6.1.11: Understands tx of common ocular conditions

Question 1

What is the treatment of cataract?

Answer 1

• Clear corneal incision: inicision on cornea to not damage ciliary body. Can tie thread round EOMs to hold eye still
• Capsulorhexis: want to preserve lens capsule & not burst it, just want to remove nucleaus so put new IOL in
• Phacoemulsification: hoover & chopper - ultrasound to suck capsule out. Use viscous gel to keep lens bag open
• Irrigation & aspiration: bag can collapse when nucleaus removed so they use lots of fluid to keep it open
• Insertion of IOL: usually no sutures as keyhole surgery
  Post-Op drops:
• antibiotic - 1 wk
• anti-inflammatory - take for 4 wks - expect cells & flare straight after surg
• px sees optom in 6weeks

Question 2

How do you describe cataract surgery in layman’s terms?

Answer 2

• Repeat tests at hospital & take measure of eye (biometry)
• Quick procedure: 15-20mins, day procedure, awake, lying down
• Put numbing drops in eyes so won’t feel anything
• They will ask you to stare straight up to ceiling
• They will break up lens in your eye and replace it with clear plastic lens to your Rx
• Will be given drops to use after to prevent infections
• After surgery your distance vision will be corrected but you will still need reading glasses
• Cataract surgery is a very successful surgery & carries a high success rate however as with any surgery there are risk. Some risks include your vision not being made better by the cataract surgery or getting an infection in your eye following the surgery

Question 3

When would you refer someone for cataract surgery?

Answer 3

• driving standard: car 6/12, HGV 6/7.5
• glare
• impact on px’s life
• decrease contrast sensitivity

Question 4

Describe the treatment for wet AMD? How do you say it in layman’s?

Answer 4

• anti-VEGF injections: Ranibizumab (Lucentis), Afilbercept (Eylea)
• course of 3 injections
• review/monitoring period
• may require further injections - so long as it is working whilst monitoring their OCT & NaFl angiography
• Discharge based on: how stable condition is OR if tx will bring any further benefits to px

Laymans: injections to stop growth of abnormal BVs. Aims to try and prevent further vision loss.

Referral: only refer active wet AMD

Question 5

Describe the treatment for dry AMD?

Answer 5

• no tx available
• advise on:
  o smoking cessation
  o control of systemic conditions
  o diet rich in antioxidants, omega 3, dark leafy greens - spinach, kale, brocolli
  Smoking causes: increase oxidative stress, slows down choroidal blood flow, promotes ischaemia, macular pigment reduction. Most important modifiable RF.
• advise to take supplements:
  o benefit moderate AMD in BEs or advances in one eye
  o should say AREDS on it
  o no proof it delays onset - taking as precaution does not help
  o e.g.s iCaps, Macushield
  o contain: lutein, zeaxanthin, vit C, vit E, zinc oxide, copper oxide
  o Vit E & beta-carotene associated with increased risk of lung cancer in smokers
• Advise healthy lifestyle, physical activity & healthy diet
• Educate about sxs, self-monitoring & progression: check Amsler 2-3x a week, SVN - RE then LE, report new sxs

Question 6

Describe treatment of advance dry AMD?

Answer 6

• referral to low vision services/social services to help around house & access to low vision aids
• charity support e.g. macular society, visibility scotland
• RNIB
• make px aware of risk of falls - get help at home if possible

Question 7

Describe 1st line treatment of POAG?

Answer 7

• 1st line NICE guidance is Selective Laser Trabeculoplasty (SLT):
  o laser applied to drainage angle which helps unclog the trab meshwork. Aqueous humour can then drain more easily through the channels, bringing down IOP.
  o Q-switched frequency-doubled Nd:YAG laser

Question 8

Describe the drops treatments for POAG?

Answer 8

• Prostaglandin Analogues e.g. Bimatoprost. Increases uveoscleral outflow (& some conventional trab outflow). Decreases IOP 25-35%. Once a night. Side effects: conj redness, periocular pigmentation, increased eyelash growth.
• Beta Blockers e.g. timolol. Decreases aqueous production by blocking sympathetic pathways of ciliary epithelium. Decreases IOP 20-25%. Contraindication: asthma, chronic pulmonary conditions, heart conditions. Causes dry eye.

Combo drop: Ganfort (bimatoprost & timolol)

• Carbonic anhydrase inhibitors e.g. Brinzolomide, Dorzolomide. Decreases aqueuous production by inhibiting enzyme carbonic anhydrase which is found within ciliary epithelium. Side effects: transient blurred vision, eye irritation, eye pain, FB sensation, Hyperaemia
• Alpha agonist e.g. brimonidine, apraclonidine. Decreases aqueous production & increases uveoscleral outflow. Decreases IOP about 20-25%. Usually combined with other drops. High rate of allergy to brimonidine. Causes follicular conjunctivitis. Contraindications: MAOI antidepressants (increased risk of hypotension), severe cardiac disease

Question 9

What are the other glaucoma surgeries?

Answer 9

• Trabculectomy: helps drain fluid out of eye and into a small blister (a bleb) under conjunctiva. Operation creates trap door fo fluid to pass through, bypassinng normal drainage channel. Drainage of aqueous improved & this reduces IOP. Awake, local anaesthetic, 1-2hours
• iStent (MIGS): one mm tube inserted into drainage channel. Made of titanium. 2 or 3 istents. Aims of bypass blockages in drainage channel & improve flow of lfuid out eye, decreases IOP.
• Ab-interno canaloplasty w/ iTrack (MIGS): canaloplasty cleans out drainage channel. Ab-interno - drainage channel accessed from front of eye in front of pupil during surgery. iTrack: tube inserted into drainage channel. Gel injected through catheter (tube), opening up drainage channel & breaks any blockages. Flow of fluid increases, decreases IOP.

Question 10

What is the treatment for closed angle glaucoma?

Answer 10

• iridotomy: Nd: YAG laser used to create another drainage hole to decrease IOP and increase flow of aqueous. Under top lid to avoud creating another pupil.

Question 11

What is the treatment of diabetic retinopathy? PRP, Anti-VEGF, intravitreal corticosteroids, Vitrectomy

Answer 11

• Lifestyle advice, get DM under control, co-manage w/ GP
• Make sure under diabetic screening
• Refer to ophthalmology if R3 (advanced background retinopathy), R4 (proliferative retinopathy), M2 (severe maculopathy)

Pan-retinal photocoagulation (PRP): visible light laser. Use contact lens to focus on retina - promotes more O2 to region to prevent new BVs. Goal is to minimise amount of scarring lasar scar will leave. Can result in choroidal infusions, mac oedema, VF defects, night vision defects, exudative retinal detachment

Anti-VEGF injections: can arrest, or even reverse, proliferative retinopathy & mac oedema. Less destructive than laser. e.g. intravitreal ranibizumab (lucentis)

Intravitreal corticosteroids: widely used to treat mac oedema, modest increase of VA possible - unlikely to go back to 100%. Long-acting steroid implants may be used. e.g. Ozurdex (dexamethasone)

Vitrectomy: e.g. vitreous haemorrhage - proliferative DR when new BVs (fragile) burst - or vitreomacular traction. Surgical removal of vitreous. New BVs grow from retina into vitreous & can pull on vitreous - can result in tractional retinal detachment or retinal tear. May get more floaters.

Question 12

What is the treatment for blepharitis?

Answer 12

• warm compress to loosen crusts and melt meibum to express and wipe away
• heated eye mask
• eyelid massage to express glands
• lid hygiene using lid wipe - like removing makeup. 30 seconds per eye. Tea tree oil for demodex
• lubricants to replace tears
• BlephEx: in practice lid hygiene
• Advice on chronic nature, compliance, long term, no results short term

Question 13

What is the treatment for evaporative dry eye?

Answer 13

• environmental modifications e.g. air conditioning/cigarette smoke. Sunglasses on windy days
• lower VDU height
• increased blinking
• regular VDU breaks
• omega 3 - veg, nuts, cereal
• omega 6 - fish e.g. salmon, tuna
• gels:
  carbomer (pharmacy 1st) e.g. viscotears - good retention time, harder to get in, blurry when in
• drops:
  o sodium hyaluronate e.g. Hycosan - good for aqueous
  o HP-guar e.g. Systane Ultra - good for evaporative - has preservative in it
• Ointments:
  o Hycosan night: use at night as blurs vision
  o common main ingredient is paraffin
  o may also contain lanolin (wool fat) common allergy
• Evotears - lipid based drops - good for evaporative to replace lipid layer

Question 14

What is the treatment for aqueous dry eye?

Answer 14

• Sjogrens vs non-sjogren’s (post-menopausal, female, pregnant, HRT, oral contraceptive)
• Drops: sodium hyaluronate e.g. Hycosan - good for aqueous

Question 15

What are other dry eye treatments?

Answer 15

• punctal plugs
• FML
• azithromycin - 500mg once a day for 5 days - IP, antibiotic
• Topical ciclosporin - Ikervis - 1 drop at night - review 6/12
• Topical autologous serum - px’s blood as eyedrops
• Acetylsysteine e.g. iLube for filamentary dry eye (mucous strands) - v. stingy px’s hate it.
• Tetracycline - e.g. doxycycline 100mg once a day for 3 months - 2nd line tx for dry eye associated with posterior bleph. Photosensitivity.

Question 16

What is the treatment for bacterial conjunctivitis?

Answer 16

• advise self-limiting 5-7days
• cool compress
• keep area clean
• advise of contagious nature: don’t share towels, pillows, don’t wear makeup
• if lots of discharge: 0.5% or 1% chloramphenicol:
  o 0.5% drops: 1 drop every 2hrs for 48hrs then every 4 hours during waking hrs. Course should last 5 days even if healed.
  o 1& ointment: Small amount in 4x a day for 2 days, 2x a day for 5 days
  o 1% fusidic acid (child/preg/BF): 2 x a day, continue at least 48hrs after eye returned to normal

Question 17

What is the treatment for viral conjunctivitis?

Answer 17

• Self-limiting - 7 days to 14 days
• Highly contagious for family, friends, colleagues
• Cold compress and lubricants for sx relief
• Stop CL wear

Question 18

What is the treamtent for Allergic Conjunctivitis?

Answer 18

• identify and avoid allergen
• cool compress for sx relief
• avoid eye rubbing (makes it worse)
• loratadine (clarityn) or ceterizine (zirtek) - non-sedating systemic antihistamines
• sodium cromoglicate (mast cell stabiliser) e.g. Opticrom (GSL) or Optrex Allergy (P med). Takes 14 days to work - start taking before pollen season.
  GSL: SAC only, 4x a day, >6yrs old
  P med: SAC & PAC, 4x a day, can use <6 yrs
  Olopatidine (IP - Topical antihistamine) - IP only e.g. opatanol: for SAC or off-licence PAC, CLAPC, acute allergic conjunctivitis, 2x daily for up to 4 months. Instantaneous relief - within few hours.

Question 19

What is the treatment for episcleritis?

Answer 19

• self-limiting 7-10 days
• reassure px
• cold compress
• return if sx persist
• refrigerate artificial tears
• if persists past 1 wk consider FML 1.0% (IP only)
• if persists 1-2 wks or 3rd episode - refer for systemic investigation

Question 20

What is the treatment for subconjunctival haemorrhage?

Answer 20

• self-limiting 1-2wks
• reassure px
• cold compress
• return if sx persist
• lubricants
• blood all over eye: refer for BP check or may be due to blood thinner e.g. warfarin
• traumatic: check for fractuer - proptosis, motility, pupils, VAs decreased

Question 21

What is the treatment for Corneal abrasion?

Answer 21

• assess size, depth, edge using NaFl, check AC
• evert lids
• ocular lubricants for sx relief - advise to finish bottle to help avoud erosion
• review in 48 hours
• chloramphenicol 1% ointment for prophylaxis if deep/dirty - IP only
• stop CL wear
• if contaminated or suspect infection - emergency (same day) referral to ophthalmology