYCLINE • Good broad spectrum activity • Great if Pt reports Pcillin allergy • QD to BID dosing • Can take with food • Can take with dairy products • Cannot take with antacids OCULAR USES • Posterior Blepharitis • Early Acute Styes • Dry Eye • Treatment for RCE: 100mg bid x 2 months with topical steroid qid (limited success) 2/17/2016 6 Paul C. Ajamian, O.D. 5505 Peachtree Dunwoody Rd Ste 300 Atlanta, GA 30342 404-257-0814 -------------------------------------------------------------------------------------------------------------------------- NAME Leslie Smith AGE ADDRESS _____________________________________ Date 05-30-08 Rx Doxycycline 100 mg One tablet bid #90 (45 day supply) REFILLS--Zero Paul Ajamian, O.D Signature Dosing Doxy • 100mg bid short term (2 weeks) • Re‐assess • Possible additional course of 50mg bid or 50mg qd • Longest course should probably be 6 wks Doxycycline: Cost • Doxycycline Hyclate 100mg #20 $14.00 • Doxycycline Hyclate 100mg #60 $26.00 Acne Rosacea •Accompanied by blepharitis •Commonly missed if subtle •Make “nose watching” part of your routine Management •Doxycycline most commonly used •Tetracycline, Minocycline, and low dose Cyclines also options •Metrogel •Dermatology consult 2/17/2016 7 Oral Antibiotics • Tetracyclines • Penicillins • Cephalosporins • Macrolides • Fluoroquinolones PENICILLINS • Beta‐lactam antibiotic class • Inhibits bacterial cell wall formation • Penicillin, ampicillin, amoxicillin, dicloxacillin, etc. • 10‐15% of population are allergic to PCN • Well tolerated and safe otherwise • Can use in pregnancy and children • Consult OB‐GYN if nursing DICLOXACILLIN • Penicillin antibiotic • Good for staph infections • Resistant to beta lactamases (especially staph producing beta lactamases) • Take on an empty stomach • 250mg qid Dicloxacillin: Cost • Dicloxacillin 500mg #40 $30.00 Paul C. Ajamian, O.D. 5505 Peachtree Dunwoody Rd Ste 300 Atlanta, GA 30342 404-257-0814 -------------------------------------------------------------------------------------------------------------------------- NAME Leslie Smith AGE ADDRESS _____________________________________ Date 05-30-08 Rx Dicloxacillin 250 mg One tablet qid #40 REFILLS--Zero Paul Ajamian, O.D Signature 2/17/2016 8 Preseptal Cellulitis ?Dacryocystitis Not sure…but treated with Dicloxacillin 250mg qid with complete resolution 4 days later This sure is! You could treat this with an oral antibiotic (penicillin or cephalosporin), but…….. •Probably a good idea to get an orbital consult 2/17/2016 9 Children can have blepharitis and styes too! AMOXICILLIN • Penicillin antibiotic (aminopenicillin) • Extended coverage over standard PCN • Good for staph infections because resistant to beta lactamases • Inexpensive AMOXICILLIN DOSAGE • Skin and soft tissue infections • Adults • 875mg q12h • Children • 20‐40mg/kg/day divided q8h Amoxicillin Cost • Amoxicillin 500mg #30 15.00 AUGMENTIN • Augmentin = Amoxicillin + Clavulanic acid • Cannot use if penicillin allergic • Clavulanic acid is a “suicide inhibitor” • Protects amoxicillin from beta‐lactamases • Does not have antibiotic action itself • Allows increased coverage with less destruction by beta‐lactamases • Also covers anaerobes • Good for human and animal bites AUGMENTIN INFO • Can use in pregnancy (category B) • Can use in children • Can cause nausea/vomiting/diarrhea • Take with food/yogurt • Few drug interactions • Allopurinol/probenecid (both for gout) • 500mg q8h or 875mg bid • Generic available but still expensive 2/17/2016 10 Augmentin Advantages • Use in kids because that’s what the pediatricians use! • Comes in liquid form • Good against H. Influenzae Oral Antibiotics • Tetracyclines • Penicillins • Cephalosporins • Macrolides • Fluoroquinolones ALLERGIC TO PENICILLIN? • Small percentage of patients will also be allergic to cephalosporins • Literature suggests anywhere from 3‐10% cross‐sensitivity • Alternatives: –cycline or ‐quinolone • Or a macrolide • Erythromycin, clarithromycin, azithromycin Penicillin Allergy and Cephalosporins “This retrospective study of outpatients found a low absolute risk (1.1%), but a high relative risk (10‐fold increase), of reacting to a cephalosporin after having reacted to a penicillin. However, the relative risk of reacting to a sulfonamide was similar, suggesting that a specific cross‐reaction between penicillins and cephalosporins might not exist. The current approach of avoiding cephalosporins only in patients with severe allergic reactions to penicillins seems appropriate.” Source: Journal Watch, June 1, 2006 Reference: Apter AG et al. Is there cross‐reactivity between penicillins and cephalosporins? Am J Med 2006 Apr; 119:e11‐9 CEPHALOSPORINS • Beta‐lactam antibiotic class • Increased coverage over penicillin class • Four generations of cephalosporins • Increasing gram negative activity from 1 to 4 • First and second generations better for ocular conditions (more likely gram positive) CEPHALEXIN • Brand name KEFLEX® • First generation cephalosporin • Good gram positive coverage (Staph/Strep) • Cheap • Adult dose is 500mg bid • Also available in suspension for children • 20‐40mg/kg/day divided q8h 2/17/2016 11 Paul C. Ajamian, O.D. 5505 Peachtree Dunwoody Rd Ste 300 Atlanta, GA 30342 404-257-0814 -------------------------------------------------------------------------------------------------------------------------- NAME Leslie Smith AGE ADDRESS _____________________________________ Date 05-30-08 Rx Keflex 500 mg One tablet bid #20 REFILLS--Zero Paul Ajamian, O.D Signature Keflex: Cost • Cephalexin 500mg #30 $24.00 Out of Orbit • 54 WF • Lid swelling for 3 days, getting worse • Sees OD, put on Keflex 250 qid* • Next day worse, patient panics, sent to Omni Modify Therapy or CPM? • We increased dose of Keflex to 500 qid • Warm compresses • Saw patient next day: no better but no worse • 3 days later markedly better 2/17/2016 12 Oral Antibiotics • Tetracyclines • Penicillins • Cephalosporins • Macrolides • Fluoroquinolones ZITHROMAX (Azithromycin) • Macrolide antibiotic • Dosing regimen increases compliance • OK in pregnancy and children • Less GI effects than erythromycin • Less drug interactions than other macrolides • Drug of choice for chlamydial conjunctivitis ZITHROMAX • Z‐pack • 500mg day one; 250mg days 2‐5 • Great for compliance • Treatment of chlamydia with 1 g dose • Prescribe four 250mg tablets • Take all at once Chris Hoskins, O.D. 6565 West Loop South 4415 Crenshaw Rd. 15400 SW Frwy Bellaire, TX 77401 Pasadena, TX 77504 Sugar Land, TX 77478 Phone (713)797-1010 Phone (281)998-3333 (281)277-1010 -------------------------------------------------------------------------------------------------------------------------- NAME Steven Michaels AGE ADDRESS_____________________________________________________DATE 04-15-2009 Rx Zpak Use as directed REFILLS--ZERO Chris Hoskins, O.D. Z Pak: Cost • Azithromycin 250mg pak #6 $ 20.00 Z Pak for Styes? • Not commonly used • Is 5 days enough? • Fine for sinus/head/throat but not as good for lids 2/17/2016 13 Mohammed Allee, O.D. 6565 West Loop South 4415 Crenshaw Rd. 15400 SW Frwy Bellaire, TX 77401 Pasadena, TX 77504 Sugar Land, TX 77478 Phone (713)797-1010 Phone (281)998-3333 (281)277-1010 -------------------------------------------------------------------------------------------------------------------------- NAME Steven Michaels AGE ADDRESS_____________________________________________________DATE 04-15-2009 Rx Zithromax 250mg #4 Take 4 pills all at once REFILLS--ZERO Mo Allee, O.D. Oral Antibiotics • Tetracyclines • Doxycycline • Penicillins • Dicloxacillin • Cephalosporins • Keflex • Macrolides • Fluoroquinolones ANTIVIRALS • Herpes Simplex Types I and II • On cornea • Inside cornea with keratouveitis • Lids • Herpes Zoster ORAL DOSING FOR HERPES SIMPLEX If an oral agent is appropriate, a prescription for herpes simplex should be administered as follows: Valtrex (valacylovir, GlaxoSmithKline) 500mg three times daily for seven to 10 days Zovirax (acyclovir, GlaxoSmithKline) 400mg five times daily for seven to 10 days Famvir (famciclovir, Novartis) 250mg three times daily for seven to 10 days. Consider the Cost: 30 tablets (10 day supply) • Valtrex 1gm tid #15 $455.00 •Generic $45.00 Consider the Cost: 60 tablets (10 day supply) • Acyclovir 400mg $ 16.00 2/17/2016 14 Primary HSV Infection • Vesicular eruptions on the eyelid skin and/or eyelid margin • Can be limited to the skin or can also result in follicular conjunctivitis and/or corneal epithelial disease • Treatment: PO ACV 400 mg 5 x D x 1W or PO Valtrex 500 mg tid x 1W • Vesicles resolve without scarring Growing Herpes •61 WM Optometrist •Red OS x 8 days •Was traveling and self medicated with Tobradex Zirgan •1 drop 5x/day until ulcer “heals” •Then 1 drop tid for 7 days •5 gram tube Dx: Recurrent HSV Keratitis Valacyclovir vs. Acyclovir for Recurrent HSV “One‐year suppression therapy with oral valacyclovir (500‐mg tablet daily) was shown to be as effective and as well‐ tolerated as acyclovir (400‐mg tablet twice daily) in reducing the rate of recurrent ocular HSV disease.” SOURCE: Miserocchi E, Modorati G, Galli L, Rama P. Efficacy of valacyclovir vs. acyclovir for the prevention of recurrent herpes simplex virus eye disease: A pilot study. Am J Ophthalmol, Oct. 2007 Paul C. Ajamian, O.D. 5505 Peachtree Dunwoody Rd Ste 300 Atlanta, GA 30342 404-257-0814 -------------------------------------------------------------------------------------------------------------------------- NAME Leslie Smith AGE ADDRESS _____________________________________ Date 05-30-08 Rx Valtrex 500 mg One tablet qd or tid #90 REFILLS--3 Paul Ajamian, O.D Signature 2/17/2016 15 Stromal Herpes Oral Antivirals for Disciform • A balancing act with topical antivirals and pred • A word of advice……..REFER! Herpes Zoster •When you hear the complaint of scalp‐ head pain or tingling, think Zoster! •Lesions can be subtle Zoster Pearls •Question the nature of any new “headache” pain by ruling out tingling/pain of scalp and trunk •Start within 72 hrs for best effect •Comanage with a dermatologist •Oral antivirals as soon as possible Be a good observer of the face, not just the eyes! Oral Antivirals for Zoster Acyclovir 800 mg 5x day Valacyclovir (Valtrex) 1000 mg tid Famciclovir (Famvir) 500 mg tid 2/17/2016 16 Paul C. Ajamian, O.D. 5505 Peachtree Dunwoody Rd Ste 300 Atlanta, GA 30342 404-257-0814 -------------------------------------------------------------------------------------------------------------------------- NAME Leslie Smith AGE ADDRESS _____________________________________ Date 05-30-08 Rx Valtrex 1gm One tablet tid 7 day supply REFILLS--Zero Paul Ajamian, O.D Signature Case 3 •72 wf with history of skin lesions •Dx by GP: Poison Ivy •Preseptal lid swelling •First case of midline respecting poison ivy ever recorded! Zostavax • Vaccine for prevention of shingles in adults age 60 and older • Marketed by Merck as Zostavax and is given as a single dose by injection • Anyone who has been infected by chicken pox (more than 90% of adults in US) is at risk for developing shingles • Contraindicated if hx of allergy to gelatin, neomycin; hx of acquired immunodeficiency states; pregnancy • In landmark Shingles Prevention Study, Zostavax reduced risk of developing shingles by 51% (4 yrs of follow‐up) • Duration of protection after vaccination unknown 2/17/2016 1 The Future of Cataract Surgery Paul C. Ajamian, OD Bora Bora Tropical CE Where are We? •Cataract Surgery is now refractive •Patients deserve to know about the newest technologies •Doctors of Optometry should be the authority, not just the referrer The Changing Face of Cataract Surgery • Large, rapidly growing demographic • Educated, financially secure • Increased life expectancy • Longer working careers • Demand high quality vision (reading, distance, night vision) • New requirement for near vision (computers) • Unwilling to compromise active lifestyles The Baby Boomer Generation LSX11513SK Femtosecond Laser Assisted Cataract Surgery (FLACS) Are you going to do the surgery with the laser?? The future of cataract surgery available now! Do We Need FLACS? • Cataract surgery already a “good” procedure? • Only helps less experienced surgeons? • Wait for technology to improve? • Several lasers…wait to see which one is best? • Laser too expensive to justify? • Don’t believe the hype? 5 2/17/2016 2 Incisions Reproducible Primary and Secondary Incisions Computer programmed incisions • % depth • Length & position • Visualization of placement Real time Corneal thickness Customizable “planed” incisions (up to 3) Laser Arcuate Incision • Square edge • Uniform depth (no ripples) • Precise, reproducible – Arc shape – Arc length – Diameter Steinert RF, Application of the FemtosecondLaser in Cataract Surgery for the Creation of Multi-Planar, Self-Sealing Incisions, ASCRS 2010, Boston Manual Arcuate Incisions • Manually executed by “tracing” corneal marks with handheld diamond knife • Inconsistent depth control • Unpredictable effect due to imprecise wound architecture and depth • No image‐guided surgical planning or visualization LSX11513SK Laser Corneal Incisions‐ Astigmatism Management •Precise incisions made in the O.R. •Ability to titrate amount of correction •May be opened intraoperatively •May be opened postoperatively 2/17/2016 3 Opening an Incision In‐Office Capsulotomy Laser Capsulotomy Precise and reproducible • Geometrically superior circle (vs. Manual Capsulorhexis) Automatic Centration and Size • Based on limbus and (dilated / undilated) pupil Capsular Edges • Closest to manual capsulorhexis in terms of edge uniformity* * Bala C, Meades K. SEM of femtosecond laser capsulotomy edge: An inter‐platform comparison. Accepted for publication in Journal of Cataract and Refractive Surgery Why Is Capsulotomy Size Important? Effective lens position (ELP) more predictable Refractive outcome more predictable Less frequent PCO Less chance for anterior capsule phimosis 2/17/2016 4 Impact of ELP on IOL Predictability If IOL is 0.5 mm posterior to the assumed plane, a 21 D lens will produce only 20 D of correction If IOL is 0.5 mm anterior to the assumed plane, a 21 D lens will produce 22 D of correction Hyperopic Myopic 1Norrby S, Sources of error in intraocular lens power calculation,JCataract Refract Surg, 2008;34:368‐376. Fragmentation Additional Lens Fragmentation for Versatility Customizable Lens Fragmentation based on lens characteristics or surgeon preference Cylinder Chop Hybrid Frag Benefits of Lowering CDE (Cumulative Dispensed Energy) • Less ultrasound energy (CDE) • Short term * decreased k edema 1 day post‐op * faster visual recovery * decreases complications intra‐op • Long term * decreased rate of endothelial cell loss * pseudophakic bullous keratopathy less likely LSX13070SK 22 How to Present to Patients? • Laser makes more precise, accurate incisions • 3D OCT Image guided surgery vs manual procedure • Customized for the patient’s eye • Less energy/less inflammation • Manage low to moderate astigmatism • Potentially safer 23 Laser Cataract Surgery: Who is a candidate? •Premium lens patients •Astigmatism less than 1 diopter •Guttata/Fuch’s /Mature/Traumatic cataracts 2/17/2016 5 Important to Explain What’s covered Cataract removal Monofocal lens resulting in good distance vision if no astigmatism Will need readers What’s not covered Astigmatism Tx with laser Toric lenses Multifocal lenses Additional testing Interoperative Aberrometry 25 Laser Cataract Surgery: What Can You Expect Post‐Op • Subconjunctival heme (“ring around limbus”) • Less AC reaction • Decreased astigmatism • Early “wow” factor • BUT….due to arcuate incisions, there may be temporary corneal surface irregularities • A new category has emerged in private pay cataract surgery • Precision of femtosecond laser technology will drive innovation for future • And to make outcomes even better….. Femtosecond Laser in Summary And to Make Something Good Even Better….The Cataract Refractive Suite • Minimize opportunities for error • Multiple technology integration 1. A scan 2. Topography 3. Femtosecond cataract laser 4. Operating microscope • Preoperative and intraoperative • Better multifocal centration/toric alignment • Improve outcomes Cataract Refractive Suites • Verion (Alcon) 1. Only fully integrated system available (LenSx) 2. Intraoperative aberrometry (Ora) soon • Callisto (Zeiss) 1. No FSL compatibility, (?Optimedica in future) 2. No intraoperative aberrometry • Cassini/TrueVision 3D 1. Collaboration with LensAR 2. Not commercially available • Cirle 3‐D/ Spectria 1. Collaboration with Victus (B&L) 2. Not commercially available Identifying Sources of Variability in our Current Process 30 Pre-Op Intra-Op Post-Op Biometry Transcription Astigmatism Planning Manual Marking Cyclorotation SIA Capsulorhexis Construction IOL Positioning Optimizing 2/17/2016 6 VERION™ Image Guided System GUIDE VERION™ DIGITAL MARKER VERION™ REFERENCE UNIT VERION™ Image Guided System ACQUIRE IMAGE VERION™ Image Guided System TRANSFER TO PLANNER Image Guided Technology Intraoperative Aberrometry • ORA® with VerifEye® 1. Part of Alcon® Cataract Refractive Suite 2. May be used independently • Holos IntraOp™ Wavefront Aberrometer 1. Independent use only 2. Not compatible with FSL systems The ORA System® with VerifEye®: 2/17/2016 7 The ORA™ System with VerifEye® Technology • The ORA™ System uses wavefront aberrometry data in the measurement and analysis of the refractive power of the eye (i.e. sphere, cylinder, and axis measurements) • Real‐time, intraoperative refractometer • Measures anterior and posterior corneal astigmatism • Minimizes post‐op refractive surprises Improved astigmatic outcomes with VerifEye® *Results are statistically significant based on McNemar’stest (p=0.006). 1. Alcon data on file. 2. Standard of Care: Conventional biometry measurement of the pre‐op corneal astigmatism and toric calculator determination of IOL cylinder power. This carefully controlled clinical study demonstrates that the ORA System® with VerifEye® provides for better astigmatic outcomes in cataract surgery.1 Percent of Patients Within ≤ 0.50 D of Intended Target at One Month; n = 111 patients, p = .006 Custom Cataract Surgery w/ Advanced Technology IOL’s What’s New and What’s Coming? RES15034SK ReSTOR +2.5: Who is this lens for? Aspheric Monofocal AcrySof® IQ IOL Aspheric Apodized Diffractive Multifocal ReSTOR® +2.5 D IOL Aspheric Apodized Diffractive Multifocal ReSTOR® +3 D IOL The ReSTOR® +2.5 Patient • Patient w/ active lifestyle that wants good interm. and dist. Va • Not willing to compromise distance for a full range • Desires more opportunity for a range of vision vs monofocal • Desires spectacle independence at 21 inches and beyond • May need +1.00 reader for 16‐20 inches Optic Design Differences: ReSTOR® +2.5 vs. ReSTOR® +3.0 Reduced the add power from 3.0D to 2.5D by: • Reducing diffractive rings from 9 to 7 and increasing spacing Altered the light distribution by: • Increasing the distance energy of the center zone from 40% to 100% • Reducing apodized diffractive area by 18% • Increasing the outer distance area by 6% RES15034SK Simulated Headlight Images in Alcon Model Eye (5 mm Pupil Measured on the Optikos MTF System) AcrySof IQ ReSTOR +2.5 Crystalens HD500 Tecnis ZMA00 ReSTOR +3.0 2/17/2016 8 Alcon Acrysof Restor +2.50 add dominant eye +3.00 add non‐dominant eye RESTOR TORIC • FDA has delayed approval yet again++ • 1st multifocal toric • +3.0 add • 1D‐3.0D corneal astigmatism ++?late 2016 Acrysof Toric‐Extended Power Range • SN6AT3‐ 1.03D corneal plane • SN6AT4‐ 1.55D • SN6AT5‐ 2.06D • SN6AT6‐ 2.57D • SN6AT7‐ 3.08D • SN6AT8‐ 3.60D • SN6AT9‐ 4.11D OD’s Role IS Crucial in IOL Decision • Be involved in decision making PREOP • It all starts with patient goals and topography • ?Monovision • ?Eliminate distance Rx • ?Eliminate Rx totally Cassini Corneal Shape Analyzer 2/17/2016 9 Patients Want YOUR advice • Easier conversion , better experience • Embarrassing if they hear it for first time from surgeon • Prepare them regarding out‐of‐ pocket costs Selecting The Right Surgeon • Closest not always the best • Very skilled/consistent results • Communicates well with patient & OD • Understands comanagement/history of supporting optometry/makes you look good • Welcomes OR observation • Organized/efficient practice Post‐Op Care • Don’t abdicate it to someone else • Post‐Op management of premium IOL’s and LACS fairly straightforward • Be positive on Day 1: its early, results won’t always be perfect Why not do post op care? • I’m not on Medicare • “I’m not set up for it” • Takes too much time for the $120 I get from Medicare • Just not interested in doing this, let the surgeon do it even though he is an hour away! Once you drill it down…. •Medications are the real time suck on post op care! •Alternatives: CatarActiv3 •Designer Drugs Chattanooga 888‐935‐ 2930 •Trimoxi 2/17/2016 10 Imprimis Dropless Therapy™ The modality of “Dropless” therapy involves the injection of an eye‐compatible compound at the end of the cataract case as prophylaxis against inflammation and infection. Currently, there are 2 combinations available only from Imprimis: • Tri‐Moxi: triamcinolone acetonide and moxifloxacin hydrochloride • Tri‐Moxi‐Vanc: triamcinolone acetonide, moxifloxacin hydrochloride and vancomycin Dropless Therapy™ Patient Benefits • Physically/mentally challenged patients • Eliminate compliance challenges of drops • Lift burden from family members/caregivers • Put patients with “Eye Drop Phobia” at ease • Avoid pharmacy issues: refills, generics • Help patients in nursing facilities • Aid patients without insurance, money or access to sample drops Osteoarthritis Rheumatoid Arthritis Scoliosis Parkinson’s Kyphosis Alzheimer’s Dementia Drop Therapy with branded medications can cost over $400 MIGS – Micro‐Invasive Glaucoma Surgery • Ab‐interno approach • Clear corneal micro‐incision (<2.0mm) • Conjunctival sparing • Minimally traumatic • Negligible disruption of normal anatomy/physiology • Excellent biocompatibility • Efficacious • Extremely high safety profile • Rapid recovery Curr Opin Ophthalmol 2012, 23:96 ‐ 104 iStent® Specifications • iStent dimensions are customized for a natural fit within the 270 µm canal space • Made of surgical‐grade nonferromagnetic titanium • Heparin‐coated to promote self‐priming iStent is the smallest medical device known to be implanted in the human body and weighs just 60 µg Self-Trephining Tip Snorkel 0.3 mm Lumen 120 µm iStent® Therapeutic Objectives • Lowers IOP and may reduce or eliminate medication burden1 • Decrease risk of IOP fluctuations associated with non‐adherence to prescription medication regimens • Avoid serious complications associated with end‐stage filtration and shunt procedures • Spare the conjunctiva and safely preserve future treatment options • Minimizes risks of hypotony and bleb related complications iStent® is designed to be used in conjunction with cataract surgery to safely and effectively reduce IOP 1 Elimination of medication following iStent implantation is at the discretion of the physician. A Little Stent with that Cataract? • 64 WM Brother in Law of a referring OD • On Lumigan OU qhs for moderate glaucoma • Uses it once a week according to “inside sources” • Comes in for cataract evaluation. Moderate cupping IOP of 22 OU • s/p IOL OS with iStent, IOP 1 day 16 IOP 1 week 14 IOP 1 month 13 • d/c Lumigan and IOP has remained in 12‐14 range 2/17/2016 11 Status of Co‐Management for Cataract Surgery with iStent® Implantation 100% Co‐management Fee 50% Reduction in Co‐management Fee MIGS Study Group • Prospective study,119 iStent® patients followed for 18 months • Patients did not undergo cataract surgery (non‐FDA approved) • All patients on 1‐3 glaucoma meds • Compared IOP after 1, 2, and 3 iStents placed (without Phaco/IOL) • IOP = 19.8, 20.1, and 20.4 respectively, before washout • IOP = 25.0, 25.0, and 24.9 respectively, after washout • IOP = 15.6, 13.9, and 12.3 respectively, 18 months post‐op Future MIGS Devices iStent inject® • Two stents pre‐loaded per injector • US IDE Phase III Trial under way Head (resides in Schlemm’s Canal) 0.4 mmNeck (Trabecular Meshwork) Flange (in Anterior Chamber) 0.3 mm dia Caution: Investigational device limited by Federal (U.S.) law to investigational use only. iStent SUPRA® Product Description • Lumen Size: 0.165 mm • Outer Diameter: 0.365 mm • Length: 4 mm • Length of Sleeve:1.1 mm US IDE Trial Under Way CyPass® Micro‐Stent 2/17/2016 12 Hydrus™ Microstent What else in the Pipeline? •Studies to put stents into phakic and already pseudophakic eyes •Studies to put two in at once iStent® Summary • Effective in lowering IOP for many glaucoma patients • Ideal for COAG patient having cataract surgery • Decreases or eliminates need for glaucoma meds • Well tolerated, good safety profile • Minimally invasive Take Home Points • Work with leading surgeons who are on cutting edge of technology • Go visit their office and OR and see for yourself what patients will see • Be involved in post op care: we earned it • Compliance with glaucoma and post op meds a nightmare…now we have some answers! 2/17/2016 1 What a Pain! Paul C. Ajamian, OD Tropical CE Bora Bora Oral Analgesics • Pain tolerance varies with each individual • Signs usually should match symptoms • Have compassion but don’t panic when someone appears to be in pain Pain Tolerance • Varies with each individual • Signs usually should match symptoms • Have compassion but don’t panic when someone appears to be in pain The Psychology of Pain • A firm, calm, confident and competent voice and manner will go a long way to reassuring patient The Reasons People are in Pain • Chemical injury • Corneal/conjunctival abrasions • RCE • Foreign Bodies • Uveitis • Herpes Zoster • Migraine attacks • Very high IOP/angle closure • Preseptal cellulitis/ acute chalazion Severe Pain • Quick VA and pinhole • Diagnose the problem fast • Topical anesthetics will help your exam 2/17/2016 2 If topicals aren’t enough…. • Oral Pain Meds: • Double Dose OTC Alleve/Motrin/Tylenol • Non‐narcotics and narcotics Tylenol (Acetaminophen) •Aka APAP •N‐acetyl‐para‐aminophenol** In the news…. • While the medicine is effective in treating headaches and reducing fevers, even recommended doses can cause liver damage in some people. And more than 400 people die and 42,000 are hospitalized every year in the United States from overdoses. Jul 28, 2011 • Tylenol's maximum dose reduced to help prevent overdoses • The maximum daily dose for Tylenol will be lowered on all acetaminophen‐containing adult products from 4,000 mg (8 Extra Strength Tylenol pills) to 3,000 mg (6 pills), the manufacturer said today. The move is intended to reduce the risk of accidental acetaminophen overdoses that can lead to liver failure and death. Old Guidelines Extra Strength Tylenol 500 mg per geltab, gelcap, caplet or tablet Two every 4-6 hours Do not exceed 8 in any 24 hr period Regular Strength Tylenol 325 mg per tablet Two every 4-6 hours Do not exceed 12 in any 24 hr period 2/17/2016 3 New Guidelines Extra Strength Tylenol 500 mg per geltab, gelcap, caplet or tablet 1 to 2 tabs every 6 hours* *Unless directed by physician Do not exceed 6 in any 24 hr period* Regular Strength Tylenol 325 mg per tablet Two every 4-6 hours** *Dosing instructions coming this year Do not exceed 10 in any 24 hr period PRESCRIBING CONTROLLED SUBSTANCES • Don’t pre‐print your DEA number on your Rx pad • Do not leave Rx pads where patients have access • Closely monitor what prescriptions are called in to the pharmacy and keep a record of refills especially glaucoma and narcotics Edward C. Eyedoc, O.D. Major Payne, O.D. Omni Eye Services of Atlanta -------------------------------------------------------------------------------------------------------------------------- NAME AGE ADDRESS_____________________________________________________DATE Rx REFILLS-- DEA___________________________ PRESCRIBING GUIDELINES • Write legibly • Specify length of treatment for acute care • Narcotics: write out number of pills • Ex: 12(Twelve) • Vs 12 which could become 120 Before you prescribe… • Allergic to anything? • What systemic conditions do they have? • Especially note hepatic and renal problems • Drug interactions/precautions • Narcotics and Alcohol don’t mix • “I am allergic to narcotics” • What exactly happens when you take them? • “I get nauseous” or • “I become sleepy” DISTINGUISH SIDE EFFECTS FROM ALLERGY! 2/17/2016 4 SIDE EFFECTS OF PAIN MEDS • Constipation • Nausea and vomiting • Sedation • Dizziness • Addiction ALLERGIC REACTIONS • Skin rash, hives, or itching • Wheezing or trouble breathing • Swelling of the face, lips, or throat • Discontinue use immediately • Consult doctor immediately • Severe reactions demand emergency care NARCOTICS •Schedule III and IV narcotics •Corneal abrasions, post‐op PRK, post‐ op pterygium surgery, etc. •Short term therapy only •Need DEA # to prescribe •Can call in III and IV by phone, but not schedule II (Percodan) Schedule I (C‐I): • High abuse potential and no accepted medical use (heroin, marijuana, LSD) Schedule II (C‐II): • High abuse potential with severe dependence liability (narcotics, amphetamines, and barbiturates: Percoset (apap), Percodan (asa), Oxycontin (oxycodone), Ritalin, Adderal, Methadone, Fentanyl • Pure hydrocodone considered Schedule II • ***Many states now require a special embossed RX pad for Schedule II’s Schedule III (C‐III): • Less abuse potential than schedule II drugs and moderate dependence liability (nonbarbiturate sedatives, nonamphetamine stimulants, limited amounts of certain narcotics: (Vicodin and Lortab) Hydrocodone combinations 2/17/2016 5 DEPARTMENT OF JUSTICE Drug Enforcement Administration 21 CFR Part 1308 [Docket No. DEA–389] Schedules of Controlled Substances: Rescheduling of Hydrocodone Combination Products From Schedule III to Schedule II AGENCY: Drug Enforcement Administration, Department of Justice. ACTION: Final rule. SUMMARY: With the issuance of this final rule, the Administrator of the Drug Enforcement Administration reschedules hydrocodone combination products from schedule III to schedule II of the Controlled Substances Act. This scheduling action is pursuant to the Controlled Substances Act which requires that such actions be made on the record after opportunity for a hearing through formal rulemaking. This action imposes the regulatory controls and administrative, civil, and criminal sanctions applicable to schedule II controlled substances on persons who handle (manufacture, distribute, dispense, import, export, engage in research, conduct instructional activities with, conduct chemical analysis with, or possess) or propose to handle hydrocodone combination products. DATES: This rule is effective October 6, 2014. Unintended Consequences • Intended to prevent opioid abuse, AOA estimates it will in effect cause OD’s in 16 states to lose their prescribing authority for narcotics with hydrocodone. Black Box Warning • Now appearing on opioid/acetaminophen combinations warning of potential for acute liver failure over 4000 mg • Effective January, 2014 – those combinations can contain no more than 325 mg of acetaminophen per tablet/capsule Lortab/Vicodin • Lortab 5’s : previously contained 500 mg along with 5 mg hydrocodone….now will be lowered • Vicodin: recently reformulated 500>>300 • Zohydro ER: approved October 2013..the first single entity drug containing only hydrocodone, for chronic pain management (10,15, 20, 30, 40, 50 mg capsules bid) Schedule II Summary • The FDA has recommended tighter controls, expected to take place next year • Approval by HHS and DEA expected • 2011: 131 million prescriptions of hydrocodone containing meds written • For 47 million patients • Equals 5 billion pills! • Number of deaths from narcotics up 4x since 1999 (70% contain hydrocodone) 2/17/2016 6 Summary: the new rules • Hydrocodone combinations drugs: • No call ins, must have written Rx • 180 day supply cut in half to 90 days max • Added storage and record keeping regs for pharmacists • In some states nurse practitioners will no longer be able to Rx For a complete list of what’s what… www.usdoj.gov/dea/pubs/scheduling.html Or Google “Scheduled Narcotics” and it’s the first link to come up GETTING A DEA NUMBER • On‐line application • www.deadiversion.usdoj.gov • Optometrists are mid‐level practitioners (MLP) unfortunately…wasn’t always that way • First time applicant‐Form 224 • Renewal‐Form 224a • Cost $551/Good for 3 years “Should I Get One? Should I Renew Mine? “It’s Expensive” Pain Management • When topical NSAID’s don’t work….. and • If no allergy to codeine or hydrocodone, break out the schedule III’s TYLENOL #3 for Mild Pain • Schedule III • Central acting narcotic analgesic • 300mg acetaminophen + 30mg codeine • Avoid in liver disease/alcoholism • No extra Tylenol® by patient in addition • No alcohol • GI distress and sedation are main side effects *** 2/17/2016 7 Paul C. Ajamian, O.D. Omni Eye Services of Atlanta 7505 Main, Suite 370 Atlanta, GA 30342 404 257-0814 -------------------------------------------------------------------------------------------------------------------------- NAME Leslie Smith AGE ADDRESS ________________________________________ Date 03-12-08 Rx Tylenol #3 One q4-6h for pain #12(twelve) REFILLS--Zero Paul Ajamian, OD DEA# MA01234565 Hydrocodones for Moderate to Severe Pain • LORTAB and generics : Schedule III narcotic • Hydrocodone with acetaminophen • Also available with aspirin (Lortab ASA) • Was available in 5.0/500, 7.5/500, 10/500, • 5.0/500 5 mg hydrocodone 500 mg acetaminophen (tylenol, APAP) Hydrocodones for Moderate to Severe Pain • LORTAB and generics : Schedule III narcotic • Hydrocodone with acetaminophen • Also available with aspirin (Lortab ASA) • Was available in 5.0/500, 7.5/500, 10/500, • 5.0/325 5 mg hydrocodone 500 mg acetaminophen (tylenol, APAP) Omni Eye Services 5505 Peachtree Dunwoody Rd. Ste 300 Atlanta, GA 30342 Phone (713)797-1010 -------------------------------------------------------------------------------------------------------------------------- NAME Doug Addact AGE ADDRESS_____________________________________________________DATE 03-12-2008 Rx Lortab 5’s 1 po qid x 3 days #12(twelve) REFILLS--ZERO Paul Ajamian, O.D. • Most internists/dentists still use hydrocodone because it is a synthetic form of codeine • Stronger, more effective in reducing pain • Less severe side effects • Vicodin/Lortab prescribed far more frequently than Tylenol #3 Other Hydrocodones • Old Vicodin ES (APAP w/hydrocodone) • 650mg APAP + 7.5mg hydrocodone • Schedule III • Vicoprofen • 200mg ibuprofen + 7.5mg hydrocodone • When Tylenol® is contraindicated/liver disease 2/17/2016 8 New Vicodin • VICODIN 5mg/300mg (was 500mg) • VICODIN ES 7.5mg/300mg (was 750mg) • VICODIN HP 10mg/300mg (was 660mg) Darvocet‐N for Mild Pain (Schedule IV) • Propoxyphene is a mild narcotic analgesic structurally related to methadone. The potency of propoxyphene napsylate is from two thirds to equal that of codeine. • TAKEN OFF THE MARKET FALL 2010 due to cardiac toxicity! Tramadol (Ultram) • An opioid related narcotic analgesic • Exact mechanism of action unknown • Binds to opioid receptors and inhibits NE/Serotonin reuptake producing central analgesia • Start: 25 mg PO qam, may incr. by 25 mg/day q3 days to 25 mg PO q6h Your Go‐To Prescription Narcotic Drugs for Pain • Tylenol #3 • Lortab • Vicodin It all boils down to this…. Doxycycline Dicloxacillin Keflex Valtrex Lortab 2/17/2016 1 Glaucoma: The Sneak Thief of Sight Paul C. Ajamian, OD Tropical CE Bora Bora Glaucoma is Very Manageable! Clinical Decisions in Glaucoma Hodapp, Parrish, Anderson • Primary open angle glaucoma is a chronic condition. Patients who have POAG do not get better: their visual function stays the same or worsens. Treatment does not make them feel better. The doctor sees no dramatic cures and receives few immediate emotional rewards. The best treatment does not always work, and some people lose vision despite the clinician’s best efforts. • The picture is not uniformly grey however. Most people with glaucoma have adequate vision for their needs throughout their lives. In addition, the management of POAG is conceptually straightforward. Attention to detail, careful follow‐ up, and appropriate treatment favorably affect the course of the disease. The Glaucoma Book • PAUL SCHACKNOW AND JOHN SAMPLES • On amazon.com Doctors: When was YOUR last “real” eye exam to rule out glaucoma? 2/17/2016 2 42 YO WF Optometrist at my last talk in Niagra Falls • No exam for 15 years • Noted “blind spot” OD • Had a colleague in community measure IOP which was 34/26 • 58 yo optometrist • Experiences a series of migraine auras in right eye this past summer • Covers left eye, notes an inferior field defect • Has an assistant “examine him” • NCT pressure 15 OU • VF: inferior arcuate OD Overview: The 5 Step Plan 1. Make the diagnosis early on 2. Set target pressures 3. Treat aggressively 4. Follow for progression and constantly re‐ evaluate treatment 5. Maintain compliance Make the Diagnosis! • 76 yo Braves Shortstop • Best VA 20/60 ou from dense NS • Sent in for “same day” cataract evaluation 2/17/2016 3 Yes, 3+ NS but don’t forget the fundus! But….. • IOP 19/18 • Significant cupping, inferior arcuate defects Moral of the Story • NEVER NEVER miss a cupped disc! • Patients can have more than one problem with their eye! “Every Patient You Examine Has Glaucoma Until Proven Otherwise” 2/17/2016 4 OAG frequently occurs at normal IOP: get used to it ! • Population surveys show 50% of OAG patients rarely have IOP >21 • The risk factor is not “elevated” IOP • It’s the level of IOP that matters • The higher the IOP, the greater the risk whatever the baseline IOP is • Dump the magic number Wilson MR. The myth of “21”. J Glaucoma 1997;6:75-7. 50% of OAG is undiagnosed We miss 1/3 of OAG by stressing the magic number “21” Do more visual field tests in those with suspect discs We miss many ACG by not doing gonioscopy Don’t separate “Low Tension” and “High Tension” • Disc and field findings are very similar • Treatment is the same: target IOP concept • MRIs on “low tension” are worthless and scare patients needlessly Schulzer M, Drance SM, Carter CJ, Brooks DE, Douglas GR, Lau W Biostatistical evidence for two distinct chronic open angle glaucoma populations. Br J Ophthalmol. 1990;74:196-200. Failure to gonioscope • Medicare billing database 30 times more OAG than ACG • “Real” population prevalence: 5 to 1: OAG to ACG • Chart review (300 glaucoma charts): No place for “gonioscopy” on office forms 50% of “glaucoma” no gonio finding Quigley, Friedman, Hahn. Ophthalmology 2007 Cassard, Quigley, Gower et al. Ophthalmology 2012 2/17/2016 5 Angle Classification Systems Angle Classification Systems • Scheie – Based on extent of angle structures visualized – Wide open (Grade I) to occluded (Grade 4) [reverse of current grading systems] • Shaffer – Based on angular width of recess – Grade 0 (partly/totally closed) to grade 4 (30‐45) • Spaeth – Based on angular approach to recess, configuration of peripheral iris, insertion of iris root – A (anterior to Schwalbe’s line) through E (extremely deep); grades A & B are always pathological Recording Your Findings • Grading system IV, III, II, I, slit, closed • Grid drawing • Label each quadrant numerically or with description of structures seen (ie CBB, or 2+ PTM) IV CBB A. Recess III SS II TM Gonioscopy Guidelines • Baseline gonioscopic exam for every – New glaucoma suspect – Already diagnosed glaucoma patient – Pt with family history of glaucoma – Pt with shallow chambers – Pt with history of transient pain, blurred vision • Repeat if neovascularization or sudden change in pressure • Repeat yearly: – Post‐iridotomy – If angle is narrow • Repeat yearly: – Open angle (COAG) patients – Hyperopes older than 40 years 2/17/2016 6 Pigment Dispersion Syndrome 20 to 45 yo; M>F Deep anterior chambers Mid‐peripheral TI defects Krukenberg spindle 50% risk of associated glaucoma Pigment Dispersion Syndrome Exfoliation Syndrome Narrow (or Crowded) Angle Narrow Angles 2/17/2016 7 Chronic Angle Closure (Indentation Gonioscopy) This is clearly a case of angle recession. To the left of the arrow is a classic wide open Grade IV angle with ciliary body band visible. To the right of the arrow the angle starts deepening in an erratic fashion, indicating angle recession. Note the scattered pigment clumps to the left of the arrow Gonioscopy: Just Do It! • Your insurance policy that you will never dilate a dangerous angle • Gain confidence by doing it on one patient a day! Making the Diagnosis Failure to diagnose glaucoma, open and closed angle, is the # 1 cause of malpractice claims against doctors of optometry How do you avoid a lawsuit? • Look at the discs! • PHOTOS and DISC DRAWINGS • Pay attention to details –Family history, narrow angles, pigment on endothelium, gonioscopy • Treat your chart as well as you treat your patient! 2/17/2016 8 Superior notch, inferior arcuate 2/17/2016 9 68 AA F • Routine Exam • VA 20/25 with 1+ NS • GAT 19/20 Pachs 571/586 • Right disc .7 with superior notch • Left disc .5 with normal visual field/OCT PERRLA vs… 6.0/6.0 round, blue 3+/3+ ‐APD Making the Diagnosis • Family history: ask everyone • Confrontation fields: don’t forget them • Goldmann pressures: still the standard • Pachymetry: gives you a lot of information 2/17/2016 10 Have we gotten any better over the years at diagnosing OAG? Harry Quigley, SECO 2014 Many undiagnosed OAG cases found at Johns Hopkins medical clinic Many of these had an eye exam by optometrist or ophthalmologist within the last year More of the undiagnosed cases had normal IOP His conclusion: “We need to do a better job of examining the nerve, drawing the nerve and doing more fields in eyes with suspicious discs” • Lee Study: less than 40% of MD’s (non glaucoma specialists) examined or documented optic nerve head within two years of last exam • While photos and drawings are the standard of care, less than 30% of patients audited in study had one or the other performed Paul P. Lee, MD JD Ophthalmology Times May 2005 Estimate Risk, then Determine a Baseline IOP and a Target IOP in each patient’s eyes Jampel HD. Target pressure in glaucoma therapy. J Glaucoma. 1997;6:133‐8. Can We Judge the Baseline IOP with only 1 Visit ? Visit Visit Visit # 1 # 2 # 3 Baseline Target 25 26 25 25 20 25 20 18 21 17 25 30 35 30 24 worse damage = lower target Baseline Field Damage IOP Zero Some Severe 16 13 20% 12 25% 11 30% 22 17 23% 15 14 26 19 26% 17 15 40 24 40% 21 18 (CIGTS Clinical Trial Method) 2/17/2016 11 Treat Aggressively • Education up front is key • Prescribe drops they can afford Drug alerts • Simbrinza – Brinzolamide (Azopt)/Brimonidine .2%(Alphagan) combination Battle of the PGAs – Lumigan/Travatan vs Generic – Zioptan (Akorn) – Latanaprost and other generics on the way – Sun Pharma with gentler preservative Have Your Cake and Eat it Too Advantages if you can stay with a branded product: • Consistency • Bottle fill size • Bottle design • Drug delivery • Manufacturer • Availability of samples • If there’s a problem, you know who to talk to 2/17/2016 12 But beware! • The switch may happen whether you write for branded product or not! Potential Disadvantage: •CO$T • And some people insist on a brand name Glaucoma • Lots of great brand name options – PGA’s: Xalatan, Lumigan, Travatan Z – Alphagan P: high allergy rate – Azopt: high rate of stinging with all CAI’s – Simbrinza: Azopt/Gen Brimonidine – Rescula: ? Its future looks bleak • Preservative free Zioptan and Cosopt are no guarantee of tolerance 2/17/2016 13 Which drop to choose ? • Generics appear equivalent, lower cost • Prostaglandin: latanoprost – Potent – One time per day – Minimal side effects – Iris and lid skin color change – Eyelash growth – Orbital fat atrophy Remember…. • When the patient is switched……by you or insurer…..the followup visits temporarily increase in number First line PGAs • Refrigeration not needed! • Refrigeration = lower compliance • Out of sight=out of mind Second line • Beta blockers –Cheap –Can work once per day –Low allergy rate –Tolerated well –Asthma, bradycardia, CHF, On O2 Second or Third line • CAI inhibitor: dorzolamide generic – Stand alone or inexpensive combination with beta blocker for 24 hour control due to formulation – BID obligatory Second or Third line • Alpha agonist: Brimonidine generic • Very high allergy rate • No evidence of neuroprotection or benefit with low tension glaucoma • High rate of allergy 2/17/2016 14 Lessons Learned • Compliance goes way down when price of drops goes way up • Ask patients how much their copay is…….. they will tell you! • They will be grateful that you care enough to ask and to offer alternatives if necessary Lessons Learned • Despite many ophthalmologists slamming generic latanaprost because “we don’t know where its made, often its in India”, it works very very well • Downside: chincy filling of bottle often causes patient to run out a few days or week prior to RX expiring….sometimes I supplement with a sample GOODRX.com Type in your drug and zip code And print out a coupon! 2/17/2016 15 Or…..there’s an app for that! WeRx.com How to help the indigent? • Samples: harder to get • Patient assistance programs – Alcon Cares – Allergan Rx Hope Case: A+ Complier • 65yo WM Retired Executive • Relocated to Atlanta approx. 2006 • Awesome in terms of commitment and follow up. Compliance A++. • Family history is positive for POAG • IOP upon first encounter was sub‐optimal in my opinion at 18/19 on monotherapy with Timolol BID OU. • Baseline IOP unknown • Jockeyed meds for several visits….IOP has remained stable at approximately 12mmHg. • Current regimen Lumigan HS OU and Combigan BID OU • Physical exam is unremarkable with the exception on early cataracts, maintains excellent VA. 2/17/2016 16 Bottom Line • Younger man with advanced disease • Aggressive target IOP and careful F/U. • On MMT (in my opinion 2 bottles) • A case where technology and clinical examination correspond very well. • Adherence is critical and results are evident in this case When his cataracts are ready…… 2/17/2016 17 MIGS in his Future? • iStent by Glaukos • Done at the time of cataract surgery as a primary procedure • Learning curve! • 2‐6 mm of IOP reduction Case: By the Book • Virginia N DOB 3‐16‐28 • No insurance, no money, OD calls and says she may have glaucoma OS • VA 20/40, 20/50 with NS c/w decreased VA • TA 19/25 • Discs, VF’s, GDX as shown 2/17/2016 18 Start Travatan Z OS bid • 3 week followup: IOP 15/18 Adding to Meds • Good case for adding Timolol OS qam to Travatan Z ou qhs • Cheap/no contraindication/good insurance given damage OS • IOP 14/13 consistently • Visual field stable has been stable now for 4 years at this level Ocular Hypertension • 63 WF (Married to an internist) • Positive family HX :Mother, Diagnosed age 65, now deceased. • Been followed since 1995 • IOP has ranged in the low 20’s during that time frame • PACHs are approximately 620 OU • Medical Hx non‐contributory 2/17/2016 19 • Thick corneas, normal discs, OCT and VF • Family history (we think) • Watchful waiting but no treatment How Well Do Patients Really Comply? A huge problem in glaucoma, where the patient never thought they had a problem to begin with, and now you are treating them with drops that are expensive, inconvenient, and often have side effects OAG patients given a first prescription for drops, less than 50% are still taking it at the end of one year And many are lost to followup The revolving door of OAG 2/17/2016 20 Interviews with patients and their doctors • 95% of patients claim to take every drop • Doctors think 80% of patients compliant • Patients take drops only 70% of the time Friedman, Nordstrom, Mozaffari, Quigley. Glaucoma management among individuals enrolled in a single comprehensive insurance plan. Ophthalmology 2005;112:1500‐4. Electronically monitored adherence Median = 75% doses taken Below median randomized Okeke, Quigley, Friedman et al. The Travatan Dosing Aid Study. Ophthalmology 2009;116:191-9. Poor adherers drop off after visit, ramp up just before seeing Doctor Best adherers Medium adherers Worst adherers Visit Don’t use IOP as adherence test • Adherence improved, IOP at visit didn’t • IOP not correlated to adherence • Yet, Ophthalmologists report using IOP at visit as primary means to judge adherence • If IOP is good at visit—you don’t know • If IOP not at target: first check adherence, then change or add meds Identify those likely to be non‐adherent • Admit that they missed 1 or 2 drops in past 2 weeks • Cannot name their drops • Miss return visits • Youngest and oldest patients • Do not know anyone who lost vision from glaucoma • African‐American Cell phone robo‐calls worked teach them to use alarm Okeke, Quigley, Jampel Ophthalmology 2009 Improvement from 49% to 67% drops taken among non‐adherents with cell phone reminders Boland et al (in press) 2/17/2016 21 Available at: Amazon.com “An overwhelming majority of glaucoma patients do well . A smaller percentage (not to be discounted) do poorly no matter what you do. Treat the majority, identify the problem patients, and send them out in a timely way with lots of documentation that you did so!” The Moral of the Story 8/20/2015 1 Anti‐Infective Agents: Making the Right Choice Jill Autry, OD, RPh Eye Center of Texas Houston Jill Autry, OD, RPh • Speaker’s Bureau/Consultant • Allergan • Alcon • B&L • Owner/Partner • Eye Center of Texas Ophthalmology • Tropicalce.com • Editorial Boards/Contributor/Columnist • Primary Care Optometry News • Optometry Times • Review of Optometry Ocular Infections • Adnexa • Eyelid • Nasolacrimal system • Lacrimal gland • Conjunctival • Corneal • Intraocular • Orbital Eyelid Infections • Generally gram + organisms • Staphylococcus and streptococcus • Corynebacterium • Anterior blepharitis p • Internal hordeolum • External hordeolum • Preseptal Cellulitis Gram Positive vs. Gram Negative • Gram positive • Thick and tough cell wall • Harder to kill with disinfectants than gram negative organisms • More likely to survive on dry surfaces longer • On skin, mostly find gram positive • Staph and Strep species predominate • Predominant organisms of the normal ocular and periocular flora Gram Positive vs. Gram Negative • Gram negative • Thinner cell walls but bilayered • Harder to kill with antibiotics than gram positive • Will survive longer on a moist surface • More likely to be found in the gastrointestinal system • Common cause of urinary tract infections 8/20/2015 2 Gram Positive Gram Negative Anterior Blepharitis • Staph epi and staph aureus predominantly • Mechanical debridement • Hot compresses • Commercial lid scrubs Oi• Ointments • Bacitracin or erythromycin ointments • Rotate ointments monthly • Add steroid ointment if eyelid inflammation • Tobradex, maxitrol, lotemax Demodex • Two types of ocular parasitic mites • Demodex folliculorum (anterior bleph) • Demodex brevis (posterior bleph) • High incidence with age and anterior bleph • Seen in 84% of patients 60 years of age p y g • Seen in 100% of patients 70 years of age • Inflammation due to mite bacillus production • May be association with acne and ocular rosacea • Cylindrical sleeves on the lashes • Epilation and microscopic analysis Clinical Presentation • Anterior blepharitis with inflammation • Eyelid itching, redness, burning, foreign body sensation, crusting of eyelashes • Refractory to other treatments • Increased symptoms in the morning • Associated ocular and acne rosacea • Mites visible at slit lamp and under microscope DemodexTreatment • Tea tree oil products • Commercially available Cliradex • Compounded 50% tea tree oil scrubs • To eyebrows and eyelids once weekly for one month • Apply to lid margin with Q‐tip • Anesthetic first! • Tea tree oil shampoo (10%) to hair, eyebrows, and eyelid margins nightly for one month • Lid hygiene 8/20/2015 3 Pthiriasis/PediculosisInfestation • Pthirus pubis (pubic lice) more common periocular infestation • Less mobile and prefers eyelashes compared with pediculus species (body or head) • More coarse hair • Close lash base proximity py • Signs/symptoms • Bilateral ocular itching and inflammation • Visible orgnaisms, skin bites, brown feces deposits PthiriasisTreatment • Resistant to mechanical and chemical removal • Recommend removal of organisms and nits (eggs) with forceps • Trim eyelashes and eyebrows, shave beard if present • Use Rid, Kwell, Nix or similar pediculocitic OTC shampoo to Use Rid, Kwell, Nix or similar pediculocitic OTC shampoo to hair • Apply Lacrilube nightly to lashes and eyebrows for one month • Wash all bedding, clothes, etc. that might have existing organisms • Educate patient on cause and spread of disease • See general practitioner for work‐up including other STDs Hordeolum • Infection/inflammation of eyelid margin gland(s) • Localized pain, erythema, swelling • External hordeolum • Internal hordeolum • Internal hordeolum External Hordeolum • Localized infection of a ciliary gland • Zeiss or Moll • Pain, redness, purulent discharge • Staph aureus is causative organism in 95% of the Staph aureus is causative organism in 95% of the cases Internal Hordeolum • Localized inflammation of a meibomian gland • More likely obstructive etiology • Less likely infectious etiology • “Early chalazion” • Early chalazion HordeolaTreatment • Topical medications are ineffective • Manual expression in office • Removal of associated lashes if applicable • Hot compresses with massage are mainstay of p g y therapy • Oral antibiotic which covers gram positive organisms if necessary 8/20/2015 4 HordeolaTreatment • Oral antibiotic only if necessary which covers Staph aureus such as: • Amoxicillin 875mg BID • Keflex 500mg BID • Zpack • Doxycycline 100mg BID Penicillins • Beta‐lactam antibiotic class • Predominantly gram positive coverage • Inhibits bacterial cell wall formation resulting in bacterial death • Penicillin, ampicillin, amoxicillin, dicloxacillin, methicillin • 10‐15% of population are allergic to PCN • Well tolerated and safe otherwise • Can use in pregnancy and children Amoxicillin • Penicillin antibiotic • Aminopenicillin • Extended coverage over standard PCN • Good for gram positive infections Good for gram positive infections • Resistant to beta lactamases • Also has some gram negative coverage • Inexpensive • Ok with pregnancy and children Amoxicillin Dosage • Skin and soft tissue infections • Adults 875mg q12h • Children 20‐40mg/kg/day divided q8h • How supplied • 125mg/5ml • 200mg/5ml • 250mg/5ml • 400mg/5ml Cephalosporins • Beta‐lactam antibiotic class • Increased coverage over penicillin class • 3‐10% cross‐sensitivity to penicillin class in regards to allergic reactions • Four generations of cephalosporins • Increasing gram negative activity from 1 to 4 • First and second generations better for ocular conditions (more likely gram positive) 8/20/2015 5 Cephalexin • Brand name KEFLEX® • First generation cephalosporin • Good gram positive coverage (Staph/Strep) • Cheap • Cheap • Adult dose is 500mg bid • Also available in suspension for children • 20‐40mg/kg/day divided q8h Macrolides • Inhibit bacterial protein synthesis • More gram positive coverage than gram negative • Erythromycin, clarithromycin, azithromycin • Use with caution in liver disease • Use with caution in liver disease • Drug interactions with class • Great for penicillin allergic patients Azithromycin • Macrolide antibiotic with chemical structure changes leading to • Less drug interactions • Less GI side effects • Less frequent dosing • Better gram negative coverage • OK in pregnancy and children Azithromycin • Z‐pack • 500mg day one; 250mg days 2‐5 • Great for compliance • For milder ocular infections • Do not recommend for more aggressive infections Tetracycline Derivatives • Inhibits bacterial protein synthesis • Tetracycline, Doxycyline, Minocycline • Cannot use in children younger than 8 • Cannot use in pregnancy/nursing • Can cause photosensitivity and photophobia • Does not need dosage change in renal disease • Can alter Coumadin levels • Minocycline more common to cause pseudotumor cerebri • Doxycycline most commonly used in eye care 8/20/2015 6 Doxycycline Pearls • Can take with food • Can take with dairy products • Cannot take with antacids • Space 2 hours apart • Cannot take before lying down Cannot take before lying down • Wait 2 hours before lying down • Propensity to cause eosphageal/stomach erosion • Can causes photosensitivity but only with antibiotic dosage • Can alter bleeding times with Warfarin/Coumadin Doxycycline Dosage • Antibiotic use • 100mg bid x 10 days • Covers MRSA • Increased risk of GI toxicity and photosensitivity with antibiotic dosage • Posterior bleph and dry eye • Can do 20mg Periostat® product once or twice daily • OR 50mg bid x 4‐6 weeks then 50mg qd x 3‐6 months or indefinitely • Rosacea • Consider Oracea 40mg delayed release product PreseptalCellulitis • Generally follows acute hordeolum • Spreads from focal, localized gland infection • Other causes: • Eyelid trauma • Insect bite • Spread from adjacent upper respiratory infection • Larger and more diffuse eyelid • Periorbital soft tissue erythema, edema, tenderness • Occasional mild fever Gram + PreseptalPathogens • Staph aureus • Methicillin susceptible • Amoxicillin 875mg BID • Keflex 500mg BID • Methicillin resistant (MRSA) Methicillin resistant (MRSA) • Septra DS 1 po BID or 2 po BID • Doxycycline 100mg BID • Clindamycin 300mg q6h • Levaquin 500mg qd plus Rifampin 300mg BID • Strep pyogenes • Amoxicillin 875mg BID Why suspect MRSA? • Purulent with or without abcess • Initial appearance like a pimple or spider bite • Pain and edema out of proportion with clinical appearance Hi f i MRSA i f i• History of previous MRSA infection • History of recent hospitalization • Health care worker • Student athlete • Prison inmate • Unresponsive to standard antibiotic therapy Sulfamethoxazole/Trimethoprim • aka Septra DS or Bactrim DS • 2 antibiotics working synergistically to stop production of bacterial folic acid and therefore bacterial DNA • Less drug resistance • High penetration rate into various tissues High penetration rate into various tissues • Covers a wide variety of gram positive and gram negative organisms including: • Staph, strep, haemophilus • Ocular toxoplasmosis • MRSA • Best oral choice if not allergic • May need 2 DS tablets bid instead of 1 DS tablet bid 8/20/2015 7 Sulfamethoxazole/Trimethoprim • Cannot be used in sulfa allergic patients • Risk of sulfa allergy is approximately 3% • Allergy generally presents as rash • Can develop delayed life‐threatening Stevens‐Johnson syndrome y • Risk of allergy increased if allergic to other medications/substances (such as PCN) • Allergy to non‐antibiotic sulfonamides is rare • Drug interaction • Most common/more serious is with Warfarin/Coumadin Clindamycin • Lincosamide antibiotic that disrupts bacterial protein synthesis • Highly gram positive in coverage • Category B M idih db li i h• More associated with pseudomembranous colitis than other antibiotics • MRSA dosage 300mg po TID • MRSA clindamycin resistance is variable by location. Check with local health dept./hospital for culture and sensitivity reports in your area • Also used for treatment of ocular toxoplasmosis Oral Fluoroquinolones • Can use in PCN and/or sulfa allergic patients • Can NOT use in children/pregnancy/nursing • Caution in athletes secondary to tendon rupture • Blocks bacterial DNA synthesis • Ciprofloxacin (CIPRO®) is prototype • Heavily prescribed for urinary tract infections • Overprescribed in the 1990s • Little staphylococcal coverage now • Not recommended for ocular skin/soft tissue infections • Mainly used for gram negative urinary tract infections Levaquin • A fourth‐generation fluoroquinolone • Ok in PCN and/or sulfa allergic patients • Ok for ocular skin/soft tissue infections • Covers MRSA on sensitivity testing • Covers MRSA on sensitivity testing • Least recommended due to increasing resistance of hospital acquired MRSA infections to fluoroquinolones • Recommended use with Rifampin to avoid monotherapy and increased resistance • Levaquin 500mg QD and Rifampin 300mg BID FluoroquinoloneDrug Interactions • Antacids/vitamins • Wait 2 hours before or 3 hours after • Caffeine • Wait 2 hours before or 2 hours after • Warfarin (Coumadin™) • Insulin • Oral antidiabetic medications • Theophylline Gram –PreseptalPathogens • Haemophilus influenza • In past, was more common pathogen in preseptal cellulitis in children • Cellulitis often with bluish hue to eyelid • Much less common pathogen now secondary to widespread H flu vaccination • Augmentin 875 BID adult dosage • 20‐40 mg/kg/day pediatric dosage 8/20/2015 8 Augmentin • Augmentin = Amoxicillin + Clavulanic acid • Cannot use if penicillin allergic • Clavulanic acid is a “suicide inhibitor” • Protects amoxicillin from beta‐lactamases • Does not have antibiotic action itself • Allows increased coverage with less destruction by beta‐lactamases • Allows for increased coverage against gram positive, gram negative, and anaerobes • Does NOT cover MRSA Augmentin Info • Can use in pregnancy (Category B) • Can use in children • Can cause nausea/vomiting/diarrhea • Take with food/yogurt • 875 mg BID is standard adult dosing • Use Augmentin ES‐600 for children • Dose 90/mg/kg/day • Few drug interactions • Allopurinol/probenecid (for gout) • Generic available but still more expensive than amoxicillin alone Body Weight (kg) Volume of AUGMENTIN ES‐600 Powder for Oral Suspension providing 90 mg/kg/day 8 3.0 mL twice daily 12 4.5 mL twice daily 16 60mL twice daily 16 6.0 mL twice daily 20 7.5 mL twice daily 24 9.0 mL twice daily 28 10.5 mL twice daily 32 12.0 mL twice daily 36 13.5 mL twice daily 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 Frwy Bellaire, TX 77401 Pasadena, TX 77504 Sugar Land, TX 77478 Phone (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 Morgan Smith AGE ___5__ g ___ __ ADDRESS_____________________________________________________DATE 3-3-14 Rx Augmentin ES 600/5 7ml q12h x 10 days REFILLS-- 0 Jill Autry, O.D. Preseptalvs. Orbital • Refer if any signs of orbital cellulitis • APD • Decreased VA • Diplopia/restricted EOMs • Proptosis • Globe involvement • Fever • Obtain orbital CT • Orbital cellulitis will need broad spectrum IV antibiotics • Patient is admitted to the hospital Nasolacrimal System • Canaliculitis • Dacryocystitis 8/20/2015 9 Canaliculitis • Common misdiagnosis/delayed diagnosis • 5:1 female • Chronic conjunctivitis with epiphora • Inferior nasal conjunctivitis Inferior nasal conjunctivitis • Pouting puncta • Expression of canalicular debris/concretions • Pain, erythema, redness • No NLD obstruction • Can be caused by old punctual plug CanaliculitisPathogens • Actinomyces • Most common pathogen especially in older patients • Gram positive bacilli • Facultative anaerobe C ti itd ith ti• Concretions associated with actinomyces • Staph and strep species • Herpes simplex • Most common cause of patients under 20 • Less commonly fungal causes CanaliculitisTreatment • Removal of any blockages • Dacryolith expression • Removal of retained plug • Surgical canaliculotomy when indicated • Followed by DCR if unsuccessful • Warm compresses • Antimicrobial therapy • Topical antibiotic/steroid combination • Plus systemic amoxicillin, cephalexin, doxycycline, or clarithromycin • Systemic acyclovir and trifluridine if HSV suspected Dacryocystitis • Localized pain, erythema, edema in the medial canthal region with lacrimal sac infection and/or inflammation • Most often due to clogged NLD • With associated epiphora and purulent discharge from puncta • May extend toward nose and cheek May extend toward nose and cheek • May have associated preseptal cellulitis • Mattering of the lids is common • Conjunctivitis is common secondary to pathogen exotoxin activity • Extension into the sinus cavities can result in orbital cellulitis Dacryocystitis • More common in females 60‐70 years old • Less common in African‐American patients • More often on the left side • 99% bacterial; only 1% fungal • 99% bacterial; only 1% fungal • Acquired form can be acute or chronic Dacryocystitis • The most common pathogens are gram positive • Strep pneumonia • Part of the normal nasopharynx flora • Can also cause associated keratitis • Staph epi (most common but likely a contaminant) • Staph epi (most common but likely a contaminant) • Staph aureus (methicillin sensitive and resistant) • Beta‐hemolytic streptococci 8/20/2015 10 Dacryocystitis • Gram negative organisms have also been isolated • E coli (suspect if copius purulent discharge) • Haemophilus (more common in children) • Pseudomonas Treatment • Acute: quick onset of symptoms • Treat with hot compresses and oral antibiotic • Drain abcess if necessary • Augmentin 875mg BID • First or second generation cephalosporin g pp • PCN allergic consider clindamycin • Need for surgical intervention is low • Chronic: longer presentation of epiphora/mattering • Likely need DCR Lacrimal Gland • Dacryoadenitis Dacryoadenitis • Infection/inflammation of lacrimal gland • Located supratemporal orbit • Chronic vs acute • Inflammation often systemic in origin • Infection thought to originate from conjunctiva and migrate • Infection thought to originate from conjunctiva and migrate through lacrimal tubules into lacrimal gland Clinical Presentation • Variable presentation • Inflammatory etiology • More common than infectious • Chronic mild redness, edema, pressure, not as painful • Unilateral or bilateral • Systemic associations • Sarcoid, Sjogren’s, Lupus, Chron’s, TB, Grave’s, Lyme, Tumor • Infectious etiology • Acute unilateral, severe pain, redness, can be purulent • Most commonly viral or bacterial • HSV, EBV, CMV, mumps • Staph, strep, Gonococcus, Moraxella, Klebsiella DacryoadenitisTreatment • Depends on etiology • Acute presentations more likely viral or bacterial • Compresses • Cold compresses if viral suspected • Hot compresses if bacterial suspected Hot compresses if bacterial suspected • Emperic antibiotic therapy in most cases is initiated • Amoxicillin 875mg BID • Keflex 500mg BID • Septra DS BID • Levaquin 500mg QD 8/20/2015 11 Animal or Human Bites • Periocular skin/soft tissue infection initiated by human or animal bite • Polymicrobial risk • Antibiotic needs anaerobic coverage • Augmentin 875mg BID g g • Augmentin ES‐600mg 90mg/kg/day divided q 12h for kids • If penicillin allergic: • Sulfamethoxazole‐trimethoprim plus clindamycin • Oral fluoroquinolone plus clindamycin Conjunctivitis • Bacterial conjunctivitis • Viral conjunctivitis • Adenovirus • Molluscum contagiosum g • Simplex conjunctivitis • Zoster conjunctivitis Bacterial Conjunctivitis • More common in children • Highly contagious • Can be unilateral but generally starts in one eye and spreads to the other • Affects second eye with less intensity y y • Yellow‐greenish discharge, hyperemic conjunctiva, clear cornea • PA node uncommon • Self‐limiting in general Bacterial Conjunctivitis • Staph and strep species most common etiologic organisms in adults and children • Tobramycin (gentamicin is more corneotoxic) • Ofloxacin, Moxifloxacin, Gatifloxacin • Ciprofloxacin has poor staph coverage • However, can see Haemophilus as well in children • Polytrim(used commonly in pediatric cases) • Polymixin B and trimethoprim Topical Fluoroquinolones • Increased gram positive coverage with later generations • Third generation still used for prophylaxis, bacterial conjunctivitis, known gram negative etilogy • Fourth generation recommended for emperic bacterial keratitis • Moxifloxacin, Gatifloxacin, Besifloxacin GonnococcalConjunctivitis • Neisseria gonorrhoeae • Gram negative • Hyperacute infection associated with copius purulence • Severe lid edema more common than with other types of bacterial conjunctivitis j • More common in newborns and sexually active patients • Treat with one gram Rocephin IM or IV then Doxycycline 100mg bid x 2 weeks • Not treated topically unless cornea becomes involved • Use fourth generation fluoroquinolone 8/20/2015 12 Chlamydial Conjunctivitis • Chlamydial trachomatis • An intracellular parasite • Seen more often in developing countries with severe sequelae leading to blindness • Often in newborns in endemic areas • Often in newborns in endemic areas • Positive PA node • Increased suspicion with a chronic, follicular conjunctivitis • Especially in sexually active patients • Treat with one gram azithromycin • Consider repeat azithromycin in 2 weeks Viral Conjunctivitis • Common in children and adults • Can be unilateral but generally starts in one eye and spreads to the other • Affects second eye with less intensity • Clear, watery discharge with mild amounts of mucous • Highly contagious, follicular conjunctivitis • Positive PA node but not always • History of recent cold or upper respiratory infection or exposure to red eye patients • Can cause more destruction than common bacterial conjunctivitis • pseudomembranes • subepithelial infiltrates Common Viral Conjunctivitis • Adenoviruses (up to 90% of conjunctivitis) • Subtypes 8 and 19 most common • Picornaviruses (hemorrhagic conjunctivitis) • Enterovirus 70 • Coxsackievirus A24 Common Viral Conjunctivitis • Virus must run its course • Treatment is supportive • Cold compresses • Artificial tears • Vasoconstrictors • Betadine wash • Topical steroids • Severe pain and inflammation • Pseudomembranes • Subepithelial corneal infiltrates Other Viral Conjunctivitis • Molluscum contagiosum • Herpes Simplex • Herpes Zoster MolluscumConjunctivitis • Consider in chronic, unilateral cases • Look for typical pearly‐white, dome‐shaped, raised papule with an umbilicated center • Found on the eyelids and/or eyelid margins • More common in children More common in children • Lesion(s) must be removed for cure of chronic conjunctivitis 8/20/2015 13 Herpes Simplex Conjunctivitis • Type I herpes virus • Initial infection • May not even be aware of infection • Recurrent infections • Virus lies dormant and is triggered by various factors • Occurs in one eye only same eye each recurrence Occurs in one eye only, same eye each recurrence • Conjunctivitis often with periocular skin vessicles • Self limiting in most cases • Can observe with AT and cold compresses • Can use antiviral if severe • Conjunctivitis (trifluridine qid or Zirgan tid) • For skin lesions do Acyclovir 400mg tid po • Watch for corneal involvement Herpes Zoster Conjunctivitis • Type 3 herpes virus • Associated with same‐sided facial and periocular lesions that respect midline • More common in elderly & immunocompromised patients • Patients need high dose oral antivirals ASAP Patients need high dose oral antivirals ASAP • Conjunctivitis • Most common ocular condition caused by zoster • Hyperemia, watery discharge, petechial hemorrhages • May be associated with keratitis and/or uveitis • Treat conjunctivitis conservatively unless corneal or intraocular involvement • Cold compresses, artificial tears, vasoconstrictors, topical NSAID Microbial Keratitis • Bacterial keratitis • Acanthamoeba • Fungal • Viral Contact Lens Associated Bacterial Keratitis • Up to 65% of keratitis cases in the US are secondary to CL wear • Risk has not decreased with the use of silicone hydrogel lenses • 5‐10x more likely to ulcerate with extended wear • Risk is less in RGP • Due to tear exchange under the lens • Risk is less in daily disposable soft CL • Due to lack of contamination with solutions/cases Gram + Contact Lens Infections • Staph aureus most common etiologic organism of all contact lens ulcers • Oval, creamy dense infiltrate • Overlying epithelial defect • Sterile AC reaction common • Streptococcus pneumonia • Round • Overlying epithelial defect with creeping, serpiginous characteristics • Sterile AC reaction common • Can lead to perferation Staphylococcal Resistance • MRSA • Methicillin‐resistant staph aureus • Once only nosocomial, now community‐acquired • MRSE • Methicillin‐resistant staph epidermidis p p 8/20/2015 14 Contact Lens Associated Bacterial Keratitis • Gram negative • Pseudomonas aeruginosa is most virulent • Causative agent in up to 40% of CL keratitis • Rapid in progression • Virulent due to bacterial exotoxins • Serratia Serratia • More in RGP than SCL wear infections • Klebsiella Pseudomonas Aeruginosa • Suppurative (soupy) appearance secondary to stromal necrosis • Overlying epithelial defect • Can form ring infiltrate • Antigen‐antibody reaction • May see sterile hypopyon May see sterile hypopyon Trauma Induced Microbial Keratitis • Associated with indolent presentation • Minimal symptoms early • Dramatic • More likely to involve atypical organisms • Not part of normal flora • Wide distribution in soil • Trauma involving organic or metallic foreign bodies as primary risk factor • In up to 90% of cases Atypical Organisms • Mycobacterium (nontuberculous) • Unusual, focal, waxy “cracked windshield” appearance • May develop satellite lesions or ring infiltrate • Often in post‐Lasik cases • Nocardia • Patchy, wreath‐like stromal infiltrates • Pinhead‐sized dense opacities • May produce feathery margins like fungal • Fungi EmpericTreatment • Clinical presentation often dictates empiric broad‐spectrum treatment • Small, superficial, non‐central infiltrates • Fourth‐generation fluoroquinolones • Cover most common and even some atypical organisms yp g • Moxifloxacin (Vigamox, Moxeza) • Gatifloxacin (Zymaxid) • Besifloxacin (Besivance) • Resistance is increasing with only 15‐30% MRSA strains susceptible When to Culture • Central ulceration • Large ulceration • Greater than 3mm • Extends into middle or deeper layers of stroma • Post surgical Post surgical • Non‐responsive to current broad spectrum therapy • Chronic in nature • Atypical features • Fungal • Amoebic • Mycobacterial 8/20/2015 15 FORTIFIED ANTIBIOTICS • Need to culture • Find a compounding pharmacist BEFORE you need them • www.iacprx.org • Recommend alternating q 30 minutes to start /l ( )• Vancomycin 25 mg/ml (gram + coverage) • Can use Ancef instead of Vancomycin if MRSA not suspected • Can use commercially prepared fourth‐generation • Ceftazidime 50mg/ml (gram – coverage) • Tobramycin 13.5 mg/ml (gram – coverage) AcanthamoebaKeratitis • Free‐living, protozoa • 95% of infections associated with CL wear • Highest risk is silicone hydrogel • Commonly misdiagnosed for an average of 6 weeks • Most frequently misdiagnosed as herpetic keratitis Most frequently misdiagnosed as herpetic keratitis AcanthamoebaKeratitis • Irregular, disrupted epithelium characterizes early stages • Punctate erosions • Pseudodendrite formation • Small, cystic infiltrates • Without epithelial defect • Pain out of proportion to clinical appearance • Subepithelial infiltrates along radial corneal nerves • Radial perineuritis results in severe pain • No improvement with antibiotics/antivirals • Culture on Ecoli media • Confocal microscopy AcanthamoebaKeratitis • Later stages produces increased destruction • Ring infiltrate • Seen in only 6% of early cases • Seen in only 16% of late cases • Hypopyon Hypopyon • Progressive corneal thinning • Risk of perforation • Corneal opacification • Transplantation often end result PHARMACOLOGICAL TREATMENT • Biguanides • Polyhexamethylene biguanide (PHMB) 0.02% • Chlorhexidine (CHX) 0.02% • Diamidines • Propamidine isethionate (Brolene) 0.1% • Hexamidine 0.1% • Antifungals • Miconazole, ketoconazole, itraconazole • Aminoglycosides • Neomycin TREATMENT • Epithelial debridement • Can use a combination of PHMB, CHX, and Brolene • Dosed q1hr initially, then 6‐8 times a day, then qid • Slow taper, on treatment for several months • Antibiotic coverage qid until epithelium heals Antibiotic coverage qid until epithelium heals • Pain management • Cycloplegic • Opioid pain control • Cautious addition of steroid after improvement 8/20/2015 16 Fungal Keratitis • Increasing cause of keratitis • 10‐20% cases are trauma related • Especially vegetative/agricultural trauma • 20‐35% cases are CL related • Contact lens solution spike 2004‐2006 • Unicellular yeasts • Candida species in temperate zones • Multicellular molds • Fusarium in tropical zones Fungal Keratitis • Clinical presentation is extremely varied • Often indolent, forming over weeks • 87% of cases are misdiagnosed as bacterial/viral • Patchy, grayish infiltrates with feathery margins S lli li• Satellite lesions • With or without an epithelial defect • Hypopyon, endothelial plaques, immune ring may develop • Needs culture on Sabourauds Treatment • Commercially available Natamycin 1% • Can be used as monotherapy • Good against mold species • Fusarium • Aspergillus • May need compounded medications • Amphotericin or voriconazole • Consider addition of oral fluconazole 400mg qd Viral Keratitis • Herpes Simplex keratitis • Classic dendritic form • Disciform keratitis • Keratouveitis • Trabeculitis HERPES SIMPLEX KERATITIS • UNILATERAL redness, foreign body sensation, photophobia • Look for follicles and PA node involvement • Classic dendritic pattern • Can also see pinpoint areas of negative staining which can coalesce into dendrites • Simplex can also cause disciform keratitis and keratouveitis without epithelial disease • May have high IOP • Keratitis or uveitis with high IOP—think Herpes HERPES SIMPLEX TREATMENT • Epithelial disease • Zirgan 5X day for treatment of epithelial disease becoming standard of care • Viroptic 9X day still an option • Can also use oral antiviral agents for treatment of epithelial • Can also use oral antiviral agents for treatment of epithelial disease • +/‐ debridement • +/‐ Betadine wash • Use non‐prostaglandin agent for IOP prn • IOP rise less common with simplex • More common with zoster 8/20/2015 17 TREATMENT WITH STEROIDS • Only if stromal disease present • Only after epithelial disease has resolved • Treat stromal disease with topical steroid • Cover steroid with Viroptic®/Zirgan® or oral antiviral • Usually do steroid 2:1 ratio of topical antiviral Oral antiviral TREATMENT –In place of Viroptic or Zirgan topically –Also for disciform keratitis caused by simplex • Acyclovir 400mg 5x day x 10 days • Famvir® 250mg tid x 7 days l®• Valtrex® 500mg tid x 7 days –For prevention of recurrences or to cover steroid after epithelial disease resolved • Acyclovir 400mg qd‐bid • Famvir® 250mg qd • Valtrex® 500 qd Marginal Ulceration • Aka “Sterile infiltrates” • Bacterial exotoxin sensitivity in non‐CL wearers • Staph species • CL wearers more likely overwear • Treat with topical steroid lid scrubs/hygeine and Treat with topical steroid, lid scrubs/hygeine, and bacitracin/erythromycin oph ung Infectious ulceration vs Non‐infectious (sterile) ulceration Infectious • >1 mm in size • Diffuse injection • Central to paracentral Non‐infectious • <1 mm in size • Sectoral injection • Limbal to midperipheral • Generally single infiltrate • Excavated center of ulcer matches underlying infiltrate • Severe pain • Treat with topical antibiotics • Often numerous pinpoint infiltrates • Area of staining smaller than infiltrate • Less pain • Treat with topical steroids Phlyctenulosis • Unilateral or bilateral tearing, photosensitivity, ocular irritation, history of previous episodes • Hypersensitivity to bacterial antigens • Staph (most common cause in US), TB, rosacea, Chlamydia, etc. • Corneal or conjunctival j • Conjunctival • A raised, 1‐3 mm hard, triangular shaped, yellow‐white nodule with surrounding hyperemia on inferior conjunctiva • Corneal • More symptomatic. A white, initially limbal lesion that migrates onto and moves perpendicularly across the corneal surface. It is vascularized and leaves infiltrative area behind as it moves. PhlyctenuleTreatment • Lid hygeine/staph control • Warm compresses and scrubs • Bacitracin/erythromycin ointment • Possibly oral doxycycline • Topical steroids p • Treatment of any underlying systemic pathology 8/20/2015 18 Interstitial keratitis • Non‐ulcerative infiltrative, inflammatory keratitis • Not involving the epithelium or endothelium but stromal focused • Immune response to the following infectious etiolgies: • Syphillis Syphillis • Herpes simplex/zoster • Epstein‐Barr • Lyme • Treatment consists of topical steroids for inflammatory process and lab testing • Oral antivirals in addition for suspected herpetic etiology Infectious anterior uveitis • Higher level of suspicion • Recurrences • Bilaterality • History of rash • History of tick bite f ll d d• History of sexually transmitted diseases • Family history of TB • History of incarceration • History of travel to endemic areas of TB • HIV positive • Lyme disease • Syphilis • Tuberculosis Anterior uveitis labwork • Lupus (ANA) • Sarcoid (ACE, if + run Chest X‐ray) • Rheumatoid arthritis (RF, anti‐CCP) • Ankylosing spondylitis (HLA B27 if + ili ilfil )• (HLA‐B27, if + run sacroiliac spinal films) • Psoriatic arthritis (ESR‐Sed rate) • Syphilis (RPR, FTA‐ABS) • Lyme (IgG and IgM) • TB Gold • CBC with differential Post‐operative Endophthalmitis • Early • Staph species most common organism • Other gram positive organisms • Vancomycin and Ceftazidime injections with or without vitrectomy • +/‐ Dexamethasone injection +/ Dexamethasone injection • Late • Propionibacterium acnes (P acnes) • Gram positive, anaerobic organism • Indolent infection • Post‐intravitreal injection • Staphylococcal organisms but also streptococcus viridans • Strep viridans is highly virulent Posterior uveitis • Toxoplasmosis • The most common cause of infectious posterior uveitis • Typical chorioretinal lesion • Vitritis, anterior chamber reaction, may have increased IOP • Toxoplasmosis IgG and IgM blood testing • Bactrim DS 1 po BID, add oral steroids on day 3 • Other oral treatments available • Syphilis • CMV • Tuberculosis Orbital cellulitis • Sources • Spread from periorbital structures • Spread from paranasal sinuses • Trauma or surgery to the orbit • Spread through bloodstream from distant infection • Staph and strep species most common • Treat with broad spectrum IV antibiotics • Fungal • Diabetic or immunocompromised patients • Treat with IV antifungals 2/17/2016 1 Practice Essentials In Posterior Segment Care Maynard L. Pohl, OD, FAAO Pacific Cataract & Laser Institute 10500 NE 8th Street, Suite 1650 Bellevue, WA 98004 USA Dr. Maynard Pohl has no financial interests to disclose. Choroidal Melanoma Epidemiology • Incidence 6 per million per year (.0006%), choroidal nevi 6% • Mean age of diagnosis 60 years • More common in Caucasians, northern European descent • Predisposition in lightly‐colored irides, sunlight exposure, family hx of uveal melanoma, uveal nevus, cutaneous nevi Symptoms • Asymptomatic • Blurred visual acuity • Paracentral scotoma • Painless and progressive visual field loss • Flashes or floaters • Ocular pain – can be severe • Weight loss, marked fatigue, cough, change in bowel or bladder habits Clinical Features • External include sentinel (dilated episcleral) vessels, episcleral pigment from extrascleral extension • Lenticular astigmatism from tumor growth • Extension of tumor into iris, iris nv • Secondary glaucoma from angle closure • Ophthalmoscopic findings Ophthalmoscopic Findings • Variably pigmented uveal mass, may be amelanotic • May have collar button from extension through Bruch’s membrane • Subretinal fluid, orange coloration to surface • RPE atrophy and hypertrophy, drusen • Choroidal nv, RD, vitreoretinal invasion, vitreous heme • Extrascleral extension intoorbit, metastasis to liver, lung, skin, and CNS 2/17/2016 2 Types of Tests for Ocular Oncology • Cross‐sectional imaging modalities: Ultrasonography – tumor detection, assessment of shape, calcification, extraocular extension; best for larger tumors > 2mm thick; A‐scan, B‐scan, UBM OCT ‐ best for small tumors < 3mm thick, smooth dome‐shaped surface, subretinal fluid MRI – small role in diagnosis, can evaluate extrascleral extension; globe and orbit CT – very little role in management Types of Tests for Ocular Oncology • Vascular imaging modalities: Intravenous fluorescein angiography (IVFA) ‐ patchy hypo/hyperfluorescence, late staining Optical coherence tomography angiography (OCT‐A) ‐ angiography without injection Multispectral imaging ‐ angiography without injection, nevi (< 1mm in height) • Other imaging modalities: Autofluorescence Transillumination ‐ best for ciliary body tumors Fundus photography ‐ wide angle imaging with montage, technology improving Treatment and Mangement • Observation – small tumors, serial photography/imaging; consider earlier intervention • Enucleation • Plaque brachytherapy – for medium‐sized posterior uveal tumors (< 10mm in height and < 15mm in diameter); patient survival similar between radiotherapy and enucleation (up to 12 years) • External beam irradiation – for medium and larger tumors Choroidal Melanoma: Optometric Management Guidelines • Differentiate a choroidal nevus from a choroidal melanoma • Monitor with photodocumentation and regular followup (DFE) • Referral to highly skilled retinal specialist for consultation, A/B scan, serology/imaging prn, and management • Interprofessional communication Plaquenil Retinopathy Signs and Symptoms • Asymptomatic, VA initially is excellent, progressive • Metamorphopsia, difficulty with reading and critical visual tasks, dimness • Corneal deposits, PSC (chloroquine), loss of foveal reflex, RPE mottling, bulls eye maculopathy, peripheral pigmentary (RP‐like) changes 2/17/2016 3 Factors Associated with Toxicity • Daily dose > 400 mg • Maintenance dose > 6.5 mg/kg in short or obese people (5 mg/kg of real body weight ideal in all) • Total cumulative dose > 1000 g • Duration of treatment > 5 years • Evidence of renal insufficiency • Evidence of liver disease • Underlying retinal disease or maculopathy (AMD) • Age older than 60 years Clinical Examination (AAO) • History • Visual Acuities (UCVA, BCVA) • Slit lamp biomicroscopy • Visual fields: central 10‐2 white‐on‐white pattern • Spectral domain optical coherence tomography (SD‐OCT), or Fundus autofluorescence (FAF), or Multifocal electroretinogram (mfERG) Plaquenil Retinopathy: Optometric Management Guidelines • Case history • Best corrected visual acuities • Slit lamp exam and fundus biomicroscopy • Central 10‐2 white‐on‐white pattern VFs • SD‐OCT (or FAF or mfERG) • Annual monitoring • Interprofessional communication (rheumatology) Vitreomacular Traction (VMT) Categories of VMT Disease • Vitreomacular adhesion (VMA) – focal or diffuse, may be asymptomatic, may spontaneously release (34%), can lead to traction (VMT) and macular hole • Vitreomacular traction (VMT) – posterior hyaloid remains tethered at macula, tractional foveal distortion, cystic edema, foveal detatchment • Macular hole – stage 0‐4, 10% bilateral if fellow eye has attached vitreous • May be associated with epiretinal membrane (ERM) • Best evaluated with SD‐OCT Intervention for VMT • If VMT and ERM, pars plana vitrectomy (PPV) with membrane peeling • If small area of VMA (< 1500 microns) and no ERM with or without small macular hole (<250 microns), consider intravitreal injection of ocriplasmin (Jetrea) • What about pharmacovitreolysisin the symptomatic patient with reasonable VA, VMA, no ERM, no macular hole? • Observation may be reasonable when comparing success rates and cost of ocriplasmin to natural history of VMA. • Pneumatic vitreolysis – intravitreal perfluoropropane gas 2/17/2016 4 VMT: Optometric Management Guidelines • Case history • Best corrected visual acuity • Potential (retinal) acuity • Fundus biomicroscopy • Amsler grid • SD‐OCT of macula • Monitor until significantly symptomatic • Referral to highly skilled retinal specialist for consultation and treatment: pharmacologic vitreolysis vs vitrectomy/pneumatic vitreolysis Vascular Disease Vascular Disease • Cerebrovascular Disease • Hypertension • Atherosclerosis • Diabetes mellitus Ocular Manifestations of Vascular Disease • Hypertensive retinopathy • Venous occlusive disease • Arterial occlusive disease • Diabetic retinopathy Systemic Hypertension Systemic Hypertension: Epidemiology • 60 million Americans • 1 billion people worldwide • A normotensive (BP 120/80) American at age 55 has a 90% lifetime risk of developing hypertension. 2/17/2016 5 Systemic Hypertension: Pathophysiology • Essential hypertension • Malignant hypertension (hypertensive crisis) Systemic Hypertension: Target Organ Damage • Left ventricular hypertrophy • Angina • Myocardial infarction • Heart failure • Stroke • Peripheral vascular disease • Chronic kidney disease Systemic Hypertension: Ocular Manifestations • Hypertensive Retinopathy: vasoconstrictive phase exudative phase sclerotic phase complications of sclerotic phase Systemic Hypertension: Ocular Manifestations • Hypertensive Choroidopathy: Elschnig’s spots Siegrist’s streaks Large patches of chorioretinal atrophy Systemic Hypertension: Ocular Manifestations • Hypertensive Optic Disc Edema: increased intracranial pressure ischemia Systemic Hypertension: OD Management • Blood pressure management • Referral to family physician or internist, depending on severity of hypertension • Fundus monitoring at least every 12 months, referring to retinal specialist prn • Patient counseling • Interprofessional communication 2/17/2016 6 Complications of the Sclerotic Phase • Retinal arterial macroaneurysm (RAM) • Branch retinal vein occlusion (BRVO) • Central retinal vein occlusion (CRVO) • Branch retinal artery occlusion (BRAO) • Central retinal artery occlusion (CRAO) Diabetic Retinopathy Crisis? What Crisis? Diabetes in the United States • Obesity is on the rise • Number of people diagnosed with type 2 diabetes has increased from 5.6 million in 1980 to 20.9 million in 2011 Evidence‐Based WHO Guidelines (2012) • South Asian and Pacific Island populations now considered “high‐risk” populations • All Type 2 DM patients examined at diagnosis • Type 1 DM patients examined at puberty • Women with DM examined before pregnancy and during first trimester • All DM patients regardless of degree of DR examined at least every 2 years • Prevalence of blindness from DR is escalating in developing countries with a younger age of onset of DM • Detection of referrable retinopathy with single 45 degree non‐mydriatic camera using trained operator with off‐site grading by ophthalmologist, or trained ophthalmic medical officer or optometrist performing dilated fundus exam Laser Photocoagulation & Vitrectomy in Diabetic Retinopathy • Laser in Type 1 and Type 2 DM patients with NVE with vitreous heme, or with NVD with/without vitreous heme • PRP considered in severe or very‐severe NPDR • Modified ETDRS macular laser in CSME when macular ischemia absent • Vitrectomy in advanced DR: severe PDR with nonresolving vitreous heme or fibrosis, RD, or areas of retinal traction threatening macula • Vitrectomy in persistent diffuse macular edema Intraocular Steroids & Anti‐VEGF Agents in PDR and CSME • Macugen • Avastin – BOLT study (monotherapy) • Lucentis– RESOLVE study (monotherapy), READ‐2 study (Lucentisvs laser vs combo) • DRCR.net – greatest improvement in VA is Lucentis and deferred laser (>6 mos after injection) • NHMRC – consider anti‐VEGF as an adjunct to laser and prior to vitrectomy • Eylea – VIVID and VISTA studies, DRCR.net Protocol T • Triamcinolone acetonide (IVTA) – in refractory DME, weighing risk vs benefit; as an adjunct to PRP in PDR 2/17/2016 7 Anti‐VEGF Agents in Diabetic Retinopathy • The new gold‐standard treatment for DME • Protocol T study by DRCR.net in overall patient population with DME, comparing Lucentis vs Avastin vs Eylea (N Engl J Med, Feb 2015) ‐ no differences in drug safety or efficacy ‐ Eylea better effect in patients with 20/50 or worse VA, suggesting higher affinity for VEGF receptors and longer duration of action • Mitigates diabetic retinopathy severity status • Adjunctive therapy with intravitreal corticosteroids, via injection or depot Intravitreal Steroid Implants in Diabetic Retinopathy • Ozurdex (Allergan) – dexamethasone release x 3 to 4 months • Iluvien (Alimera) – fluocinolone acetonide (0.19 mg) release x 36 months • MEAD, FAME, DRCR.net Protocol I studies showing ETDRS 15+ letters of BCVA • An option to improve patient compliance with monthly or as needed or TAE injections • Provides constant antiinflammatory efficacy for extended periods of time • Not first‐line option due to risk of IOP increase and less profound VA benefit Age‐Related Macular Degeneration AMD Pipeline • Refinement of anti‐VEGF agents to development of mechanisms that extend drug delivery and prolong anti‐VEGF effect • Gene therapy utilizing viral vectors manufactured to contain genetic sequences that alter localized ocular tissue to produce anti‐VEGF activity • Platelet‐Derived Growth Factor (PDGF) inhibitors in combination therapy with anti‐VEGF agents • Treatments for geographic atrophy – Chroma and Spectri phase 3 trials (lampilizumab) Recent Understandings in AMD • Genetic factors potentially affect response to therapy. • There are individualized responses to therapy. • Potentially several AMD subtypes exist. • AMD therapy must be individualized. Ongoing Innovations in Retina • Drug and device development • Optical Coherence Tomography (OCT) • Anti‐VEGF agents • Shift away from slowing vision loss to preserving vision ability to restoring vision by accessing intact visual pathways not yet affected by the disease (AMD and DME) • Agents such as genetic modifiers and stem cell therapies in the future may make it possible for “regenerative” medicine to more effectively treat and cure retinal pathologies. 2/17/2016 1 Retinal Vascular Occlusive Disease: See It, Know It, Manage It Maynard L. Pohl, OD, FAAO Pacific Cataract & Laser Institute 10500 NE 8th Street, Suite 1650 Bellevue, WA 98004 USA 425‐462‐7664 Dr. Maynard Pohl has no financial interests to disclose. Vascular Disease • Cerebrovascular Disease • Hypertension • Atherosclerosis • Diabetes mellitus Ocular Manifestations of Vascular Disease • Hypertensive retinopathy • Venous occlusive disease • Arterial occlusive disease • Diabetic retinopathy Systemic Hypertension Systemic Hypertension: Epidemiology • 60 million Americans • 1 billion people worldwide • A normotensive (BP 120/80) American at age 55 has a 90% lifetime risk of developing hypertension. Systemic Hypertension: Pathophysiology • Essential hypertension • Malignant hypertension (hypertensive crisis) 2/17/2016 2 Systemic Hypertension: Target Organ Damage • Left ventricular hypertrophy • Angina • Myocardial infarction • Heart failure • Stroke • Peripheral vascular disease • Chronic kidney disease Systemic Hypertension: Ocular Manifestations • Hypertensive Retinopathy: vasoconstrictive phase exudative phase sclerotic phase complications of sclerotic phase Complications of the Sclerotic Phase • Retinal arterial macroaneurysm (RAM) • Branch retinal vein occlusion (BRVO) • Central retinal vein occlusion (CRVO) • Branch retinal artery occlusion (BRAO) • Central retinal artery occlusion (CRAO) Retinal Venous Occlusive Disease • Branch Retinal Vein Occlusion (BRVO) • Central Retinal Vein Occlusion (CRVO) Branch Retinal Vein Occlusion Branch Retinal Vein Occlusion (BRVO) • Thrombus formation at arteriovenous crossing • Systemic hypertension commonly associated • Age 60 – 70 most common 2/17/2016 3 BRVO: Acute Findings • Sectoral superficial hemorrhages • Sectoral retinal edema • Sectoral cotton‐wool spots BRVO: Chronic Findings • Microvascular abnormalities • Macular edema • Intraretinal collaterals • Sclerosis and sheathing of retinal vessels Macular grid laser photocoagulation remains the criterion standard treatment of eyes with perfused macular edema secondary to BRVO. BRVO: Laser Treatment Techniques • Scatter Photocoagulation: presence of neovascularization presence of vitreous hemorrhage BRVO: Other Treatment Techniques • Laser‐induced chorioretinal anastomosis • Arteriovenous decompression (sheathotomy) • Vitrectomy • Intravitreal Kenalog (triamcinolone acetonide) – SCORE Study • Ozurdex (0.7 mg dexamethasone intravitreal implant) • Avastin, Lucentis, Eylea Pathogenesis in RVO • Critical role of Vascular Endothelial Growth Factor (VEGF) ‐ macular edema, intraretinal hemorrhages, retinal nonperfusion • Role of other vasoactive proteins in chronic edema ‐ Hepatocyte Growth Factor (HGF), Endocrine Gland VEGF (EG‐VEGF), Activin‐A 2/17/2016 4 Vascular Endothelial Growth Factor (VEGF) • VEGF is a potent inductor of vascular permeability and intraocular neovascularization. • Human aqueous levels of VEGF and interleukin 6 (IL‐6) are correlated with the degree of retinal ischemia and the severity of macular edema in BRVO. • Therefore, VEGF inhibition is a promising treatment modality for macular edema. Clinical Evidence‐Based Conclusions • Timing of diagnosis and management of BRVO is important. • Eyes with macular edema secondary to BRVO should be offered VEGF inhibition upon diagnosis to achieve the best possible visual outcome (BRAVO Study, HORIZON Trial, RETAIN Study). Injections monthly up to 6 mos, then prn. • Eyes are eligible for laser after 3 months if hemorrhages have sufficiently cleared to allow safe laser treatment and if vision acuity remains worse than 20/40. • Persistent edema: consider Dex implant if pseudophakic and after 2 years in phakic patient • Retinal nonperfusion is related to intravitreal VEGF levels and may result in loss of visual gains. The prevention of worsening retinal nonperfusion should be a treatment objective as important as the resolution of macular edema. • Periodic fluorescein angiograms should be performed to monitor perfusion status. Central Retinal Vein Occlusion Central Retinal Vein Occlusion (CRVO) • Thrombus formation in retinal vein at lamina cribosa • Etiology of thrombus formation unclear: arteriosclerosis, vasculitis • Primary open angle glaucoma: 20% have POAG, 20% develop POAG Central Retinal Vein Occlusion (CRVO) • Systemic associations: CVD ‐ 74% HTN ‐ 57% DM ‐ 34% • Risk factors include oral contraceptives and diuretics • 90% of patients are over 50 Non‐Ischemic CRVO • 30+% convert to ischemic type (CVOS) • < 10 dd of retinal non‐perfusion (CVOS) 2/17/2016 5 Ischemic CRVO • Marked optic disc, retinal, and macular edema • Marked venous dilatation and tortuosity • Many retinal hemorrhages, cotton‐wool spots • VA worse than 20/200 • Afferent pupillary defect CRVO: Incidence of Neovascularization • Non‐Ischemic: Any NV in < 5% NV glaucoma in < 2% • Ischemic: Any NV in > 60% NV glaucoma in 33% CRVO: Other Advocated Treatments • Aspirin • Anti‐inflammatory agents • Isovolemic hemodilution • Plasmapheresis • Systemic anticoagulation with warfarin, heparin, and alteplase • Fibrinolytic agents • Systemic corticosteroids • Intravitreal treatments – the standard of care CRVO: Intravitreal Treatments • Local anticoagulation with intravitreal injection of alteplase (Activase) • Intravitreal injection of triamcinolone (Kenalog) • Ozurdex intravitreal implant • Intravitreal injection of Lucentis • Intravitreal injection of Avastin • Intravitreal injection of Eylea Intravitreal Injection of Triamcinolone • SCORE Study ‐ CRVO Trial demonstrated effectivity in resolving perfused macular edema and improving vision • 1‐mg dose and retreatment prn may be considered up to 12 months (preferred over 4‐ mg dose due to fewer adverse effects) SCORE Study: Conclusion • No difference in longterm outcome between triamcinolone injections and grid photocoagulation with BRVO. • Ozurdex biogradable implant (Allergan, June 2009) is considered superior to triamcinolone as a delivery method, with fewer injections. • Triamcinolone remains a viable option for patients with financial troubles. 2/17/2016 6 Anti‐VEGF Trials For RVO • After 6 months of Lucentis therapy, between 55% and 61% of BRVO patients and 47% of CRVO patients gained at least 3 lines of BCVA (BRAVO and CRUISE studies). • 12 month data: vision gained at 6 months continued after 6 months of subsequent prn dosage. • From a strictly evidenced‐based perspective, slightly better visual outcomes and huge safety profile, relative to steroids. • Lucentis approved for treatment of macular edema following RVO in June 2010. • Eylea approved for macular edema following CRVO in September 2012 (COPERNICUS and GALILEO trials) • Anti‐VEGF therapy ranks as the preferred first‐line therapy for RVO. Head‐to‐Head Studies in RVO • COMO and COMRADE B – comparing Lucentis with dexamethosone IVT in BRVO patients • COMRADE C – in CRVO patients • RABAMES – comparing Lucentis, argon laser monotherapy, and Lucentis plus adjunctive argon laser therapy in BRVO patients (completed) • BRIGHTER (EUDRACT 2011) – European studies with similar treatment arms Retinal Venous Occlusive Disease: OD Management • Blood pressure measurement • Referral to family physician or internist for management of any underlying cardiovascular disease, hypertension, diabetes • Fundus monitoring (macular edema, neovascularization) every 4‐6 weeks; timely referral to retinal specialist • Patient counseling • Interprofessional communication Retinal Arterial Occlusive Disease • Branch Retinal Artery Occlusion (BRAO) • Central Retinal Artery Occlusion (CRAO) Ocular Disorders in Atherosclerotic Cerebrovascular Disease • Amaurosis fugax • Retinal emboli • Branch Retinal Artery Occlusion (BRAO) • Central Retinal Artery Occlusion (CRAO) • Cental Retinal Vein Occlusion (CRVO) • Ocular Ischemic Syndrome (OIS) Clinical Features of Amaurosis Fugax Incidence: 14/100,000 annually Duration: 1-15 min Onset: dimming or curtain of darkness Total or partial field loss Positive phenomena: flashing lights, shimmering vision, streaks or jagged lines (30%) 2/17/2016 7 Sudden Painless Loss of Vision: What Should You Ask? What activities immediately preceded? One eye or both? Was vision completely lost? Was vision blacked‐out or just blurry? How long did it last? If vision returned, was it suddenly or gradual? Any permanent vision loss? Has this happened before? How often? Any headache after the episode? Any history of migraine? Significance of Amaurosis Fugax A predictor of significant carotid disease and of subsequent TIA, stroke, and retinal infarction: Ipsilateral carotid disease is found in 50-80% Risk of TIA or CVA = 2-6%/year Risk of retinal infarction = 3%/year Retinal Emboli (Branch Retinal Artery) Cholesterol Emboli Yellow-orange Hollenhorstplaques, at bifurcations, often asymptomatic Predict cardiovascular mortality (6%/year), retinal ischemia (3%/year) and stroke (6%/year) Platelet/Fibrin Emboli Arise from heart or proximal-vessel atheromas Gray-white, long, smooth; high rate of occlusion and visual symptoms Calcific Emboli Arise mainly from heart, sometimes proximal lesions White, opaque, frequently symptomatic Branch Retinal Artery Occlusion Symptoms Abrupt, painless loss of visual field Sometimes prior amaurosis fugax Exam Retinal whitening in areas of ischemia/infarct Retinal embolus visible > 2/3 of patients Flame hemorrhages may be present at margin of ischemia BRAO: Pathophysiology and Clinical Features • Embolization or thrombosis of vessel, usually temporal arteries • Edematous, opaque retina due to infarction • Vessel recanalization, permanent field defect CRAO: Pathophysiology and Clinical Features • Arteriosclerosis‐related thrombosis or embolic event at lamina cribosa • Sudden, severe, painless, unilateral loss of vision • Edematous, opaque retina with “cherry red” spot • CRA recanalization, final vision less than 20/400 2/17/2016 8 Central Retinal Artery Occlusion Embolism Carotid, aortic atherosclerosis Cardiac thrombi, valvular sources Inflammation Vasculitis (GCA) Retinal Arterial Occlusive Disease: Therapy • BRAO: no direct ocular therapeutic measures indicated • CRAO: emergency measures advised if < 24 hours duration; reversibility dependent on initial vision and duration of visual loss (100 minutes) CRAO: Emergency Therapy • Anterior chamber paracentesis: topical anesthetic, 25‐guage needle, remove 0.1 ‐ 0.4 cc of aqueous • Ocular massage: digital pressure x 10 seconds, sudden release • Inhalation of Carbogen (95% O2, 5% CO2) • Acetazolamide ‐ 500 mg PO or IV • Intra‐arterial fibrinolysis • Hyberbaric oxygen • Translumenal Nd:YAG Embolectomy (TYE) Retinal Arterial Occlusive Disease: OD Management • Initiate emergency steps for CRAO if same‐day onset • Blood pressure measurement, carotid palpation and auscultation • Referral to family physician or internist to determine cause of embolization or thrombosis; non‐invasive carotid and cardiac studies • Communicate with the retinal specialist Carotid Endarterectomy • North American Symptomatic Carotid Endarterectomy Trial (NASCET) ‐ N Eng J Med 1991; 325 • European Carotid Surgery Trial (ECST) ‐ Lancet 1991; 337 • Asymptomatic Carotid Atherosclerosis Study (ACAS) ‐ JAMA 1995: 273 (18); 1421 • Carotid Revascularization Endarterectomy Versus Stenting Trial (CREST) – Stroke 2011; 227 Retinal Arterial Occlusive Disease: OD Management • In CRAO, immediate erythrocyte sedimentation rate (ESR) and C‐reactive protein (CRP) in patients > 55 if no emboli are seen, to rule out giant cell arteritis (GCA); if GCA suspected, initiate immediate high dose corticosteroids • Patient counseling • Interprofessional communication 2/17/2016 1 Essentials In Cataract Patient Care Maynard Pohl, OD, FAAO Pacific Cataract & Laser Institute 10500 NE 8th Street, Suite 1650 Bellevue, WA 98004 USA 425‐462‐7664 Dr. Maynard Pohl has no financial interests to disclose. Trends In Cataract Care • Aging population • Innovations in surgery: femtosecond laser • IOL technologies: modified prolate, toric, presbyopia‐correcting (accommodative, multifocal), light adjustable • Comanagement issues and guidelines ‐ patient choice • Higher patient expectations for visual outcome • “Standard” Cataract Surgery vs “Custom” Cataract Surgery The Importance of Public Perception • Public perception matters in ophthalmic political issues. • “The public is the newest ally in ophthalmologists’ battle to limit optometric scope of practice.” (Dunbar Hoskins, MD) • Ophthalmologists are in an age of increasing accountability as the public notices and questions ophthalmologists’ relationships with industry. The Importance of Patient Perception • Patients are confused about who is doing eye care and want to know who is doing what to them. • Maintaining patients’ trust is perhaps the most important issue facing both ophthalmologists and optometrists today. Pre‐Operative Cataract Care Special Instrumentation • Glare testing • Contrast acuity testing • Potential acuity testing • Corneal topography • A/B scan • IOL Master, Lens Star • Endothelial cell counts • Pachymetry 2/17/2016 2 When Is A Cataract “Visually Significant”? Refractive Considerations • Astigmatism ‐ in general, pre‐operative and post‐operative corneal astigmatism are similar; consider placement of incision, toric IOL, LVC post‐CE • Anisometropia ‐ 2 D or less difference in the vertical meridian • Discuss target refractive endpoint • Discuss standard vs toric vs presbyopia‐ correcting IOL options Post‐Refractive Effective K Calculations • Historical Method • Contact Lens Method • Computerized Topography Method Small Pupil and Floppy Iris Syndrome • Cardura ‐ doxazosin • Flomax ‐ tamsulosin • Hytrin ‐ terazosin • Minipress ‐ prazosin • Uroxatral ‐ alfuzosin Other Considerations • Pediatric cases • Secondary IOLs • Traumatic cataracts • Subluxated lenses • IOL repositioning • Combined procedures (keratoplasty, glaucoma filtering) 2/17/2016 3 Controversies In Cataract Surgery • Anesthesia: peribulbar, topical • Incision: mini‐scleral tunnel (MSTI), clear corneal (CCI) • Femtosecond laser application • IOL: silicone, acrylic • Drops vs dropless Benefits of Femtosecond Technology • Reproducible accuracy • Rapid innovation of technology & technique • A potential option for interested patients • An opportunity to further develop refractive cataract surgery The Challenge: Providing the Best Visual Outcome • Accurate IOL power calculation • Best IOL material and type • Excellent centration/orientation of IOL – expert surgery • Managing other visual conditions IOL Technologies • Tecnis (AMO) • Staar Toric (Staar Surgical Co.) • AcrySof IQ Toric (Alcon) • Tecnis Toric (AMO) • CrystaLens AO (B&L) • Synchrony (Visiogen Inc.) • ReSTOR (Alcon) • Tecnis Multifocal (AMO) • Light Adjustable Lens (Calhoun Vision) Post‐Operative Cataract Care • Uncomplicated post‐operative course • Early emergent post‐operative complications • Early urgent post‐operative complications • Later post‐operative complications Dysphotopsias 2/17/2016 4 Optic Edge Design • Square Posterior Edge – Limits migration of lens epithelial cells – Less incidence of PCO – Acrylic material: very biocompatible, higher index of refraction, dysphotopsias Early Emergent Post‐Operative Complications Early Emergent Post‐Operative Complications • Severely elevated IOP • Ocular hypotony/wound leak with flat anterior chamber • Endophthalmitis • Vitreous to wound, iris prolapse • Retinal break / detachment • IOL dislocations Early Urgent Post‐Operative Complications Early Urgent Post‐Operative Complications • Elevated IOP (possibly steroid‐induced) • Hyphema • Wound leak with well‐formed AC • Retained lens material ‐ cortical, nuclear • IOL malpositions ‐ decentration Early Urgent Post‐Operative Complications • Diplopia • Ptosis • Corneal edema: epithelial stromal striate 2/17/2016 5 Later Post‐Operative Complications Later Post‐Operative Complications • Cystoid macular edema (pseudophakic CME) • Persistent iritis • Corneal decompensation (pseudophakic bullous keratopathy) • Glaucoma Later Post‐Operative Complications • Diplopia ‐ r/o vascular, mass, myasthenia; consider neurological consult • Ptosis ‐ determine etiology and stability • Retinal detachment Case 1 • S/P: CE/PC IOL OD x 1 day • CC: Vision slightly blurred, mild discomfort • DVA (sc): 20/40 ph 20/25 • TApp: 0 mm Hg (Goldmann) • SLE: – Cornea: 1+ endothelial folds, “waffle” pattern – AC: 75% formed, 1+ cells and 1+ flare – Wound: + Seidel Management of Wound Leak • If AC flat, refer for anterior chamber reformation & wound suture • If AC well‐formed or slightly shallow – Discontinue corticosteroid – Continue antibiotic – Consider topical aqueous suppressant & eyeshield – Consider wound suture at 1 week Ocular Hypotony • Wound leak vs. ciliary body shutdown – Seidel testing to differentiate • Choroidal detachment 20 to choroidal effusion – Typically monitored unless visually threatening or “kissing” choroidals – Resolution as IOP increases – r/o RD 2/17/2016 6 Case 2 • S/P: CE/PC IOL OS x 1 day • CC: Very hazy and fluctuating vision upon awakening • VA(sc): CF @ 3 ft ph NI • TApp: 10 mm Hg (Goldmann) • SLE: See photo • Fundus: red light reflex; difficult view of ONH, vessels, macula Hyphema • Risk factors – Posterior synechiae – Surgical manipulation of iris tissue – Iridectomies – Anticoagulants (e.g. ASA, Coumadin, Plavix) – Iris neovascularization – Fuchs’ heterochromic iridocyclitis • Maintaining anticoagulants prior to surgery usually is supported from a risk‐benefit standpoint. Hyphema Management • Continue antibiotic (1 drop q.i.d.), increase topical steroid (1 drop q 2h) • Antiglaucoma drop prn • Avoid vigorous activity • Sleep with head slightly elevated • Avoid unprescribed anticoagulants • Follow up in 3 – 5 days • Compassionate reassurance Case 3 • Hx: S/P: CE/PC IOL OS x 8 weeks • CC: Blurred central vision over past week in left eye • BCVA: 20/70 SPH: NI • SLE: 1+ PCO, trace cells/flare • Fundus: vitreous/ONH/vessels nl; macular thickening with small yellow spots at fovea Clinical Detection of Macular Edema • Fundus contact vs. non‐contact lens • Thin slit beam • Bright illumination • Narrow angle (10 to 20 degrees) between slit beam and microscope • OCT Cystoid Macular Edema (CME) • Pseudophakic Macular Edema: leakage from perifoveal capillary bed, often in petalloid pattern; disc leakage possible • Diabetic Macular Edema: leakage from microaneurysms, rarely in petalloid pattern; no disc leakage 2/17/2016 7 Pseudophakic CME Management • Monitor – High rate of spontaneous resolution • Pharmacologic therapy – Topical, periocular, intravitreal, oral corticosteroids – NSAIDs • Surgical therapy – Anterior vitrectomy – YAG laser procedure Management of Case 3 • 1% Prednisolone Acetate 1 drop q 4h OD, Acular 1 drop q 4h OD • Tapering of drops after 7 weeks, over next 4 weeks; at 11 weeks BCVA = 20/40 and SPH = 20/25 • YAG posterior capsulotomy 2/17/2016 1 Learn to Comanage the Complex and Unusual Maynard L. Pohl, OD, FAAO Pacific Cataract & Laser Institute 10500 NE 8th Street, Suite 1650 Bellevue, WA 98004 USA 425-462-7664 Dr. Maynard Pohl has no financial interests to disclose. Ocular Surgery Comanagement • Cataract Extraction • Laser Vision Correction • Corneal Transplantation • Pterygiectomy • Glaucoma Filtration Penetrating Keratoplasty (PK): Indications • Visual • Structural • Therapeutic • Cosmetic Considerations in Corneal Transplant Surgery • Timing of surgery: vision may be worse than before surgery for 6 months • Complicating factors: eyelids, dry eye, surface and intraocular inflammation, IOP, previous grafts and incisions Considerations in Corneal Transplant Surgery • Definition of success: better vision, less pain, successful spectacle or CL wear, less glare, quality of life improvement • Meticulous pre, intra, and post-operative care = meticulous comanagement Expected Outcomes • Excellent Prognosis (>90% success) : keratoconus, central or paracentral inactive scars, stromal dystrophies, early central Fuchs’ dystrophy • Good Prognosis (80% – 90% success) : advanced Fuchs’ dystrophy, aphakic and pseudophakic corneal edema and bullous keratopathy, inactive herpetic keratitis 2/17/2016 2 Expected Outcomes • Fair Prognosis (50% – 80% success) : active bacterial keratitis, active herpetic keratitis, active fungal keratitis, mild chemical burns, grafts on young children, moderate keratoconjunctivitis sicca • Poor Prognosis (<50% success) : severe chemical burns, radiation burns, ocular ciccatricial pemphigoid (OCP), neurotrophic disease, congenital glaucoma, anterior cleavage syndromes, multiple graft failures PK: Surgical Techniques • Anesthesia • Corneal trephine - approximate 8.0 mm diameter button removed, 8.25 mm diameter donor Advantages of Suture Adjustment • Decreased early post-op astigmatism • Increased regular corneal topography • Better visual acuity in early post-op period • Quicker visual rehabilitation PK: Postoperative Evaluation Ideal one day post-op: • well-positioned, clear graft • epithelium intact • suture(s) intact • negative Seidel • formed anterior chamber • normal IOP PK: Postoperative Medications • Pred Forte q 2 hrs x 2 weeks, then qid • Fluoroquinolone Ab qid • Artificial tears qid (Celluvisc) • Oral Ab (ciprofloxacin) x 1 week • Eye shield qhs PK: Postoperative Followup • 1 day, 3 days • 1 week, 3 weeks, 5 weeks • 2 months, 3 months • 6 months, 12 months • Annually 2/17/2016 3 PK: Postoperative Complications • Graft rejection – early, late • Endophthalmitis • Glaucoma • Wound leak • Delayed reepithelialization • Refractive surprise Graft Rejection • Symptoms include redness, light sensitivity, decreased vision • Start or increase steroid drops immediately • Examine for confirmation asap • Signs include stromal edema, line of keratic precipitates, uveitis, neovascularization Lamellar Keratoplasty • Techniques to transplant individual layers of the cornea • Superficial • Deep • Anterior • Posterior Why Lamellar Keratoplasty? • Leaves cornea more intact structurally • Addresses only the abnormal layer • Some forms (DSAEK, DMEK) eliminate surface incisions and are sutureless, avoiding suture- related complications and surface irregularities, resulting in faster wound healing, smoother topography, and greater stability • Lower risk of endothelial rejection • Steroid-sparing surgery Lamellar Keratoplasty Terms • Endothelial Techniques – PLK – Posterior Lamellar Keratoplasty – DLEK – Deep Lamellar Endothelial Keratoplasty – DSEK – Descemet’s Stripping Endothelial Keratoplasty – DSAEK – Descemet’s Stripping Automated Endothelial Keratoplasty – DMEK – Descemet’s Membrane Endothelial Keratoplasty • Anterior Stromal Techniques – SALK – Superficial Anterior Lamellar Keratoplasty – DALK – Deep Anterior Lamellar Keratoplasty – BBDALK - Big Bubble Deep Anterior Lamellar Keratoplasty Endothelial Keratoplasty (EK) 2/17/2016 4 DSAEK and DMEK • Eliminates surface incisions and results in faster wound healing, smoother topography, and greater stability • Avoids post-PK surface irregularities • Avoids post-PK suture-related and wound healing complications • The preferred surgical method for corneal endothelial disease DSAEK vs DMEK: Does graft thickness matter? • University of Erlangen, Nuremberg Germany – case series of 38 consecutive DMEK patients and 35 consecutive DSAEK patients for Fuchs’ dystrophy or PBK (2012) • At 3 mo s/p: DMEK – 83% 20/40+, 36% 20/25+ • At 3 mo s/p: DSAEK – 28% 20/40+ • At 6 mo s/p: DMEK – 95% 20/40+, 50% 20/25+ • At 6 mo s/p: DSAEK – 43% 20/40+ • Conclusion: DMEK provides faster and more complete vision rehabilitation by 6 mos, compared to DSAEK. • Longterm: Probably no significant difference in BCVA outcomes between DSAEK and DMEK. Scheimpflug Image + 3D Anterior Chamber Analyzer + Pachymetry Map + Topography Maps (ant. & post.) + Elevation Maps (ant. & post.) + Anterior Chamber Depth Map + Cataract Analyzer + Holladay Report + Tomography = Pentacam Pentacam Anterior Lamellar Keratoplasty (DALK) The Big Bubble Technique Endothelial Cells after FT Penetrating Keratoplasty - Bourne 2001 Castroviejo Lecture -Progressive Biexponential Decay of Endothelial Cell Counts • Months/Years • Pre-Op • 2 Mo • 3 Yr • 10 Yr • 20 Yr • Cell Density %Loss • 2973 • 2467 17% • 1376 53% • 960 67% • 756 77% 2/17/2016 5 Corneal Graft Survival (Cornea. July 2012; 31(6): 621- 626) • PK: 90% at 5 years and progressively diminishes by 10 years and dramatically thereafter • DALK: 99.3% at 10 years (graft failure with irreversible opacity in 3 of 502 cases) • 11% average endothelial cell loss from 6 months to 10 years Comparison of FT with Lamellar • Full Thickness Graft • Advantages – Simple – Long track record – High success rate • Disadvantages – Irregular astigmatism – Unpredictable spherical equivalent – Vulnerable wound – Sutures – Progressive endothelial cell loss • Lamellar Graft • Advantages – Addresses only the abnormal – Less vulnerable wound – Less irregular astigmatism (PLK) – Greater predictability (EK) – Endothelial rejection is impossible (DALK) – Stable endothelial cells (DALK) • Disadvantages – Technically more difficult – Interface haze and irregularity Who is a Good Lamellar Candidate? • DALK – Thinning disorders • Keratoconus • Pellucid marginal degeneration • Terrien’s corneal degeneration – Deep non-perforating corneal scars • Traumatic • Post-infectious • Herpetic with stromal involvement • Shallow RK Patient Education – What are Special Considerations for DALK? • Better longterm endothelial results • More uncertainty of successful lamellar procedure • Patients must know that a possible fallback with DALK is full thickness PK • Must look for double AC – treatment with AC air Who is a Poor Lamellar Candidate? • DALK – Combined stromal and endothelial disease – History of hydrops in keratoconus – Old scars through Descemet’s (deep RK with prior perf) – Complex anterior reconstruction cases – Prior PK • DSAEK / DMEK – Complex anterior reconstruction cases – Phakic patients – Angle closure glaucoma suspects Post-Op Comanagement • DSAEK / DMEK – Look for wound leaks – Early on expect air bubble in the AC – quantify by % – Look carefully for graft separation – Other clues include marked stromal edema – Don’t worry too much about decentration – Look for pupillary block in patients with air bubble in the eye – Expect longterm gradual improvement even with mild interface haze (host cells stimulated by donor cells) 2/17/2016 6 DSAEK / DMEK Edge Slit Lamp Exam DSAEK / DMEK Dislocation Slit Lamp Exam Post-Op Comanagement • DALK – Look for double anterior chamber – Stromal edema may be a clue – Double AC more common with intraoperative Descemet’s rupture – Treatment is AC air injection – similar to detached Descemet’s membrane – Expect longterm gradual improvement even with mild interface haze – Longterm epithelial cell ingrowth is rare Pterygiectomy: Indications • Loss of clarity within visual axis • Increasing corneal astigmatism • Chronic irritation and inflammation • Cosmesis • Motility restriction Pterygiectomy: Surgical Approaches • Bare scleral excision/closure • Conjunctival flap • Conjunctival autograft • Peripheral lamellar keratoplasty • Adjunctive therapy: chemotherapy, radiation therapy • Amniotic membrane Typical Surgical Times • Sutured grafts – 18 minutes to 26 minutes • Fibrin grafts – 6 minutes to 15 minutes 2/17/2016 7 Pterygiectomy: Normal Postoperative Followup • 1 day, 1 week, 3 weeks, 5 weeks, 12 weeks • Patch 1st night • Vicodin ES, #18, 1 or 2 po q 4 hr prn for pain • Ab/steroid drop qid x 1 week Pterygiectomy: Normal Postoperative Followup • Steroid drop qid with taper until quiet • Artificial tears qid (indefinitely) • UV protection (indefinitely) Pterygiectomy: Complications • Recurrence • Subepithelial scarring • Scleral melt (mitomycin-C) • Muscle insertion damage Pterygiectomy: Complications • Graft inversion • Dellen • Steroid complication Trabeculectomy Risk Factors for Glaucoma Progression • Age • Central corneal thickness • Intraocular pressure • Vertical C/D ratio • Pattern Standard Deviation • Disc hemorrhage • OCT measurements of RNFL and GCC 2/17/2016 8 Structure and Function • Structural progression is associated with functional progression in glaucomatous eyes. • Structural and functional progressions are not in perfect agreement. • Both are useful in detecting glaucoma progression. • A combination of structural and functional measurements is the future in managing glaucoma. Practical Considerations in Glaucoma Management • When to start treatment ? • When to change treatment ? • What to use ? • Would you like help putting drops in ? • How to implement: Use nonjudgemental words. Be on the patient’s side. • Comanage with skilled and respectful surgeons. Goals In Patient Treatment • Highest efficacy with lowest side effects at lowest cost • Prevention of blindness during a patient’s lifetime • Patient understanding of the disease • Compliance with treatment Treatment Approaches • Current therapy is directed solely at reducing IOP, despite other possible factors. • If glaucoma is detected, then the IOP is considered to be at a damaging level. • Target IOP: the lower the pre-tx IOP, the lower the target IOP; the greater the ONH and VF damage, the lower the target IOP Treatment Approaches • LTP has been shown to be effective in lowering IOP (Glaucoma Laser Trial). • Filtration surgery is more successful than medical tx in stabilizing ONH and VF changes. • Combined cataract and filtration surgery • Cataract surgery: 70% of eyes will have up to 20% reduction in IOP Treatment Approaches • Targeting other contributing factors such as neuroprotection and optic nerve perfusion (neuroprotective agents, calcium channel blockers) • More “patient friendly” surgical techniques with even higher success rates (> 95 %) continue to evolve; earlier intervention • Increase in selective laser trabeculoplasty (SLT), aqueous drainage devices, MIGS 2/17/2016 9 Laser Therapy In POAG • Thermal Laser Trabeculoplasty (Argon or Diode) - LTP, ALT, SLT 180 vs. 360 degrees early vs. later tx repeat tx with SLT • Cyclophotocoagulation (CPC) – cyclodestructive procedure for endstage cases Filtration Surgery In POAG • Trabeculectomy with chemical manipulation has been the standard of care • Chemical manipulation of wound healing (mitomycin-C, 5-fluorouracil): previous ocular surgery inflammation younger patients Black patients Other Filtration Techniques • Tubes, valves, shunts, stents (aqueous drainage implants): Molteno to Express • Canaloplasty (FDA-approved) – for moderate glaucoma • Trabectome (FDA-approved) – long term results poor • MIGS (Micro-Invasive Glaucoma Surgery): iStent (FDA-approved), Hydrus, CyPass, Aquecentesis, Gold-Micro Shunt - for milder glaucoma and combined with cataract surgery (> 20% IOP reduction) Trabeculectomy Postop Care • The ideal postoperative outcome is low IOP, a deep anterior chamber, and a well-functioning bleb. • Evaluate at day 1, at day 2 or 3, at week 1, and weekly until week 6, or until relatively stable. • Consider suturelysis or suture removal at 1 to 4 weeks. • Consider ocular massage after suture removal. • Antibiotic drop x 1 week, corticosteroid drop x 12 weeks (with slow taper). • Once stable, continued regular monitoring of IOP, VF, and ONH, maintaining an ideal target IOP, reinstating antiglaucoma meds prn. Trabeculectomy Postop Evaluation • IOP • Anterior chamber depth • Nature of the filtering bleb IOP • Immediately after surgery IOP may be low, medium , or high; typically low (0 to 8 mm Hg); higher with combined CE/Trabeculectomy. • Eventual ideal IOP is 10, but may range 8 to 15. • With persisting low IOP, consider overfiltration, wound leak, or ciliary body shutdown. • With moderate or high IOP, consider bleb failure: tight sutures if early, encapsulated bleb if later. • If higher IOP and a well-functioning bleb, consider a steroid response. 2/17/2016 10 Anterior Chamber Depth • Immediately after surgery, a shallow anterior chamber in 10 to 20 % of cases, resolving spontaneously within the first week. • Shallow anterior chamber = ocular hypotony • Ocular hypotony = overfiltration or wound leak or ciliary body shutdown • Consider pressure patching x 2 to 3 days prior to suturing of a wound leak. • Monitor choroidal detachment. Nature of the Filtering Bleb • The ideal bleb is diffuse, moderately- elevated, microcystic…and functions well. • Most blebs are comfortable regardless of shape or size. • With an early poorly-formed bleb, consider wound leak, tight scleral flap sutures, hyposecretion of aqueous, or scarring tendency. • With a well-formed bleb and high IOP, consider an encapsulated bleb vs a steroid response. Take Home Message to Patients • Immediately report any excessive pain, unusual redness, discharge, or blurred vision at any time following filtering surgery and immediately direct patient management to either the comanagement center or glaucoma specialist. 2/17/2016 1 What’s New In Corneal Transplant Surgery? Maynard L. Pohl, OD, FAAO Pacific Cataract & Laser Institute 10500 NE 8th Street, Suite 1650 Bellevue, WA 98004 USA 425‐462‐7664 Dr. Maynard Pohl has no financial interests to disclose. Corneal Disease • Fourth leading cause of global blindness…after cataract, glaucoma, AMD • 10 million affected through infectious and inflammatory eye diseases with scarring and loss of best‐corrected vision • Keratoconus, pseudophakicbullous keratopathy, Fuchs’ dystrophy are main indications for corneal transplantation in Western world • Asia and Africa have higher prevalence of infectious keratitis, corneal scars, late‐stage endothelial disease, allograft rejection Corneal Transplant Procedures • Standard full penetrating keratoplasty (PK) • Endothelial keratoplasty (EK) • Deep anterior lamellar keratoplasty (DALK) • Keratoprostheses New Techniques In Corneal Surgery • Stem cell transplants: autograft allograft tissue culture • Femtosecond lasers • Corneal inlays • Lamellar keratoplasties: posterior, anterior • Collagen Cross‐Linking (CXL) • Intacs – keratoconus, ectasia • Keratoprostheses • Biosynthetic corneas (cross‐linked recombinant human collagen) Future Promise In Stem Cell Research • Best type of cell to transplant (autologous limbal stem cell biopsy from contralateral eye) • Best method to transfer cultured cells to eye surface (fibrin disc) • Measures to decrease risk of rejection (immunosuppressive therapies) Femtosecond Lasers • Specialized donor or recipient tissue preparation for PK or EK (DSAEK, DMEK) • Lamellar dissections for DALK • AK, LRI • Corneal tunnels for Intacs • Corneal pockets for corneal inlays 2/17/2016 2 Femtosecond Lasers • Laser cataract surgery: corneal incisions, anterior capsulotomy, lens fragmentation • Intrastromal pockets for riboflavin in collagen crosslinking • Femtosecond lenticule extraction (FLEx) • Small incision lenticule extraction (SMILE) • Intrastromal correction for presbyopia (IntraCor) Applications of the Femtosecond Laser • Ability to create specially‐shaped tissue • Works by creating small vaporized pockets (cavitation bubbles) precisely and contiguously placed at desired depths and positions, resulting in tissue resection • Short‐duration pulses at 1053 nm • Femtosecond = 10‐15 sec Corneal Inlays • Corneal inlay technologies • Kamra (FDA‐approved, 2015): preoperative care intraoperative care postoperative care Lamellar Keratoplasty • Techniques to transplant individual layers of the cornea • Superficial • Deep • Anterior • Posterior Why Lamellar Keratoplasty? • Leaves cornea more intact structurally • Addresses only the abnormal layer • Some forms (DSAEK, DMEK) eliminate surface incisions and are sutureless, avoiding suture‐related complications and surface irregularities, resulting in faster wound healing, smoother topography, and greater stability • Lower risk of endothelial rejection • Steroid‐sparing surgery Lamellar Keratoplasty Terms • Endothelial Techniques – PLK – Posterior Lamellar Keratoplasty – DLEK – Deep Lamellar Endothelial Keratoplasty – DSEK – Descemet’s Stripping Endothelial Keratoplasty – DSAEK – Descemet’s Stripping Automated Endothelial Keratoplasty – DMEK – Descemet’s Membrane Endothelial Keratoplasty • Anterior Stromal Techniques – SALK – Superficial Anterior Lamellar Keratoplasty – DALK – Deep Anterior Lamellar Keratoplasty – BBDALK ‐ Big Bubble Deep Anterior Lamellar Keratoplasty 2/17/2016 3 Endothelial Keratoplasty (EK) DSAEK and DMEK • Eliminates surface incisions and results in faster wound healing, smoother topography, and greater stability • Avoids post‐PK surface irregularities • Avoids post‐PK suture‐related and wound healing complications • The preferred surgical method for corneal endothelial disease DSAEK vs DMEK: Does graft thickness matter? • University of Erlangen, Nuremberg Germany – case series of 38 consecutive DMEK patients and 35 consecutive DSAEK patients for Fuchs’ dystrophy or PBK (2012) • At 3 mo s/p: DMEK – 83% 20/40+, 36% 20/25+ • At 3 mo s/p: DSAEK – 28% 20/40+ • At 6 mo s/p: DMEK – 95% 20/40+, 50% 20/25+ • At 6 mo s/p: DSAEK – 43% 20/40+ • Conclusion: DMEK provides faster and more complete vision rehabilitation by 6 mos, compared to DSAEK. • Longterm: Probably no significant difference in BCVA outcomes between DSAEK and DMEK. Scheimpflug Image + 3D Anterior Chamber Analyzer + Pachymetry Map + Topography Maps (ant. & post.) + Elevation Maps (ant. & post.) + Anterior Chamber Depth Map + Cataract Analyzer + Holladay Report + Tomography = Pentacam Pentacam Anterior Lamellar Keratoplasty (DALK) The Big Bubble Technique 2/17/2016 4 Endothelial Cells after FT Penetrating Keratoplasty ‐ Bourne 2001 Castroviejo Lecture ‐Progressive Biexponential Decay of Endothelial Cell Counts • Months/Years • Pre‐Op • 2 Mo • 3 Yr • 10 Yr • 20 Yr • Cell Density %Loss • 2973 • 2467 17% • 1376 53% • 960 67% • 756 77% Corneal Graft Survival (Cornea. July 2012; 31(6): 621‐626) • PK: 90% at 5 years and progressively diminishes by 10 years and dramatically thereafter • DALK: 99.3% at 10 years (graft failure with irreversible opacity in 3 of 502 cases) • 11% average endothelial cell loss from 6 months to 10 years Comparison of FT with Lamellar • Full Thickness Graft • Advantages – Simple – Long track record – High success rate • Disadvantages – Irregular astigmatism – Unpredictable spherical equivalent – Vulnerable wound – Sutures – Progressive endothelial cell loss • Lamellar Graft • Advantages – Addresses only the abnormal – Less vulnerable wound – Less irregular astigmatism (PLK) – Greater predictability (EK) – Endothelial rejection is impossible (DALK) – Stable endothelial cells (DALK) • Disadvantages – Technically more difficult – Interface haze and irregularity Who is a Good Lamellar Candidate? • DALK – Thinning disorders • Keratoconus • Pellucid marginal degeneration • Terrien’s corneal degeneration – Deep non‐perforating corneal scars • Traumatic • Post‐infectious • Herpetic with stromal involvement • Shallow RK Patient Education – What are Special Considerations for DALK? • Better longterm endothelial results • More uncertainty of successful lamellar procedure • Patients must know that a possible fallback with DALK is full thickness PK • Must look for double AC – treatment with AC air Who is a Poor Lamellar Candidate? • DALK – Combined stromal and endothelial disease – History of hydrops in keratoconus – Old scars through Descemet’s (deep RK with prior perf) – Complex anterior reconstruction cases – Prior PK • DSAEK / DMEK – Complex anterior reconstruction cases – Phakic patients – Angle closure glaucoma suspects 2/17/2016 5 Post‐Op Comanagement • DSAEK / DMEK – Look for wound leaks – Early on expect air bubble in the AC – quantify by % – Look carefully for graft separation – Other clues include marked stromal edema – Don’t worry too much about decentration – Look for pupillary block in patients with air bubble in the eye – Expect longterm gradual improvement even with mild interface haze (host cells stimulated by donor cells) DSAEK / DMEK Edge Slit Lamp Exam DSAEK / DMEK Dislocation Slit Lamp Exam Post‐Op Comanagement • DALK – Look for double anterior chamber – Stromal edema may be a clue – Double AC more common with intraoperative Descemet’s rupture – Treatment is AC air injection – similar to detached Descemet’s membrane – Expect longterm gradual improvement even with mild interface haze – Longterm epithelial cell ingrowth is rare Treatments for Corneal Degeneration • Intacs • Collagen Cross‐Linking (CXL) Collagen Crosslinking (CXL) • Covalent bonding: photosensitizer riboflavin (vitamin B2) + ultraviolet A light (370 nm) = oxygen‐free radicals and biomechanically strengthening (stiffening) of collagen fibrils • CXL stops the disorder of keratectasia • Earliest intervention at earliest detection • CXL “normalizes” the corneal shape, flattens Ks, reduces total aberrations, improves VA • What is the best strategy for patient’s overall vision? 2/17/2016 6 Keratoprostheses • AlphaCor • Boston Keratoprosthesis (Type I, Type II) • Osteo‐Odonto Keratoprosthesis (OOKP) AlphaCor • Artificial Cornea – Porous periphery and central optical element in a one‐piece hydrogel implant – First implanted 1998 (Australia), FDA‐ approved 2003 – Two‐stage surgery – Complex procedure and aftercare, risk of inflammation and stromal melt The AlphaCor Procedure • Gunderson conjunctival flap • Superior to inferior limbal lamellar dissection • 3 mm trephination of central posterior cornea • Placement, centration, and suturing of keratoprosthesis into surgical bed • Central flap excised “opening the window” to underlying implant Boston Keratoprosthesis • One‐stage procedure utilizing donor cornea • PMMA optic and back plate with donor tissue clamped in between, then sutured into trephined host similar to PK • FDA‐clearance in 1992 • Design and therapeutic management much improved since, 1100 cases in 2009 • Two graft rejections and high likelihood of recurrence are indications Boston Keratoprosthesis • Postop care – Must wear continuous wear soft contact lens – Lifelong vancomycin to prevent infection – Close followup with surgeon – Not ideal comanagement cases The Ideal Keratoprosthesis • Inert and not rejected by immune system • Quick to implant • Maintain longterm clarity • Easy to examine and allow excellent view of retina • Inexpensive – Irregular astigmatism – Unpredictable spherical equivalent – Vulnerable wound – Sutures – Progressive endothelial cell loss • Lamellar Graft • Advantages – Addresses only the abnormal – Less vulnerable wound – Less irregular astigmatism (PLK) – Greater predictability (EK) – Endothelial rejection is impossible (DALK) – Stable endothelial cells (DALK) • Disadvantages – Technically more difficult – Interface haze and irregularity Who is a Good Lamellar Candidate? • DALK – Thinning disorders • Keratoconus • Pellucid marginal degeneration • Terrien’s corneal degeneration – Deep non‐perforating corneal scars • Traumatic • Post‐infectious • Herpetic with stromal involvement • Shallow RK Patient Education – What are Special Considerations for DALK? • Better longterm endothelial results • More uncertainty of successful lamellar procedure • Patients must know that a possible fallback with DALK is full thickness PK • Must look for double AC – treatment with AC air Who is a Poor Lamellar Candidate? • DALK – Combined stromal and endothelial disease – History of hydrops in keratoconus – Old scars through Descemet’s (deep RK with prior perf) – Complex anterior reconstruction cases – Prior PK • DSAEK / DMEK – Complex anterior reconstruction cases – Phakic patients – Angle closure glaucoma suspects 2/17/2016 5 Post‐Op Comanagement • DSAEK / DMEK – Look for wound leaks – Early on expect air bubble in the AC – quantify by % – Look carefully for graft separation – Other clues include marked stromal edema – Don’t worry too much about decentration – Look for pupillary block in patients with air bubble in the eye – Expect longterm gradual improvement even with mild interface haze (host cells stimulated by donor cells) DSAEK / DMEK Edge Slit Lamp Exam DSAEK / DMEK Dislocation Slit Lamp Exam Post‐Op Comanagement • DALK – Look for double anterior chamber – Stromal edema may be a clue – Double AC more common with intraoperative Descemet’s rupture – Treatment is AC air injection – similar to detached Descemet’s membrane – Expect longterm gradual improvement even with mild interface haze – Longterm epithelial cell ingrowth is rare Treatments for Corneal Degeneration • Intacs • Collagen Cross‐Linking (CXL) Collagen Crosslinking (CXL) • Covalent bonding: photosensitizer riboflavin (vitamin B2) + ultraviolet A light (370 nm) = oxygen‐free radicals and biomechanically strengthening (stiffening) of collagen fibrils • CXL stops the disorder of keratectasia • Earliest intervention at earliest detection • CXL “normalizes” the corneal shape, flattens Ks, reduces total aberrations, improves VA • What is the best strategy for patient’s overall vision? 2/17/2016 6 Keratoprostheses • AlphaCor • Boston Keratoprosthesis (Type I, Type II) • Osteo‐Odonto Keratoprosthesis (OOKP) AlphaCor • Artificial Cornea – Porous periphery and central optical element in a one‐piece hydrogel implant – First implanted 1998 (Australia), FDA‐ approved 2003 – Two‐stage surgery – Complex procedure and aftercare, risk of inflammation and stromal melt The AlphaCor Procedure • Gunderson conjunctival flap • Superior to inferior limbal lamellar dissection • 3 mm trephination of central posterior cornea • Placement, centration, and suturing of keratoprosthesis into surgical bed • Central flap excised “opening the window” to underlying implant Boston Keratoprosthesis • One‐stage procedure utilizing donor cornea • PMMA optic and back plate with donor tissue clamped in between, then sutured into trephined host similar to PK • FDA‐clearance in 1992 • Design and therapeutic management much improved since, 1100 cases in 2009 • Two graft rejections and high likelihood of recurrence are indications Boston Keratoprosthesis • Postop care – Must wear con