Eye Disorders I Flashcards
Functions of the lens
• The lens can adapt and change shape (accommodation) in order to change the direction of a light wave (refraction).
This allows us to focus on an image.
• As we get older (usually starting in our 40s), our ability to have our lens change shape weakens.
• This causes us to need reading glasses as we can’t focus on close objects.
• We completely lose this ability when we are about 55-60.
• Then lens also blocks harmful ultraviolet (UV) light from entering the eye
attached to zonules which attach to ciliary bodies
Dry Eye Disease
•Dry eye disease is an multifactorial, inflammatory
disease involving the entire lacrimal
functioning unit.
inflamm involved, dk if it causes it or is caused by dry eye
• Management of the condition mostly focuses on
replenishing the deficient tear layer.
• May not necessarily treat the cause of the inflammation
Components of tears:
- Lipid: Slows down evaporation of tears secreted by Meibomian glands
- Aqueous: Supplies moisture; aka watery component, secreted by lacrimal gland
- Mucin: Coats the eye to allow the aqueous layer to stick to a water repellent cornea
Pathophysiology:
Aqueous-Deficient Dry Eye
Refers to not producing enough aqueous or mucin.
- Type 1: Sjogren syndrome
- Autoimmune disease that involves damage to goblet cells that are involved in tear production (mucin).
- Type 2: Non-Sjogren syndrome
- Primary or Secondary lacrimal gland deficiencies
- Obstruction of lacrimal ducts
- Reflex hyposecretion
Pathophysiology:
Evaporative Dry Eye (EDE)
• Characterized by a high level of tear evaporation
- External
- Environmental Factors
- High temperature or low humidity
- Certain exposures to sun, dust and wind.
• Internal
• Meibomian gland dysfunction
• Chronic inflammation that leads to squamous debris, gland obstruction and
changes in glandular section.
- Intrinsic
- Conditions that affect closing of eyelids or decreased blinking.
• Other Risk Factors
• Thyroid dysfunction, laser eye surgery, medications (oral contraceptives), excessive
digital/screen time
Aqueous or Evaporative Dry Eye: Symptoms
Aqueous and Evaporative dry eye are not separate entities and they
are believed to exist on a continuum.
- The tricky thing is patients may have:
- Symptoms but no physical signs on the eye
- Signs on the eye but no symptoms
- Stinging/ gritty/ scratchy eyes
- Fluctuating vision (intermittent blur)
- Burning or feeling of a foreign body in the eye
- Severe cases: Blurry vision, light sensitivity, excess tear production.
- Over time can lead to inflammation/redness around the eyes
- History/Onset:
- Can develop over days, months or years.
- Sometimes patients get used to the symptoms so symptoms “go away
Management: Non-Pharmacologic
- Education on environmental management
• Using a humidifier or adjusting temperature at home. (winter time due to hea)
• Blinking exercises - Reassessing systemic medications
- Warm Compress
• Using a warm cloth, place over eyelids for 5-10 minutes.
• Patient must keep rewetting cloth; a better solution is a Bruder Mask that stays hot for 10 minutes.
(need to be warmed longer for movement in eyes) - Other: lipiflow, radiofrequency, intense pulse light
Management: Pharmacologic
Artificial Tears
• So many on the market, preferences based on clinician and samples available.
• Preservative containing versus Preservative free.
• Look at the four categories to determine equivalencies between drops.
• Cost
• Viscosity
• Demulcents
• Emollients
Preservative Containing Drops
• The preservative prevents bacterial growth.
• Most common and the cheapest.
mutidose vials, exposed to environment
Preservative Free Minums
• They are usually in vials called minums.
•Can be expensive ($$$)
•Generally recommended if patient requires
frequent drop use (ie. After eye surgery) (more than 4x.day)
one use only
Management: Pharmacologic
• Cost (more important)
- Viscosity agent (more important)
- Determines length of action
- Lower viscosity (Short acting, eye drops)
- Higher viscosity (Long acting, gels and ointments)
- Demulcents (less important)
- Protect and lubricates mucous membranes, relieves dryness.
- Emollients (less important)
- Protect and soften tissues, prevents drying and cracking
Artificial Tears
- Viscosity
- Lower: Eye drops
- Good for all day use.
- Does not disrupt vision after use.
- Needs to be used at an increased frequency.
• Higher: Gels and Ointments
• Better for use at night time or before bed.
• Blurry vision after use.
• Longer lasting type of tear
don’t use with contact lens, smears on lens
Systane Ultra vs Systane Balance vs Systane complete
key diff:
ultra: just aqeious layer (demulcent)
balance: has a lipid component too
Commonly Recommended Gels and
Ointments
• Liposic • Lacrilube • Systane gel ointment • Refresh PM give to pt who sleep with eyes open to shield cornea from drying out
Management: Prescription Medications
• Topical (Ophthalmic) corticosteroids:
- Examples:
- Lotemax/Alrex (Loteprednol 0.5%)
- FML (Fluorometholone 0.1%)
• Mechanism of Action:
• Anti-inflammatory corticosteroid. Inhibits inflammatory processes
and mediators of inflammation.
• *Dose and length of therapy is dependent on the diagnosis and
steroid chosen–> commonly tapered but not always
- Adverse Effects: Blurred vision, photophobia, burning/stinging
- Length of Therapy: 14 – 28 days
- Onset of Effect: Generally would expect benefit within a week
NSAIDS do not work for DED, rsiks of integrity of cornea
Management: Prescription Medications
• Restasis (Cyclosporine 1% ophthalmic solution)
• Mechanism of Action:
• Exact action unclear
• Increases goblet cell density -> increase mucin, allows tear film to bind
• Thought that it is a partial immunomodulator in patients whose tear production is
suppressed due to ocular inflammation.
- Ophthalmic Dose: 1 drop into each eye twice daily
- Adverse Effects: Burning eyes
- Length of Therapy: Lifelong
- Onset of Effect: Expect benefit in 12 weeks (90 days to get better, give steroid concurrently to bridge)
some ppl use twice before throwing
Management: Prescription Medications
• Xiidra (lifitegrast 5% ophthalmic solution)
- Mechanism of Action:
- Exact mechanism is unknown
- Blocks key inflammatory markers
- Ophthalmic Dose: 1 drop into each eye twice daily
- Adverse Effects: Dysgeusia (altered taste), blurred vision, irritation/burning eyes
- Length of Therapy: Lifelong
- Onset of Effect: Some patients may experience improvement in symptoms as early as 2 weeks but can be up to 12 weeks.
Conjunctivitis
Allergic, Bacterial and Viral
• Refers to inflammation to the conjunctiva.
• Can be caused by allergies, viral and/or bacterial infections
wraps around scleara and eyelid
skin thats red not eyeball
• Hypersensitivity reaction to allergens
• Seasonal
• Allergens such as pollen from trees, grass, weeds and flowers.
• Timing usually is in spring/summer/fall, depends what allergen the patient is
sensitive to.
• Perennial
• Allergen from dust, pets (eg. Dander from cats)
• Can happen all year round.
Symptoms of conjuctivitis
- Usually itchy, irritated and red eyes
- Often accompanied with nasal congestion or sneezing.
- Sometimes swollen eyelid
- Never ocular pain or light sensitivity.
- Generally you will see BOTH eyes affected.
Management: Non-Pharmacologic
• Avoid allergens • Cold compresses • Avoid rubbing of the eyes • Minimize contact lens wear • Artificial Tears • Rationale: Helps moves/flush allergens out of the eye and reduces the inflammatory response.
Management: Pharmacologic
• Antihistamine/Decongestant
• Example: Pheniramine/naphazoline (Naphcon A
low systemic ffect, might be ok for HTN
plug lacrimal duct to lower syst abs
Mechanism of Action:
• Block histamine receptors and provides faster relief than oral
antihistamines.
• Constrict blood vessels to reduce redness.
• Ophthalmic Dose: 1-2 drops up to 4 times per day (freq use)
• Adverse Effects: Can cause eye irritation or burning, contraindicated in patients with angle-closure glaucoma, if used for extended time can cause rebound redness.
• Length of Therapy: Used as needed
• Onset of Action: Symptoms will start to improve within the day
rebound effect after use for a long time
Management: Pharmacologic
• Mast cell stabilizers
• Example: Cromolyn
• Mechanism of Action:
• Prevents the mast cells from releasing contents that leads to a inflammation
response.
• Ophthalmic Dose: 1-2 drops up to 4 times per day
• Adverse Effects: Can cause eye or burning.
• Length of Therapy: Used as needed
• Onset of Action: 3-5 days before any relief
Management: Pharmacologic
• Combination Mast Cell Stabilizer/Antihistamine
• Example: Olopatadine (Patanol 1%, Pataday 2%, Pazeo 7%)
• Example: Bepotasine (Bepreve) 1.5%
more common
• Mechanism of Action:
• Block histamine receptors and stabilizes mast cells.
• Ophthalmic Dose: 1 drops once (Pataday, Pazeo) or twice a day
(Patanol, Bepreve)
• Adverse Effects: Can cause eye irritation if used too long
• Length of Therapy: Used as needed
• Onset of Action: Symptoms will start to improve within the day
What is the most common organism that
causes red eyes (conjunctivitis)?
- A) Bacteria
- B) Virus
- C) Fungus
- D) Anerobes
B viral
- Bacterial:
- Direct contact with contaminated surfaces causing an alteration in bacterial flora on the ocular surface.
- Viral:
- Most commonly caused by adenoviruses spread by respiratory droplets, or coming in contact with the eyes by fingers.
- COVID-19: This virus can also cause viral conjunctivitis!
Risk Factors of conjunc
• Certain occupations ( ie: Patient working in the hospital, working at a
day care, works with children, etc)
• Contact lens wearers
• History of Herpes (simplex or zoster)
Symptoms/Presentation: Bacterial Infections of conj
• Ocular redness (one or both eyes)
• Usually not itchy, just uncomfortable.
• No history of a cold/ sinus problems
• Yellow discharge with crusts in the morning, sticky eyelids
• Papillae/ follicles on lid inversion.
papillae not folliciles for bacterial inf
no central vessel
Symptoms/Presentation:
Viral Infections of conj
• Eye redness (one or both eyes) • Usually not itchy • Patient is getting over a cold/ has a cold • Watery eyes • Papillae/follicles upon lid inversion. clear, no discharge
Which of the following infections will self
resolve on its own?
• A) Bacterial conjunctivitis
• B) Viral Conjunctivitis
• C) Both; bacterial and viral
• D) Neither; both require antibacterials or antivirals
• C) Both; bacterial and viral
Management of Bacterial Conjunctivitis:
Pharmacologic
• Topical (Ophthalmic) Antibiotics
speed up recovery
- Polymyxin B (Polysporin)
- Tobramycin
- Moxifloxacin (Vigamox)
• Dose: Dependent on the antibiotic, generally used 3-4x/day
• Adverse Effects: Based on agent used, but range from well tolerated to blurry vision/irritation
• Length of Therapy: 7 – 10 days
• Length of Disease w/o Therapy: 14 days
contagious until 24 hours of taking abx
Management of Bacterial Conjunctivitis:
Pharmacologic
• Fusidic Acid 1% (Fucithalmic) Eye drops
• Commonly prescribed by family physicians.
• Not a great antibiotic to use for bacterial conjunctivitis
• Organisms develop resistance readily.
• Therefore educate patient to see optometrist if conjunctivitis does not improve in the next 1-2 days.
could adapt?
Management of Viral Conjunctivitis:
Pharmacologic
- Cool compresses & Artificial Tears
- Corticosteroids (For symptomatic relief) - increase viral replication, feels better
- Length of Disease with or without therapy: 14 –
21 days
• Severe Cases: Betadine (povidone-iodine) wash in
office.
Keratitis
• Refers to inflammation to the cornea most commonly due to
bacterial or viral causes.
• Pathophysiology and Risk Factors
• Similar as bacterial/viral conjunctivitis except inflammation involves the cornea.
• Key: Refer if your patient is sensitive to light; if the eye is painful; or there
is a foreign body sensation.
Keratitis
Management: Pharmacologic
Bacterial Keratitis:
• Topical (Ophthalmic) Antibiotics
• Fluoroquinolone eye drops Q1H
• Examples: besifloxacin, moxifloxacin, gatifloxacin
• Viral Keratitis (specially: Herpes Simplex & Zoster):
• If HSV: Topical Trifluridine 1% (Viroptic) 8x/day
• Can see topical corticosteroids or oral antivirals as well.
• In some situations, topical corticosteroids should not be used
