6.1.11. Understands the treatment of a range of common ocular conditions Flashcards
Indicators Demonstrates a basic understanding of the treatment regimens of cataract, AMD, glaucoma, diabetic eye disease and minor anterior eye problems Can discuss the treatment options for two of the above condition
Dry eye disease
DEWS - Dry eye is a multifactorial disease of the ocular surface characterised by a loss of homeostasis of the tear film, and accompanied by ocular symptoms, in which tear film instability and hyperosmolarity, ocular surface inflammation and damage, and neurosensory abnormalities play aetiological roles.
Education and environmental/dietary modifications e.g.
Omega 3 (veg/nuts) & omega 6 (fish)
Avoid air conditioning
Stop smoking
Lowering VDU height, reduce screen time, blink more
Lid therapy – blepharitis management
Tear supplements - 3-4x daily/often as needed if preservative free
- Carbomer gel (usually 0.2%) - common first line in formalities and is used to increase tear film thickness, e.g. clinitas eye gel
- Hypromellose - mild dry eye, usually 0.3%, used more frequently (every 30mins till symptoms resolve then less freq)
- Sodium hyaluronate - tear replacement to increase viscosity and provide lubrication e.g. hycosan (original blue 0.1%, extra red 0.2%) – ADDE
- Lipid based drops to replace/enhance lipid layer to prevent evaporation of the aqueous layer in EDE e.g. Systane balance
- Combo drops e.g. thealoz duo (SH & trehalose) EDDE
Others
Blephex – in office lid hygiene
Steroids if severe inflammation e.g. FML
Antibiotics if severe blepharitis
Punctal plugs – improve retention in ADDE
Therapeutic CL for protection
Blepharitis
- Posterior - dry warm compress 10 minutes twice daily, eyelid bag >40 degrees to melt meibum
- Anterior - wet warm compress to loosen collarettes and crusts for anterior bleph
- Lid massage (mixed/posterior) – melt the meibum and encourage blockage out
- Lid cleansing to remove deposits and bacteria from lid margin - gel e.g. TTO/blephasol or wipes e.g. Blephademodex/blephaclean
- Avoid cosmetics directly on lid margin
- Once symptoms resolve can reduce measures to minimum of twice weekly
- Other options
- Chloramphenicol ointment bds, rubbing onto lid margin with finger
- Demodex if over 70 and/or CD
- Weekly in office treatments with 50% TTO to kill mites
- Nightly treatment with 5% TTO/products with terpinene-4-ol to prevent mating/migration
Initial management followed by referral if three months of treatment does not produce sufficient response
Allergic Conjunctivitis: SAC & PAC
Avoid allergen, cold compress, avoid eye rubbing to prevent degranulation of mast cells
Ocular lubricants to be used 3-4x daily for symptomatic relief i.e. viscotears
- Topical AH to relieve itching i.e. antazoline sulphate 0.5% tds
- Topical MCS i.e. sodium cromoglicate 2% qds
- Oral antihistamine i.e. loratadine od
Allergic Conjunctivitis: VKC
Cold compress when acute
Ocular lubricants symptomatic relief ^
Topical MCS e.g. sodium cromo 2% qds
Refer to HES urgently if active limbal or corneal involvement
Allergic Conjunctivitis: AKC
Cold compress
Lid hygiene for associated blepharitis
Avoid known allergens
Local pharmacy for loratadine od
Topical MCS i.e. sodium cromo 2% qds
Urgent referral if active limbal or corneal involvement
Allergic Conjunctivitis: Acute allergic
Most resolve spontaneously within a few hours
Avoid eye rubbing
Cool compress for symptomatic relief
Identify allergen and avoid future contact
Ocular lubrication for symptomatic relief
If recurrent, prophylactic topical MCS e.g. sodium cromo 2% as POM
Bacterial conjunctivitis
- Self-limiting 5-7 days without treatment
- Bathe eyelids with cooled boiled water
- Advice on contagious nature of condition
- Topical antibiotic may improve short-term outcome:
Drops 0.5%, dose: - 1 drop every 2 hours for 48 hours
- Then, every 4 hours during waking hours
- Eye drops may be supplemented with ointment at night
- Treatment course should last 5 days
- Ointment 1% dose
- qds for 2 days
- bds for 5 days
- CL wearer – quinolone i.e. levofloxacin (PoM)
Viral conjunctivitis
Self-limiting 1-2 weeks
Cold compress
Generally caused by adenovirus
Anti-viral agents are generally ineffective
Artificial tears may relieve symptoms
Sub conjunctival haemorrhage
Refer for BP check if necessary
Reassurance, condition usually clears within 5-10 days
Cold compress may reduce discomfort
Ocular lubrication if irritation is present
Episcleritis
Self-limiting in 7-10days
Cold compress
If severe discomfort, ocular lubricants for 1-2wks
PoM if IP if px is particularly symptomatic e.g. FML
Corneal abrasion
Rule out multiple parts, incl. double lid eversion
Loose FBs irrigated with saline
FB on conjunctiva removed with sterile cotton bud
Assess depth & carry out seidel test
Remove FB under topical anaesthetic
Topical antibiotic, chloramphenicol 0.5% 4x daily for 5 days if likelihood of infection
CL wearer – quinolone
Hordeolum
- External (stye) – associated gland of zeiss/moll - tender inflamed swelling of lid margin, may point anteriorly through skin
- Internal – acute bacterial infection of MG - tender inflamed swelling within tarsal plate – more painful than a stye, may point anteriorly through skin or posteriorly through conj
- Most resolve spontaneously or discharge, following by resolution in case of external
- Hot compress
- AB ointment in case of copious mucopurulent discharge – chloramphenicol 1% tds for 1 week (fusidic acid if allergic/bf/pregnant)
- Rare – refer routinely for incision in cases than do not discharge (more common in internal)
Chalazion
- Most result on conservative management – hot compress, lid massage (B2 – no referral)
- Regular lid hygiene for bleph – most likely posterior
- Routine refer if: persistent, recurrent, causing significant astigmatism, cosmetically unacceptable
Cataract: Referral
If cataract significantly reducing vision/affecting px’s quality of life – routine referral via SCI gateway after discussing with the patient
Glasgow & great Clyde – all two stop
- Assessment of VA, biometry & keratometry
- Surgery separate day
Ayrshire – one or two stop
- Two stop if more complicated px i.e. general anaesthetic, iris clamps etc
- One stop – patient counselling is very important
Cataract Surgery – explaining to a px
One eye at a time
Outpatient – day case
Local anaesthetic only
Need to lie flat 15-20 minutes and face partially covered with a sheet
Explaining Cataract : Procedure
Phacoemulsification is the current technique which uses ultrasound technology
Corneal incision is made, the top of the capsule is removed (capsulorrhexis), phaco of the lens nucleus where lens is broke down into small pieces and removed, irrigation and aspiration, insertion of IOL into capsular bag
Monofocals and torics are available on NHS
Explaining cataract surgery: Risks
95% straightforward operation
1 in 50 have some complication i.e. disappointing = not as good as we hopes
1 in 100 more serious complication resulting in a poor outcome
1 in 1000 will have a very serious complication (blind eye)
1 in 10,000 devastating complication (loss of the eye)
AMD: Dry
- No treatment available - prophylaxis only
- Address risk factors – first you would advise to modify = smoking
- Other risk factors to address: dietary/alcohol
- Encourage diet rich in leafy greens / omega 3 & omega 6/fatty acids
- Diet rich in vitamin C and E
AMD: treatments
Antioxidants
• Antioxidants to reduce free radical damage by giving an electron to a free radical to prevent the chain reaction and stop them from causing damage
• Carotenoids = antioxidant
• Macushield
- Contains 3 carotenoids including zeaxanthin
Optihealth
- Contains lutein and zeaxanthin
- Vitamin A
• Manganese also helps protect against free radicals
• Some evidence that Vitamin A supplements should not be given to smokers as it may increase the risk of lung cancer
•Amsler to monitor progression from dry to wet
• Low vision aids if necessary
• Glasgow and great Clyde guidance
- AMD/VA/amsler stable no referral
- Reduced VA/amsler distortion – routine
AMD: Wet treatment
Wet AMD fast-track referral on SCI gateway (1-2 weeks)
Anti-VEGF
• Most commonly used treatment
• Avoids the proliferation of new & unhealthy blood vessels
• Visual prognosis
- 25% cases VA improves
- 90% VA remains stable
• Ranibizumab (lucentis) – approved by NHS Scotland & NICE - £742
- Initial loading dose, 3 or more consecutive monthly injections
- Maintenance injections usually 1 or 2 months, for as long as necessary
- Effective for all lesion types
• New drug – Brolucizumab (Beovu) – now approved by NHS Scotland & NCE, can increase time between appointments to 12 weeks – minimize treatment burden for patients
Other treatments
• Laser photocoagulation – few cases suitable, not usually justified
• More historical than used now - Photodynamic treatment to occlude new blood vessels in CNV
Diabetic retinopathy: When to refer
No referral - Background retinopathy (R1 – R2)
- Microaneurysms, dot/blot haemorrhages
- Exudates >2DD from fovea
Routine - Pre-proliferative – exudates within 2DD of macula (R3 / M1)
- Cotton wool spots, venous beading, IRMA, deep retinal haemorrhages
- Exudates < 2DD of macula
Urgent - Proliferative DR and maculopathy (R4 / M2)
- Retinal neovascularising within disc diameter and/or new vessels elsewhere
- Exudates <1DD from fovea
Emergency referral
- Pre-retinal haemorrhage
- Sudden vision drop <6/24
Diabetic retinopathy: If not referring & observing only
GP visit to ensure DM under control
Ensure diabetic screening is attended at appropriate time, should be annually if any sign of DR
Ophthalmologist management of DR
- Pre-proliferative – depends how bad bleeds are
- PRP - Pan retinal photocoagulation
- 2-4000 laser burns
- Reduces VEGF by lessening the amount of retina that needs oxygen by killing off peripheral cells
- Results in scar tissue which stops blood spreading to the macula
- Anti-VEGF agents can arrest or reserve proliferative retinopathy and macular oedema e.g. intravitreal ranibizumab (Lucentis®), less destructive than PRP
- Intravitreal corticosteroids: used widely to treat macular oedema, modest improvement of VA, long-acting steroid implants may be used
- Vitrectomy: may be useful if advanced, e.g. vitreous haemorrhage
Glaucoma: Referral
- Routine referral based on SIGN guidelines via SCI gateway to glaucoma specialist
- Optic disc signs consistent with glaucoma in either eye
- Optic disc NFL haemorrhage – irrespective of other signs
- Reproduceable visual field defect
- Risk of angle closure (VH G1 or less)
- IOP >25mmHg, irrespective of CCT
- IOP 21-25mmHg, CCT <555 ages 65 of younger
- OCT? GChart thinning = earliest indicator
- Emergency referral IOP >40mmHg
POAG
Target IOP – IOP that is expected to confer optic nerve stability in px with glaucoma based on glaucoma damage, life expectancy, untreated IOP reading, additional risk factors & rate of progression
Topical hypotensives:
Prostaglandin analogue e.g. Latanoprost (Xalatan)
- Increase uveoscleral outflow by ciliary muscle relaxation
- 30-35% IOP reduction
- Main ADRs: iris hyperpigmentation & eyelash changes
Beta-blocker e.g. timolol,
- Decrease aqueous production
- 25-30% IOP reuction
Increase risk of systemic side effects e.g. systemic hypotension, exacerbation of asthma, heart failure
Do not give to: - asthmatics/COPD/heart issues
- already on beta-blocker for hbp; this will already have a IOP lowering effect, if still high then topical beta-blocker may not have much of an effect as it works in the same mechanism
Carbonic anhydrase inhibitor e.g. brizonolamide (azopt)
Decrease aqueous production
18% IOP reduction
Alpha 2 agonist e.g. brimonidine tartrate (alphagan)
Decrease production & increase outflow
25% IOP reduction
Other options for reducing iop
Other options
Selective laser trabeculoplasty – likely 1st choice if hypotensives don’t work
MIGS – minimally invasive glaucoma surgery i.e. iStent
Bypass the trabecular meshwork to drain aqueous
Trabeculectomy – surgical procedure
Ahmed vale
NTG: management
Similar to POAG
Despite ‘normal tension’ – this level of IOP is still too high for px, even if IOP is 18mmHg the px’s baseline may be 10mmHg
PACG: Management
- Pilocarpine (cholinergic agonist) qds
Increases trabecular outflow - Side effect of long-term use = severe headaches
- Systemic acetazolamide (carbonic anhydrase inhibitor) Reduces aqueous production
- YAG iridotomy if narrow/closed angles
