TMOD Flashcards
Acute External or Internal Hordeolum
TX: WC with lid massage
Blepharitis/ draining:
Bacitracin 500 u/g or Erythromycin ung 0.5% BID for 1-2 weeks
Recurrent:
Doxy 100 mg for 1-2 weeks, then reduce the dose
(CI in kids/pregnancy)
If worried about PC/OC
1. Keflex 500 mg BID for 1-2 weeks
2. Augmentin 875/125 mg BID for 1-2 weeks
3. Bactrim 160/800 mg DS BID for 1-2 weeks (CI in pregnancy)
FU: as needed or within 1 week
Chalazion and Reccurent Chalazion
Firs line TX: WC with lid massage
Second line TX: Steroid injection
- Numbing injection of 0.6 cc 2% lidocaine/epinephrine followed by 0.2-1% of triamcinolone 40 mg/mL
Blepharitis/ draining:
Bacitracin 500 u/g or Erythromycin ung 0.5% BID for 1-2 weeks
Doxy 100 mg for 1-2 weeks, then reduce the dose
(CI in kids/pregnancy)
Consider referral to OMD for incision and curettage if chronic
FU as needed or within 1 week
Lid Myokymia
Remove causative agents: stress, lack of sleep, excess caffeine, alcohol.
Consider referral to oculoplastics for botulinum toxin if it persists chronically.
FU: as needed if the condition persists chronically after removing the causative agent
Canaliculitis
If PP is retained, refer to oculoplastics for canaliculotomy.
BACTERIAL:
Polytrim 10,000 units/mL or Moxifloxacin 0.5% QID
& oral antibiotic for 1-2 weeks
FUNGAL:
Nystatin 1:20,000 drops TID, Irrigation several times per week
or Natamycin 5% drops TID
VIRAL: Consider Viroptic 5x/day
If HSV
- Acyclovir 400 mg PO 5x/day for 7-10 days
- Valacyclovir 500 mg PO TID for 7-10 days
- Famcyclovir 250 mg PO TID for 7-10 days
If VZV double the doses for HSV
FU: 5-7 days
Dacryocystitis
K (SW):
Augmentin 25-45 mg/kg/day PO BID or
Cefpodoxime 10 mg/kg/day PO BID
K (SU): Hospitalize for IV cefuroxime
A (SW)
Keflex 500 mg PO QID
Augmentin 875/125 mg PO BID
A (SU): Hospitalize for IV cefazolin 1g TID
In chronic cases, consider referral to oculoplastics or ENT for dacryocystorhinostomy.
FU: Daily until improvement confirmed; hospitalize if worsening
Dacryoadentitis
Treat empirically with oral antibiotics for 24 hours if specific etiology is unclear.
INFLAMMATORY: Medrol Dosepak (21, 4 mg tabs)
VIRAL: CC and acetaminophen as needed
BACTERIAL: Augmentin 875/125 mg BID or Keflex 500 mg BID
Severe: Hospitalize and treat as OC
FU: Daily until improvement confirmed; hospitalize if worsening
Nasolacrimal Duct Obstruction (NLDO)
Digital pressure massage to lacrimal sac QID
Discharge: Moxifloxacin 0.5% QID or Polytrim 10,000 u/mL
If not resolved in 6 months to 1 year, refer to oculoplastics for
- probing
- ballon dacryoplasty
- silicone tubing
- dacryocystorhinostomy
FU: 3 months unless there is increased discharge or worsening symptoms
Contact Dermatitis
Avoid offending agent and CC several times daily
PFAT 4-6 times daily
Consider topical olopatadine 0.1% BID
Fluorometholone steroid ung 0.1% to periocular are BID x 5 days
Oral diphenhydramine 25-50 mg PO TID-QID
FU: 5 days to monitor for resolution
Cutaneous HSV
0.5% erythromycin ung BID for skin lesions
If HSV
A 400 mg 5x/day for 7-10 days
V 500 mg TID for 7-10 days
F 250 mg TID for 7-10 days
** AVOID F in patients with HIV/AIDS due to risk of TTP
FU every 2 days until improvement then weekly thereafter
Recurrent Corneal Erosion
Cyclopentolate 1% TID for pain
Erythromycin 0.5% ung QID for prophylaxis
5% NaCl (Muro 128) ung QID
LARGE EPI defect: BCL and Moxifloxacin 0.5% QID
Continue Muro 128 and PFAT longterm
NONRESPONSIVE:
- Oral Doxycycline 50 mg BID
- Extended BCL wear
- Anterior stromal puncture if outside VA
- Epithelial debridement
- phototherapeutic keratectomy
FU every 1-2 days until epithelium is healed then every 1-3 months
Band Keratopathy
PFAT prn
SEVERE: refer to corneal specialist for chelation with disodium ethylenediamine tetraacetic acid (EDTA)
Residual anterior stromal scarring may be helped by phototherapeutic keratectomy.
FU: every 2-3 days if chelation is performed, monitor every 3-12 months
Keratitis Sicca/MGD/ Sjogrnes Syndrome
PFAT
Lifestyle modifications
Cyclosporine 0.05% BID
Liftegrast (Xiidra) 5% BID
Loteprednol 0.5% BID when starting cyclosporine or liftegrast
Consider PP, autologous serum tears, topical vitamin A
Remove corneal filaments with proparacine, forceps, and acetylcysteine 10% QID
Oral omega-3 fatty acids
Consider BCL or scleral lenses for intractable cases
FU: days to months, depending on severity
EBMD
AD
5% NaCl ung QHS
RCEs = BCL & Moxifloxicn 0.5% QID
Long term management: Doxy 50 mg po BID
Freshkote BID (increases oncotic pressure gradient of TF)
Consider anterior stromal puncture, cautery, epi debridement, phototherapeutic keratectomy, and amniotic membrane if recalcitrant
FU: 3-12 months depending on symptoms
Central Crystalline Corneal Dystrophy (Schnyder)
Stroma (AD)
Order fasting serum cholesterol and triglyceride levels
Rarely complicates vision
FU 12 months
Granular Corneal Dystrophy
Stroma (AD) - hyaline deposits (Masson Trichrome)
Spares periphery
Monitor
TX (if necessary): phototherapeutic keratectomy or corneal transplant
FU: 12 months
May recur after surgery
Lattice Corneal Dystrophy
Stroma (AD) - amyloid deposits (Masson Trichrome)
Spares periphery
Monitor
TX (if necessary): phototherapeutic keratectomy or corneal transplant
FU: 12 months
May recur after surgery
Macular Corneal Dystrophy
Stroma (AR) - mucopolysaccharide deposits
Does NOT spare the periphery
Monitor
TX (if necessary): phototherapeutic keratectomy or corneal transplant
FU: 12 months
May recur after surgery
Meesman Corneal Dystrophy
Epithelial microcysts (AD)
Monitor
TX (if necessary): phototherapeutic keratectomy
FU: 12 months
May recur after surgery
Reis-Bucklers Corneal Dystrophy
Bowman’s (AD)
Monitor
TX (if necessary): phototherapeutic keratectomy, superficial lamellar keratectomy, or corneal transplant
FU: 12 months
May recur after surgery
Fuchs Endothelial Dystrophy
Endothelium (AD)
5% NaCl drops QID with ung QHS
Treat increased IOP with aqueous suppressants
Ruptured bullae should be treated as RCE
Surgical intervention: DMEK, DSEK, DWEK, full thickness PKP
FU: 3-12 months to check IOP and assess corneal edema and symptoms
Preseptal Cellulitis
K:
Augmentin 25-45 mg/kg/day BID PO OR
Bactrim 8-12/40-60 mg/kg/day BID PO
A:
Augmentin 875/125 mg BID PO OR
Bactrim 160/800 mg BID PO
SEVERE: hospitalize for IV vancomycin 0.5-1.0g IV BID
PLUS ampicillin/sulbactam 3g IV QID for adults
FU: daily until clear and consistent improvement is demonstrated then every 2-7 days until resolution
If progression, hospitalize, CT scan of head and orbits, and switch to IV antibiotics
Orbital Cellulitis
Admit to hospital with consult with ID and ENT
Broad-spectrum IV antibiotics for 48-72 hours with oral antibiotics to follow
Ampicillin-sulbactam 3g IV QID for adults
If MRSA is suspected: Vancomycin 15 mg/kg QD-BID for adults
Ceftriaxone 2g IV QD and metronidazole 500 mg IV TID-QID
** add if MRSA is suspected but allergy to penicillin
Moxifloxacin 400 mg IV QD and metronidazole 500 mg IV TID-QID
** add if MRSA is suspected but allergy to penicillin and cephalosporins
FU: 2x daily in the hospital for the first 48 hours, clinical improvement may take 1-2 days
PRK - delayed epi healing with diabetes
Moxifloxacin 0.5% QID
Cyclopentolate 1% BID if traumatic iritis
Debride loose or hanging epithelium
If not a CL wearer, consider BCL
FU: daily until resolving, then every 2-3 days until resolved
LASIK - epi sloughing
Continue ocular antibiotics and steroids as prescribed by the surgeon
Moxi 0.5% QID and prednisolone acetate 1% QID
Consider BCL
FU: 1 day if BCL placed
LASIK - flap slip
Frequent AT
Send back to the surgeon to reposition the flap, consider suture
FU is urgent surgical repositioning then see as directed by surgeon
LASIK - diffuse lamellar keratitis (dlk)
Prednisolone acetate 1% q1h
If severe, it may require lifting the flap and irrigation of the interface
FU: daily until improvement noted
LASIK - epi ingrowth with or without flap melt
Treat if >2mm inside of flap and easily noted on SLE
Surgical debridement if dense, flap melt, approaching VA or affecting vision
Small pockets may be treated with YAG laser
FU is weekly for 1 month to determine stability
** If stable and low grade, see yearly
LASIK - decentered ablation
Offer scleral or RGP contact lens fit
Consider referral back to surgeon if patient is interested in enhancement
FU weekly for 1 month to determine stability, if stable and low grade, see yearly
LASIK-induced corneal ectasia
Offer scleral or hybrid contact lens fit
Consider referral to corneal specialist for corneal cross-linking, INTACS, penetrating keratoplasty
FU for scleral lens fit, then every 3-6 months
CE - Keratitis
Treat as dry eye unless reactivation of HSK is suspected
Frequent AT
Bruder mask
Cyclosporine 0.05% BID or lifitegrast 5% BID if persistent
Consider autologous serum tears or amniotic membrane if nonhealing
if HSK suspected
400 mg A 5x daily for 7-10 days
500 mg V 3x daily for 7-10 days
250 mg F 3x daily for 7-10 days - do not prescribe to patients with HIV AIDs due to TTP risk
Ganciclovir 0.15% 5x daily for 7-10 days
Trifluridine 1% 9x daily for 7-10 days
FU is routine for cataract surgery (1d,1w,1m, 3m) unless HSK is suspected then see back in 2-7 days to monitor tx response
CE - bullous keratopathy
5% NaCl QID with ung QHS
Reduce IOP if needed with aqueous suppressants
Erythromycin 0.5% ung BID and cyclopentolate 1 % TID for painful ruptured bullae
Consdier BCL, anterior stromal micropuncture
PKP/DMEK/DSEK if advanced
FU every 1-3 days until improvement is noted, then every 5-7 days until healed
CE - IOL displacement (subluxation or dislocation)
Mild subluxation: monitor with dilated exams
If symptomatic or significantly displaced/dislocated: refer back to surgeon for repositioning or alternate procedure (ACIOL, pars plana lensectomy, leave aphakic)
FU at the recommendation of OMD, worsening symptoms or 1 year
CE - endophthalmitis
IV vancomycin 1mg/0.1 mL OR ceftazidime 2mg/0.1 mL
INTENSIVE prednisolone acetate 1% q1h
INTENSIVE fortified antibiotic options
- cefazolin 50 mg/mL
- ceftazidime 50 mg/mL
- tobramycin 15 mg/mL
- vancomycin 25 mg/mL
Atropine 1% QID
Consider hospitalization for observation
FU as directed by OMD, see every 12-24 hours early, pt should show improvement by 48 hours
** if subacute consider fungal
- IV amphotericin B 10 mcg/0.1 mL
- IV voriconazole 100 mcg/0.1 mL
** if fungal is confirmed start natamycin 5% q1h
Dellen
frequent viscous AT (genteal gel) q2h with ung at night (genteal pm)
consider patching or BCL if not a CL wearer
consider surgical excision of pterygium/ping if that is the cause
FU in 1-7 days if thinning is not too severe and low-risk of perforation
ocular cicatrical pemphigoid (OCP)
PFAT 4-10 times daily with ung (genteal pm) QHS
Blepharitis: erythromycin 0.5% BID-TID
Immunosuppressive agents may be used for progressive SD
Consider surgical correction of entropion
Consider cryotherapy for trichiasis
Mucous membrane grafts may be used for reconstruction of fornices
FU every 1-2 weeks during acute phase and every 1-6 months during remissions
Keratoglobus
Best correct with specs, poly lenses medically necessary
HYDROPS: 5% NaCl and ung at night, 1% cyclopentolate TID, erythromycin 0.5% ung BID
PKP results are suboptimal, generally not recommended
FU every 6 months unless acute hydrops develop, then every 1-4 weeks
Keratoconus
Avoid eye rubbing
Best correct with glasses or SCL in mild cases
Consider sceral or RGP in severe cases
Corneal transplant, INTACS, and corneal cross-linking may be helpful
HYDROPS: 5% NaCl and ung at night, 1% cyclopentolate TID, erythromycin 0.5% ung BID
FU every 3-6 months depending on the severity unless acute hydrops develop, then every 1-4 weeks
Epidemic Keratoconjunctivitis (EKC)
** Adenovirus subgroup D serotypes 8,19,37
Patient education: condition will get worse for 4-7 days then recover in 2-3 weeks
Highly contagious for 2 weeks or if eyes are red and tearing
Avoid touching eyes, shaking hands, sharing towels, and restrict work/school
PFAT every 2 hours, cool compresses, antihistamine drops if itching/severe
Peel any pseudomembranes that form
*** If pseudomembranes or SEIs are present, initiate loteprednol 0.5% QID then taper
FU is in 2-3 weeks but sooner if condition worsens or steroids prescribed
Hemorrhagic conjunctivitis
Enterovirus 70, coxsackie virus A24, adenovirus serotype 11
Highly contagious for 2 weeks or if eyes are red and tearing
Avoid touching eyes, shaking hands, sharing towels, and restrict work/school
PFAT every 2 hours, cool compresses, antihistamine drops if itching/severe
Peel any pseudomembranes that form
*** If pseudomembranes or SEIs are present, initiate loteprednol 0.5% QID then taper
FU is in 2-3 weeks but sooner if condition worsens or steroids prescribed
Pharyngoconjunctival fever
Adenovirus subgroup D of serotypes 3 and 7
Highly contagious for 2 weeks or if eyes are red and tearing
Avoid touching eyes, shaking hands, sharing towels, and restrict work/school
PFAT every 2 hours, cool compresses, antihistamine drops if itching/severe
Peel any pseudomembranes that form
*** If pseudomembranes or SEIs are present, initiate loteprednol 0.5% QID then taper
FU is in 2-3 weeks but sooner if condition worsens or steroids prescribed
Noninfectious corneal infiltrate
Blepharitis: 0.5% erythromycin ung BID
WC, lid hygiene, moxifloxacin 0.5% QID, loteprednol 0.5% QID
RECURRENT or RESISTANT add doxycycline
100 mg BID x 2 weeks
then 100 mg QD x 1 month
then 50 mg QD until the disease is well-controlled
FU 2-7 days depending on s/s
Monitor IOP on steriods
Do NOT use steroids without antibiotic coverage
Do NOT taper antibiotics
Staphylococcal blepharitis with marginal ulcer and chronic meibomianitis
Blepharitis: 0.5% erythromycin ung BID
WC, lid hygiene, moxifloxacin 0.5% QID, loteprednol 0.5% QID
RECURRENT or RESISTANT add doxycycline
100 mg BID x 2 weeks
then 100 mg QD x 1 month
then 50 mg QD until the disease is well-controlled
FU 2-7 days depending on s/s
Monitor IOP on steriods
Do NOT use steroids without antibiotic coverage
Do NOT taper antibiotics
Superior limbic keratoconjunctivitis
Order thyroid function tests
MILD: aggressive PFAT with ung at night
Consider punctal occlusion
Treat blepharitis with 0.5% erythromycin ung BID
Consider cyclosporine 0.05% BID OU
MODERATE/SEVERE:
topical tacrolimus 0.03% ung BID
acetylcysteine 10% TID for filaments
loteprednol 0.5% for exacerbations
0.5% silver nitrate solution on cotton-tipped applicator for 10-20 seconds on superior bulbar conjunctiva followed by irrigation, then erythromycin ung BID x 1 week
doxycycline
100 mg BID x 2 weeks
then 100 mg QD x 1 month
then 50 mg QD until the disease is well-controlled
if still symptomatic, refer to oculoplastics for conjunctival cautery, cryotherapy, conjunctival resection
FU every 2-4 weeks during exacerbations
Thygesons SPK
MILD: aggressive PFAT with ung at night
SEVERE: loteprednol 0.5% or FML 0.1% QID for 4 weeks with slow taper
Cyclosporine 0.05% BID may be used as an alternative or adjunct therapy (BCL if necessary)
FU weekly during exacerbation, then every 3-6 months
Vernal keratoconjunctivitis
Prophylactic use of antihistamine/MCS combo for2-3 weeks before allergies
BEZPOP
Shield ulcer treated with polytrim 10,000/mL QID or erythromycin 0.5% ung QID and cyclopentolate 1% TID
Consider cyclosporin 0.05% BID if no response to other treatment
Cool compresses
If atopic dermatitis to the eyelids, consider tacrolimus 0.03-0.01% ung BID to skin
FU daily in the presence of a shield ulcer or every 2-3 weeks during exacerbation
Cataracts (ALL)
Refer to cataract surgeon if symptoms warrant or obstructing view of the posterior pole
Best correct vision with glasses
Acanthamoeba Keratitis
Consider in CL wearer and non-responsive HSK
Stain: calcofluor white with KOH wet mount
Culture: non-nutrient agar with ecoli overlay
TX
1. poly hexamethyl biguanide 0.02% q1h
OR chlorhexidine 0.02% q1h
2. propamidine isethionate 0.1 % q1h
3. oral itraconazole 400 mg (one loading dose) then 200 mg daily
Discontinue CL wear
PAIN: Cyclopentolate 1% TID or oral naproxen 500 mg BID
Delay corneal transplant by 6-12 months after treatment due to risk of recurrence
FU daily until consistent improvement, then every 1-3 weeks
Treat until no inflammation for 3 months
Fungal keratitis
consider in vegetative trauma, poor response to antibiotics, indolent onset
Stain: calcofluor white with KPH wet mount
Culture: sabouraud (acidic pH inhibits bacterial growth)
TX
Filamentous fungi: Natamycin 5% q1h around clock
Candida: Amphotericin B 0.15% q1h around clock
oral itraconazole 400 mg (one loading dose) then 200 mg daily
cyclopentolate 1% TID
FU daily until improvement, stability is a favorable sign
Herpes Simplex Keratitis (HSK)
Stain: Giemsa - shows multinucleated giant cells
Culture: Viral transport medium
SKIN: 0.5% erythromycin BID
CORNEA: Consider
Trifluridine 1% 9x/day for 1 week, then 4x/day for 1 week
Ganciclovir 0.15% gel 5x/day for 1 week, then 2x/day for 1 week
ORAL: Valacyclovir 500 mg TID for 7-10 days
** do not prescribe (F) in patients with HIV due to risk of thrombotic thrombocytopenic purpura (ttp) and hemolytic uremic syndrome
Cyclopentolate 1% TID if AC reaction or photophobia
Prednisolone acetate 1% q2h-QID for disciform keratitis WITHOUT EPI defect
Do not use PGA for IOP reduction
FU daily until improvement is noted then every 1-2 weeks
Neurotrophic Corneal Ulcer
SMALL defect: 0.5% erythromycin QID until resolved
PFAT, BCL, and Moxifloxacin 0.5% QID
If corneal ulcer is present treat as bacterial keratitis
Oral doxycycline 100 mg BID may slow stromal lysis
1g vitamin c/ascorbic acid may help promote collagen synthesis and reduce level of ulceration
Oxervate 0.002% 6x/day (2 hours apart)
tarsorrhaphy may be necessary
FU daily until improvement is noted then every week till resolved
Staph/Strep/Pseudo central corneal ulcer
staph: +, cat +
strep: +, cat -
pseudo: -
** culture if lesion is larger than 1 mm, in visual axis, or unresponsive to treatment, or suspicious history
cyclopentolate 1% TID for comfort and to prevent synechia formation
NONSTAINING peripheral infiltrate with minimal AC reaction
- Moxi 0.5% q1h while awake OR polymyxin B/trimethoprim 10000U/1mg/mL q1h
(** if CL wearer, use both***)
<1.5 mm peripheral infiltrate, epi defect, mild AC, mod discharge
- moxi 0.5% q1h with polymyxin B/trimethoprim 10000 U/1g/mL q1h around the clock with loading dose of q5min for 5 doses, then every 3o mins until midnight, then q1h
> 1.5 mm, in the
visual axis, or unresponsive to initial tx
- fortified (g) or tobramycin 15 mg/mL q1h
ALTERNATING
- fortified cefazolin 50 mg/mL
or (v) 25mg/mL q1h
(** every 30 mins around the clock)
Reserve vancomycin 25 mg/mL for patients at risk for MRSA or with penicillin/cephalopsorin allergy
If Pseudomonas is suspected: tobramycin 15 mg/mL q30 min with cefazoline 50 mg/mL every hour
Loading dose q5h for 5 doses, then every 30 -60 mins around the clock
NEVER taper an antibiotic lower than QID
Admit to hospital if infection is sight threatening, impending preforation, patient cannot adminiters antibiotics as prescribed/frequency, poor compliance with fu
FU daily to measure size and depth of defect and infiltrate, pain, and AC reaction
gonococcal corneal ulcer
Stain: will show gram-negative intracellular diplococci
Culture: chocolate agar or Thayer-martin
cyclopentolate 1% TID for comfort and to prevent synechiae
ceftriaxone 1g IV 12-24h PLUS azithromycin 1g PO one time if corneal involvement
** gentamicin 240 mg IM plus 2 mg azithromycin PO if allergic to cephalosporins
ceftriaxone 1g IM plus azithromycin 1g PO one time if conjunctival involvement
Mox 0.5% q1h around the clock
** these patients should be admitted to the hospital for IV ceftriaxone
order infectious disease consultation, sexual partners should be treated as well
FU daily until consistent improvement is noted, then every 2-3 days
Ocular Hypertension
Consider treating any IOP > than 21-32 in one eye and 24-32 in the other (despite VF damage – INVOLVE PT IN DECISION)
Consider treating all patients with IOP > 32 (cut off of OHTS)
TX options
1. Latanoprost 0.005% QHS
~ CONSIDER Rocklatan 0.02%/0.005% QHS)
2. ADD Timolol 0.05% QAM
~ CONSIDER COMBOS
** Combigan (Brimonidine 0.2%/Timolol 0.5%) BID
** Cosopt (Dorzolamide 2%/Timolol 0.5%) BID
3. Consider Simbrinza Brimonidine 0.2%/Brinzolamide 1%) TID
4. ADD Rhopressa 0.02% QHS
Monitor in 6 weeks after starting new drops
FU every 3 months at the time of diagnosis
** Rotate VF, gonio, Dilated exam/scans, and IOP checks)
If stable for years , can extend follow up every 6 months
POAG
TX options
1. Latanoprost 0.005% QHS
~ CONSIDER Rocklatan 0.02%/0.005% QHS)
2. ADD Timolol 0.05% QAM
~ CONSIDER COMBOS
** Combigan (Brimonidine 0.2%/Timolol 0.5%) BID
** Cosopt (Dorzolamide 2%/Timolol 0.5%) BID
3. Consider Simbrinza Brimonidine 0.2%/Brinzolamide 1%) TID
4. ADD Rhopressa 0.02% QHS
Surgical options (9)
ALT
SLT
Trabeculectomy
Tube shunt procedure
Laser cyclophotocoagulation
Deep sclerotomy
iStent trabecular micro-bypass
Endocyclophotocoagulation
Trabectome trabecular ablation
MIGS for mild to moderate glaucoma, often in conjunction with cataract surgery include
- canaloplasty
- deep sclerotomy
- iStent trabecular micro-bypass
- endocyclophotocoagulation
- trabectome trabecular ablation
Monitor in 6 weeks after starting new drops
FU every 3 months at the time of diagnosis
** Rotate VF, gonio, Dilated exam/scans, and IOP checks)
If stable for years, can extend follow up every 6 months
NTG
TX options
1. Latanoprost 0.005% QHS
~ CONSIDER Rocklatan 0.02%/0.005% QHS)
2. ADD Timolol 0.05% QAM
~ CONSIDER COMBOS
** Combigan (Brimonidine 0.2%/Timolol 0.5%) BID
** Cosopt (Dorzolamide 2%/Timolol 0.5%) BID
3. Consider Simbrinza Brimonidine 0.2%/Brinzolamide 1%) TID
4. ADD Rhopressa 0.02% QHS
Surgical options (9)
ALT
SLT
Trabeculectomy
Tube shunt procedure
Laser cyclophotocoagulation
Deep sclerotomy
iStent trabecular micro-bypass
Endocyclophotocoagulation
Trabectome trabecular ablation
MIGS for mild to moderate glaucoma, often in conjunction with cataract surgery include
- canaloplasty
- deep sclerotomy
- iStent trabecular micro-bypass
- endocyclophotocoagulation
- trabectome trabecular ablation
Monitor in 6 weeks after starting new drops
FU every 3 months at the time of diagnosis
** Rotate VF, gonio, Dilated exam/scans, and IOP checks)
If stable for years, can extend follow up every 6 months
Angle Recession Glaucoma
TX options
1. Latanoprost 0.005% QHS
~ CONSIDER Rocklatan 0.02%/0.005% QHS)
2. ADD Timolol 0.05% QAM
~ CONSIDER COMBOS
** Combigan (Brimonidine 0.2%/Timolol 0.5%) BID
** Cosopt (Dorzolamide 2%/Timolol 0.5%) BID
3. Consider Simbrinza Brimonidine 0.2%/Brinzolamide 1%) TID
4. ADD Rhopressa 0.02% QHS
Surgical options (9)
ALT
SLT
Trabeculectomy
Tube shunt procedure
Laser cyclophotocoagulation
Deep sclerotomy
iStent trabecular micro-bypass
Endocyclophotocoagulation
Trabectome trabecular ablation
MIGS for mild to moderate glaucoma, often in conjunction with cataract surgery include
- canaloplasty
- deep sclerotomy
- iStent trabecular micro-bypass
- endocyclophotocoagulation
- trabectome trabecular ablation
Monitor in 6 weeks after starting new drops
FU every 3 months at the time of diagnosis
** Rotate VF, gonio, Dilated exam/scans, and IOP checks)
If stable for years, can extend follow up every 6 months
Pseudoexfoliative Glaucoma
TX options
1. Latanoprost 0.005% QHS
~ CONSIDER Rocklatan 0.02%/0.005% QHS)
2. ADD Timolol 0.05% QAM
~ CONSIDER COMBOS
** Combigan (Brimonidine 0.2%/Timolol 0.5%) BID
** Cosopt (Dorzolamide 2%/Timolol 0.5%) BID
3. Consider Simbrinza Brimonidine 0.2%/Brinzolamide 1%) TID
4. ADD Rhopressa 0.02% QHS
*** International Collaborative Exfoliation Syndrome Treatment Study (ICEST): outflow enhancers (latanoprost) are more beneficial than aqueous suppressors (timolol/dorzolamide) for PXE
Surgical options (9)
ALT
SLT
Trabeculectomy
Tube shunt procedure
Laser cyclophotocoagulation
Deep sclerotomy
iStent trabecular micro-bypass
Endocyclophotocoagulation
Trabectome trabecular ablation
MIGS for mild to moderate glaucoma, often in conjunction with cataract surgery include
- canaloplasty
- deep sclerotomy
- iStent trabecular micro-bypass
- endocyclophotocoagulation
- trabectome trabecular ablation
Monitor in 6 weeks after starting new drops
FU every 3 months at the time of diagnosis
** Rotate VF, gonio, Dilated exam/scans, and IOP checks)
If stable for years, can extend follow up every 6 months
Neovascular Glaucoma
Prednisolone 1% Q1H-Q6H
Atropine 1% TID
Timolol 0.5% QAM
** Consider Combigan BID or Cosopt BID
Brimonidine 0.1% TID
Dorzolamide 2% TID
** Consider Simbrinza TID
DO NOT US PGA due to risk of increased inflammation
Refer to retinal specialist to treat retinal ischemia with PRP and or antiVEGF
Surgical options include
trabeculectomy
tube shunt procedure
laser cyclophotocoagulation of CB
cyclocryotherapy once neovascular membrane is inactive
** In a painful blind eye, treat with topical steroids and cycloplegics or consider retrobulbar alcohol injection or enucleation if unsuccessful
FU in 1-2 days for urgent therapeutic intervention, as angle closure may proceed rapidly if left untreated
Monitor in 6 weeks after starting new drops
FU every 3 months at the time of diagnosis
** Rotate VF, gonio, Dilated exam/scans, and IOP checks)
If stable for years, can extend follow up every 6 months
Glaucomatocyclitic Crisis (Posner-Schlossman Syndrome)
Prednisolone 1% Q1H-Q6H
Cyclopentolate 1% TID (if symptomatic)
Timolol 0.5% QAM
** Consider Combigan BID or Cosopt BID
Brimonidine 0.1% TID
Dorzolamide 2% TID
** Consider Simbrinza TID
DO NOT US PGA due to risk of increased inflammation
Consider oral dorzolamide 250 mg BID or methazolamide 50 mg BD if nonresponsive.
If IOP is dangerously high and nonresponsive, consider 1g/kg mannitol IV over 45 minutes.s
Surgical options (6)
- ALT
- SLT
- trabeculectomy
- tube shunt procedure
- laser cyclophotocoagulation of CB
- cyclo cryotherapy
MIGS for mild to moderate glaucoma, often in conjunction with cataract surgery, include
- canaloplasty
- deep sclerotomy
- iStent trabecular micro bypass
- endocyclophotocoagulation
- trabectome trabecular ablation
FU every 2 days during an attack, then weekly until the episode resolves
- monitor in 6 weeks after starting a new drop
- follow up every 3 months at the time of diagnosis (rotate VF, gonio, full dilation/scans, and IOP check)
- if stable for years, can extend follow-up to every 6 months
Hemolytic and Ghost Cell Glaucoma
TX options
1. Latanoprost 0.005% QHS
~ CONSIDER Rocklatan 0.02%/0.005% QHS)
2. ADD Timolol 0.05% QAM
~ CONSIDER COMBOS
** Combigan (Brimonidine 0.2%/Timolol 0.5%) BID
** Cosopt (Dorzolamide 2%/Timolol 0.5%) BID
3. Consider Simbrinza Brimonidine 0.2%/Brinzolamide 1%) TID
4. ADD Rhopressa 0.02% QHS
Surgical options (9)
ALT
SLT
Trabeculectomy
Tube shunt procedure
Laser cyclophotocoagulation of CB
cyclo therapy
** CONSIDER vitrectomy and AC irrigation if medical management fails **
MIGS for mild to moderate glaucoma, often in conjunction with cataract surgery include
- canaloplasty
- deep sclerotomy
- iStent trabecular micro-bypass
- endocyclophotocoagulation
- trabectome trabecular ablation
Monitor in 6 weeks after starting new drops
FU every 3 months at the time of diagnosis
** Rotate VF, gonio, Dilated exam/scans, and IOP checks)
If stable for years, can extend follow up every 6 months
Malignant Glaucoma
if there is no PI, refer for PI
if signs of aqueous misdirection are still present, then begin medical therapy:
- Atropine 1% and phenylephrine 2.5% QID
- Acetazolamide 2 250 mg tabs PO
- Timolol 0.5% BID
- Brimonidine 0.2% BID
- Mannitol 1g/kg IV over 45 minutes
if attack is broken, continue atropine 1% daily indefinitely
send for PI of the fellow eye if it is occludable
if previous tx is unsuccessful, then refer for surgical intervention to disrupt the anterior hyaloid face (YAG laser disruption or vitrectomy) or argon laser of the ciliary process
FU varies at the discretion of the OMD performing PI but should be closely monitored and PI of the other eye should by performed within 1 week
Choroidal detachment following glaucoma filtering surgery
if the wound leaks, then topical aqueous suppressants and bandage CL
if not yet, G3 flat chamber (lens, endo, and iris all touching), then atropine 1% TID and prednisolone 1% QID to encourage posterior rotation of the CB
If the AC is completely flat or IOP is consistently very low, refer back to the surgeon for wound closure if there is one and drainage of the choroidal detachment with the reformation of the AC with viscoelastic.
If starting a steroid, see the patient at least weekly
- if there is a wound leak, see daily until improvement or refer back to surgeon
Normotensive Glaucoma following corneal thinning refractive surgery
TX options
1. Latanoprost 0.005% QHS
~ CONSIDER Rocklatan 0.02%/0.005% QHS)
2. ADD Timolol 0.05% QAM
~ CONSIDER COMBOS
** Combigan (Brimonidine 0.2%/Timolol 0.5%) BID
** Cosopt (Dorzolamide 2%/Timolol 0.5%) BID
3. Consider Simbrinza Brimonidine 0.2%/Brinzolamide 1%) TID
4. ADD Rhopressa 0.02% QHS
Surgical options (9)
ALT
SLT
Trabeculectomy
Tube shunt procedure
Laser cyclophotocoagulation
Cyclocryotherapy
MIGS for mild to moderate glaucoma, often in conjunction with cataract surgery include
- canaloplasty
- deep sclerotomy
- iStent trabecular micro-bypass
- endocyclophotocoagulation
- trabectome trabecular ablation
Monitor in 6 weeks after starting new drops
FU every 3 months at the time of diagnosis
** Rotate VF, gonio, Dilated exam/scans, and IOP checks)
If stable for years, can extend follow up every 6 months
Narrow-Angle/ Acute Angle Closure Glaucoma
If visual acuity is HM or better, IOP reduction is urgent
Apply all available topical glaucoma meds if available and not contraindicated
- Timolol 0.5%
- Brimonidine 0.2%
- Latanoprost 0.005%
- Dorzolamide 2% (unless sulfa induced angle closure)
- Topical drops in 3 rounds each 15 minutes apart
Acetazolamide 2 250 mg tabs PO if NOT sulfa-induced angle closure or sulfa allergy
Recheck IOP in 1 hour; if still elevated, repeat drops and give IV mannitol 1g/kg over 45 minutes unless patient has heart or renal disease
If secondary angle closure, consider cyclopentolate 1% and phenylephrine 2.5% for 4 doses when laser cannot be performed
In phacomorphic glaucoma, lens should be removed as soon as the eye is quiet
For pupillary block, LPI is indicated within 1-5 days of the attack
If IOP is still elevated after 2 courses of max medical therapy, LPI or surgical PI should be performed
FU daily until IOP has been reasonably reduced, then weekly
The fellow eye has a 40-80% chance of being occluded in 5-10 years
Baseline glaucoma testing should be obtained once the attack is controlled
Recommended family members have exams due to likelihood of occludable angles
Phacolytic Glaucoma
Cataract surgery should be performed within 24-48 hours
Cyclopentolate 1% TID
Pred 1% Q1H
Timolol 0.5% QAM/BID
Brimonidine BID-TID
Dorzolamide 2% BID-TID
Mannitol 1g/kg over 45 mins if no heart disease or kidney disease
FU the day after cataract surgery
If IOP has returned to normal, see in 1 week
Pharmacologically induced glaucoma
If VA is HM or better, IOP reduction is urgent
Apply all available topical glaucoma meds if available and not contraindicated
- Timolol 0.5%
- Brimonidine 0.2%
- Latanoprost 0.005%
- Dorzolamide 2% (unless sulfa induced angle closure)
- Topical drops in 3 rounds each 15 minutes apart
Acetazolamide 2 250 mg tabs PO if NOT sulfa-induced angle closure or sulfa allergy
Recheck IOP in 1 hour, if still elevated, repeat drops and give IV mannitol over 45 minutes unless patient has heart disease or renal disease
If secondary angle closure, consider cyclopentolate 1% and phenylephrine 2.5% for 4 doses when laser cannot be performed
If topiramate or sulfa drug induced angle closure, consider atropine 1% TID to induce posterior rotation of the CB
If IOP is still elevated after 2 courses of max medical therapy, LPI or surgical PI should be performed
Discuss discontinuing causative medication with prescribing physician
FU daily until the IOP has been reasonably reduced, then weekly
- the fellow eye has a 40-80% chance of being occluded in 5-10 years
- baseline glaucoma testing should be obtained once the attack is controlled
Recommend family membrane have exam due to likelihood of occludable angles
Pigmentary glaucoma
careful observation until glaucoma develops
- Timolol 0.5% QAM
- Consider Combigan or Cospot - ADD Brimonidine 0.1% BID-TID
- ADD Dorzolamide 2% BID-TID
- Consider Simbrinza
Peripheral laser iridotomy to reduce iridozonular contact, SLT with lower energy and 180 degrees treated at a time
Consider MIGS, guarded filtration procedures, tube shunt when other therapies fail
Monitor in 6 weeks after starting new drop
FU every 3 months at the time of diagnosis (rotate VF, gonio, DFE/scans, and IOP check)
If stable for years, can extend FU every 6 months
Post-op elevated IOP
treat elevated IOP after CE with aqueous suppressants
- if inflammation is excessive, then increase the steroid
Post-op pupillary block
- YAG LPI if cornea is clear
- Consider cyclopentolate 1% and pred 1% q15 min for 4 doses
- Timolol 0.5%
- Brimonidine 0.1%
- Dorzolamide 2%
- Topical aqueous suppressants in 3 rounds separated by 15 minutes each if no contraindications
- Acetazolamide 2 250 mg tabs PO
- Perform YAG LPI or iridectomy when cornea is clear
If elevated IOP after glaucoma filtering procedure
- removal or lysis sutures over the scleral flap
- topical pilo may pull iris out of the sclerostomy if it is recent onset
- if vitrous is blocking the sclerostomy, YAG lysis may be attempted
- blood or fibrin blocking the sclerostomy may resolve over time or intracameral tissue plasminogen activator may help dissolve the clot
- treated as POAG if no success with the above
FU in 6 weeks if starting a new drop
- otherwise, FU at OMD recommendations
post op malignant glaucoma
if there is no PI, refer for PI
if signs of aqueous misdirection are still present, then begin medical therapy:
- Atropine 1% and phenylephrine 2.5% QID
- Acetazolamide 2 250 mg tabs PO
- Timolol 0.5% BID
- Brimonidine 0.2% BID
- Mannitol 1g/kg IV over 45 minutes
if attack is broken, continue atropine 1% daily indefinitely
send for PI of the fellow eye if it is occludable
if previous tx is unsuccessful, then refer for surgical intervention to disrupt the anterior hyaloid face (YAG laser disruption or vitrectomy) or argon laser of the ciliary process
FU varies at the discretion of the OMD performing PI but should be closely monitored and PI of the other eye should by performed within 1 week
Blebitis
G1: bleb infection without AC or vitreous involvement
- (F) cefazolin 50 mg/mL and (F) tobramycin 15 mg/mL alternating every half hour for the first 24 hours with a loading dose of one drop every 5 minutes for 30 minutes
G2: bleb infection with AC involvement with NO vitreous involvement
- (F) cefazolin 50 mg/mL and (F) tobramycin 15 mg/mL alternating every half hour for the first 24 hours with a loading dose of one drop every 5 minutes for 30 minutes
- ADD cyclopentolate 1% TID and more careful monitoring
G3: bleb infection with AC and vitreous involvement
** treat as endophthalmitis **
- AC or vitreous tap with gram stain and culture
- IV broad-spectrum antibiotics (vancomycin and ceftazidine) and possible steroid injection depending on severity of inflammation
- Pred 1% q1h around the clock
- (F) Tobramycin 15 mg/mL q1h around the clock for 2 days
- (F) Vancomycin 25 mg/mL q1h around the clock for 2 days
- Atropine 1% BID-QID
- Vitrectomy if vision is light perception or worse
- Consider systemic antibiotics
FU in 6-12 hours and again at 12-24 hours to ensure stability
- see at least daily until infection is resolving
- admission to the hospital may be indicated
Uveitis Glaucoma Hyphema (UGH Syndrome)
Atropine 1% TID
Pred 1% QID
Ketorolac 0.5% QID
Timolol 0.5% BID/QAM
Brimonidine 0.1% BID
Dorzolamide 2% TID
Acetazolamide 500 mg sequels PO BID
Surgical repositioning or removal of lens if patient experiences recurrent episodes, formation or PAS, or persistent CME
- consider YAG lysis of vitreous strands
FU in 1 day if treating in office, or at OMD recommendation if referring
Uveitic Glaucoma
Pred 1% q1h-6h if no active epi defect
Cyclopentolate 1% TID
Timolol 0.5% BID-QAM
Brimonidine 0.1% BID-TID
Dorzolamide 2% TID
Acetazolamide 500 mg sequels BID PO
Mannitol 1g/kg IV over 45 mins
AC paracentesis if reduction in IOP is urgent or IOP is refractory to therapy
Treat cause of uveitis (HSV, etc)
Do NOT use PGA or miotics in inflammatory glaucoma
FU daily until improvement is noted, then extend
Tension Headache
Refer to neurology if chronic, who may prescribe amitriptyline, venlafaxine or topiramate
FU as directed by neurology or yearly
Cluster Headache
Consider imaging to rule out Horners if persistent
Obtain an MRI of the brain when history is atypical or neurologic abnormality is present
Avoid alcohol and cigarettes during a cluster cycle
Refer to neurologist, who may prescribe oxygen, sumatriptan, calcium channel blockers, oral steroids, or lithium
FU in 7-10 days with neurology
FU every few weeks if patient is put on oral steroids
Migraine (Common)
New onset migraines after 50 are rare; consider another cause.
MRI of the head is indicated for atypical migraines
>50
Always on the same side of the head
Visual disturbance during or after the headache phase
Avoid precipitating factors; refer to a neurologist who may prescribe aspirin, NSAIDs, ergotamines, or serotonin agonists (sumatriptan) for abortive therapy
Prophylaxis with beta blockers (metoprolol), CCB (amlodipine) and antidepressants
FU with neurology in 4-6 weeks to evaluate therapy
Migraine (Classic)
New onset migraines after 50 are rare; consider another cause.
MRI of the head is indicated for atypical migraines
>50
Always on the same side of the head
Visual disturbance during or after the headache phase
Avoid precipitating factors; refer to a neurologist who may prescribe aspirin, NSAIDs, ergotamines, or serotonin agonists (sumatriptan) for abortive therapy
Prophylaxis with beta blockers (metoprolol, CCB (amlodipine) and antidepressants
FU with neurology in 4-6 weeks to evaluate therapy
Migraine (Acephalgic)
New onset migraines after 50 are rare; consider another cause.
MRI of the head is indicated for atypical migraines
>50
Always on the same side of the head
Visual disturbance during or after the headache phase
Avoid precipitating factors; refer to a neurologist who may prescribe aspirin, NSAIDs, ergotamines, or serotonin agonists (sumatriptan) for abortive therapy
Prophylaxis with beta blockers (metoprolol, CCB (amlodipine) and antidepressants
FU with neurology in 4-6 weeks to evaluate therapy
Amiodarone Optic Neuropathy (1%) with vortex keratopathy (70-100%)
Mean 9 months of use before vision loss (VA typically better than 20/40)
Insidious onset, nerve swelling persists for months and resolves slowly (months to years)
Consult a cardiologist concerning stopping the drug.
Vortex keratopathy alone does not require therapy.
FU several times in the first year of taking amiodarone, then annually
- If active disc edema is present, follow every 3 months
Adies Tonic Pupil
Test for cholinergic hypersensitivity with pilocarpine 0.125% in both eyes, the dilated Adie pupil should constrict while nothing happens to the other pupil
If pupil is not hypersensitive in acute onset, retest in 2-3 weeks
If any questions about the diagnosis, refer to neruo for work-up
Consider pilocarpine 0.125% BID-QID for cosmesis and accommodation
If diagnosis is certain, FU annually
Horner Syndrome
Confirm diagnosis with reversal of anisocoria with 1% apraclonidine
Confirm the location of the lesion with 1% phenylephrine (if pupil dilates = POST) or 1% hydroxyamphetamine (if pupil dilates = PRE)
If transient vision loss, headache/neck/face pain, pulsatile tinnitus, or dysgeusia, then consider ICA dissection
Check for thyroid enlargement or neck mass
Investigate history of headache, arm pain, stroke, neck surgery, trauma, and neck pain
Order CBC with differential.
CT of the chest to evaluate the apex of the lung for Pancoast tumor
MRI and MRA of the brain and neck
Lymph node biopsy if lymphadenopathy is present
Treat the underlying disorder with consult to neurology
FU is ASAP with neurology for acute Horners, imaging should be performed immediately for dissection
Remaining workup should be performed within 2 days
FU with optometry in 1 year
Argyll Roberstons Syndrome
Order FTA ABS or MHA TP or VDRL testing to confirm diagnosis of syphilis
If diagnosis of syphilis is established, order infectious disease consult for potential lumbar puncture
Tx for untreated syphilis: penicillin g 4 million units IV q4h for 10-14 days followed by benzathine penicillin 2.4 units IM weekly for 3 weeks
FU within a few days for workup and infectious disease consult
Repeat lumbar puncture should be performed every 6 months to 2 years until cell counts normalize
Isolated CN3 Palsy - pupil involved
Cause (most common): aneurysm between ICA and pcomm
order immediate contrast-enhanced CT and CTA or gadolinium-enhanced MRI and MRA of head and neck
if results are equivocal or shows a mass and patient is older than 10, order cerebral angiography
Consider ordering CBC with diff in children, ice test if MG is suspected, FBG, HbA1c and BP
- ESR and CRP and platelets if GCA is suspected
treat underlying abnormality, patch the involved eye if symptomatic of diplopia
- strab surgery if condition is stable for years
FU urgently with neuro, then at recommendation of neuro
Isolated CN3 palsy - pupil spared
Cause (most common): ischemic microvascular disease (diabetes)
microvascular thrid nerve palsies will NOT have aberrant regeneration
order immediate contrast-enhanced CT and CTA or gadolinium-enhanced MRI and MRA of head and neck
if results are equivocal or shows a mass and patient is older than 10, order cerebral angiography
Consider ordering CBC with diff in children, ice test if MG is suspected, FBG, HbA1c and BP
- ESR and CRP and platelets if GCA is suspected
treat underlying abnormality, patch the involved eye if symptomatic of diplopia
- strab surgery if condition is stable for years
FU urgently with neuro, then at recommendation of neuro
- if secondary to ischemia, function should return in 3 months
Isolated CN 4 Palsy
If vertical fusional vergence is greater than 6, it is likely congenital.
If a double Maddox rod is rotated a total of 10 degrees between the two eyes, then a bilateral SO paresis is likely present.
Ice test if MG is suspected
- CT of head and orbits if orbital disease is suspected
- BP, FBG, A1c if ischemia is suspected
- Immediate ESR, CRP, and platelets if GCA is suspected
- MRI of the brain, if accompanied by other neurologic abnormalities
MRI of the brain for all patients less than 45 without a history of head trauma and all patients 45-55 with no vasculopathy risk factors or trauma
Treat underlying disorder - consider patching or prescribing prism if stable
Defer strab surgery for at least 6 months after the onset of palsy
FU annually if congenital
If acquired and workup is negative, presume vascular and see back in 3 months
- if it does not resolve in 3 months or neurologic abnormalities develop, order MRI of the brain for possible lesion
Return to clinic if any ptosis, worsening double vision, sensory abnormalities or pupil abnormalities
Isolated CN 6 palsy
Check carefully for papilledema
- check FBG, BP A1c
- ESR/CRP/platelets if suspected GCA
- Lyme antibody and FTAABS and RPR/VDRL
- MRI of the brain in all children with CN6 palsy
MRI of brain if younger than 45, no vasculopathic risk factors, severe pain or neurologic signs, history of cancer, bilateral, or papilledema is present
Treat underlying condition
- patch affected eye
- prism for longstanding stable deviations
- consider strab surgery after 6 months of stability y
FU every 6 weeks after onset of the palsy until resolves
MRI is indicated if any new neuro signs develop, abduction deficit increases, or the isolated 6th nerve palsy does not resolve in 6 months
CN7 Bells Palsy (Central or Peripheral)
Central: weakness to the lower facial musculature only
Peripheral: weakness to upper and lower facial musculature
Order CT scan if h/o trauma to r/o basilar skull fracture
Order MRI/CT if
- neurologic signs
- h/o of cancer
- duration >3 months
- 6th nerve involvement
- 8th nerve involvement
ORDER
CT chest
ACE
CBC with diff
Lyme antibody
EBV titer
HIV testing
FTA-ABS and RPR/VDRL
RF
ESR
ANA
ANCA
– h/o of stroke = Carotid ultrasound/ekc
– h/o of primary neoplasm = LP
** Stroke/CPA mass/temporal bone fracture/nerve laceration: Refer to NEUROLOGIST
** Otitis: Refer to ENT
** RH Syndrome
- Start Acyclovir 800 mg 5x for 10 days
- Refer to ENT
- Contraindicated in pregnancy and renal failure
** Guillan Barre: Refer to NEUROLOGIST
** Lyme Disease
- Refer to INFECTIOUS DISEASE
- Tx oral doxy, pnc, IV ceftriaxone
** Sarcoid
- Refer to a NEUROLOGIST if CNS involvement or an internist for systemic elevation
- May require Prednisone
** Metastatic Disease
- Refer to Oncologist for chemotherapy or radiation
** Bell Palsy (Idiopathic)
- 86% resolve completely with observation in 2 months
- PT with a facial massage or electrical stimulation
- Prednisone 60 mg PO daily for 7 days, followed by 10 mg per day increases likelihood of facial nerve recovery
- Treat dry eye/corneal exposure
FU 1 moth and 3 months
- If not resolved at 3 months, order MRI of the brain to r/o mass lesion
Nonarteritic Ischemic Optic Neuropathy (NAION)
Order immediate ESR, CRP, and platelets if there is any suspicion of GCA or if the patient is older than 55
Confirm with temporal artery biopsy
Consult internist to r/o cardiovascular disease
Observation, avoid BP meds at night (if possible), treat OSA if present
FU monthly to monitor nerve edema (should resolve in 8 weeks) with mild vision improvement over 6 months
Arteritic Ischemic Optic Neuropathy (AAION)/ GCA/ Temporal Arteritis
Order immediate ESR, CRP, and platelets if there is any suspicion of GCA or if the patient is older than 55
Confirm with temporal artery biopsy
Biopsy should be performed within a week of starting systemic steroids
IV methylprednisolone 250 mg q6h for 12 doses, then 80-100 mg oral prednisone daily
If temporal artery biopsy is (+) for GCA, patient should be on 1 mg/kg prednisone initially
Without steroids, contralateral eye may be involved within 1 day
New tx options: tocilizumab (IL - 6 blocker) weekly infusions with a shorter (26 week) steroid taper
FU as directed by neurology who will manage steroid taper
TX should last at least 6-12 months, use the smallest amount of steroid possible to suppress the disease
Transient vision loss (TVL)/Amaurosis Fugax (unilateral or bilateral)
Current AHA guidelines suggests MRI with diffusion-weighted imaging, urgent carotid and cardiac studies (carotid ultrasound and ekc), and neurology consultation
Immediate ESR/CRP/platelets if GCA is suspected
Cardiac and carotid auscultation
Order CBC with diff, FBG, A1c, and lipid profile
The cardiologist may prescribe aspirin 81-325 mg PO daily
- consult vascular surgery in patients with high-grade carotid stenosis for stent or endarterectomy
- for thrombus, consider hospitalization and heparin therapy
FU is immediate diagnostics for possible therapeutic intervention
- see at least every 6 months or at recommendation of cardiology
Cavernous Sinus Syndrome/ Carotid Cavernous Fistula (CCF)
CT/MRI scan of sinuses, orbits, and brain
Lumbar puncture for patients with h/o of carcinoma
Lymph node biopsy if lymphadenopathy is present
Consider CBC with diff, ESR, ANA, RF, and ANCA
AV fistula may close spontaneously.
Metastasis should be managed by oncology.
Intra-cavernous aneurysm/dissection should be managed by neurosurgery.
Mucormycosis requires immediate hospitalization with emergent CT scans of the orbit, sinuses, and brain
- several consults (ID, neuro, ENT, endocrinology)
- tx with amphotericin B IV
Pituitary apoplexy needs immediate referral to neurosurgery
Cavernous sinus thrombosis: hospitalization for IV antibiotics or anticoagulants
Tolosa Hunt Syndrome
- Prednisone 60-100 mg daily PO for 2-3 days then gradual taper over 5-6 weeks as pain subsides
- Diagnosis of exclusion
FU is immediate hospitalization, no matter the cause!
Cerebral space-occupying lesion (benign or malignant)
Order gadolinium-enhanced MRI with referral to neurosurgery and oncology
If metastatic disease is suspected, a CT of the chest, abdomen, and pelvis will be ordered
Treatment may include chemotherapy, radiation, and resection surgically
Follow up is immediate referral to neurosurgery and oncology for evaluation
Cerebrovascular accident (CVA) – Involving the visual pathway
The central macula is represented by the most posterior part of the occipital cortex
Have the patient say, “You can’t teach an old dog new tricks.”
Have patient smile
Have patient close eyes and hold out arms
If one of the three is abnormal, there is 72% chance of CVA
Call 911 at any sign of a stroke
ER will check BP, FBG, A1c, carotid ultrasound, CT/MRI of the head and neck and possibly echocardiogram
If ischemic stroke, tissue plasminogen activator may be injected if within 4 hours of symptom onset
A carotid stent may be placed or an endarterectomy performed
If stroke is hemorrhagic, give drugs to reduce ICP and BP and prevent seizures
Surgical clip may be placed, or an aneurysm may be coiled
Follow up closely every few hours for the first day after emergency treatment
Cerebrovascular accident (CVA) – midbrain, pons, medullary lesion
Midbrain (3,4), Pons (5, 6, 7, 8), Medulla (9, 10, 11, 12)
Have patient say, “you can’t teach an old dog new tricks.”
Have patient smile
Have patient close eyes and hold out arms
If one of the three is abnormal, there is 72% chance of CVA
Call 911 at any sign of a stroke
ER will check BP, FBG, A1c, carotid ultrasound, CT/MRI of the head and neck and possibly echocardiogram
If ischemic stroke, tissue plasminogen activator may be injected if within 4 hours of symptom onset
A carotid stent may be placed or endarterectomy performed
If stroke is hemorrhagic, give drugs to reduce ICP and BP and prevent seizures
Surgical clip may be placed, or an aneurysm may be coiled
Follow up closely every few hours for the first day after emergency treatment.
Drusen of the optic nerve
Order B scan ultrasound, FAF, fluorescein angiography, CT scan of the orbits, or enhanced depth imaging of the ONH on OCT
No treatment is proven to alter the clinical course of drusen
Some use brimonidine due to its “potentially neuroprotective properties”
Follow up annually once there is no progression noted
Benign Essential Blepharospasm (BEB)
If hemifacial spasm is suspected, order MRI of the brain with attention to the posterior fossa and path of CN 7
Consider botulinum toxin injections into the orbicularis muscle every 3-4 weeks if severe
Consider surgical excision of the orbicularis muscle from the upper eyelids and brow if botox does not help
FL-41 tint has shown to decrease light sensitivity and help some patients with BEB
Surgical ablation of the facial nerve has been largely abandoned due to high recurrence and high incidence of facial paralysis
Follow up in 1 month after botox injections (90% improvement symptomatically)
Nystagmus
In suspected spasmus nutans, order MRI of the brain to rule out an anterior visual pathway lesion
- Resolves between 2-8 years. Head nodding, torticollis, and nystagmus
In saccadomania/opsoclonus, order abdominal and chest imaging to rule out neuroblastoma or visceral carcinoma
Visual field is indicated if seesaw nystagmus is present
- Lesion involves parasellar region and chiasm (may have bitemporal hemianopia)
Convergence retraction nystagmus in up gaze is likely pineal gland or other dorsal midbrain tumor
Downbeat nystagmus: Cerebellar degeneration or lesion at the cervicomedullary junction
Periodic alternating nystagmus: Lesion of cervicomedullary junction, posterior fossa, MS
- May respond to baclofen (NOT SAFE FOR KIDS)
Peripheral vestibular nystagmus: Accompanied by vertigo, deafness, or tinnitus
Prescribe prism in glasses to set eyes at null point, consider muscle surgery if large face turn
Severe and disabling nystagmus may be treated with retrobulbar botulinum toxin
Follow up at recommendation of neurology, at least annually
Internuclear Ophthalmoplegia (INO)
Convergence may be intact
- Brainstem and posterior fossa pathology should be ruled out
If skew deviation is present, Park 3 step will not isolate a specific muscle
Order MRI of the brainstem, midbrain, and brain
If acute stroke is diagnosed, admit to hospital for neurologic evaluation and observation
- If concern for demyelinating disease, consider treatment recommendations in optic neuritis section
Follow up with neurology as directed, there is no treatment for INO itself
- Patients mostly recover within 1 year
Orbital Pseudotumor and Orbital Myositis
Explosive painful onset is the hallmark of IOIS/orbital pseudotumor
Bilateral presentation should be a trigger to rule out systemic disease, metastasis, and lymphoma
This is a diagnosis of exclusion
Orbital CT with contrast may show involvement of the EOM tendons (unlike TED)
In atypical cases, order ESR, CBC with diff, ANA, ACE, ANCA, LHD, IgG levels, BUN/creatinine, FBG, HbA1c, chest CT, mammography, or prostate evaluation
Incisional biopsy before starting steroid therapy
Be suspicious for metastasis in patients with a history of cancer
Prednisone 1 mg/kg per day as an initial dose with 40 mg omeprazole po daily
May be treated with orbital radiation, cyclophosphamide, or methotrexate as an alternative to steroids
Follow up in 1 day
Maintained at the initial dose for 3-5 days and a very slow taper is performed to 40mg per day over 2 weeks and to 20 mg per day over several weeks
Papilledema
OCT and FAF of the optic nerves. Evaluate for SVP. Check BP.
Emergent MRI with gadolinium and MRV of the head are preferred over CT. If MRI/MRV are unremarkable order lumbar puncture with CSF analysis and opening pressure measurement.
Directly treat the cause of the elevated ICP.
Follow up with neurology emergently for MRI/MRV and possible lumbar puncture.
Papillitis and Non-demyelinating Optic Neuritis
MS is unlikely if vision is NLP, no pain is present, disc edema is present, or peripapillary hemes or exudates are present
MRI of the brain and orbits with gadolinium and fat suppression in ALL cases
Check BP
Consider CBC, ESR, ACE, Lyme antibody, FTA-ABS, RPR/VDRL, Chest X-ray or CT, ANA, FBG, and A1c
If MRI shows one area of demyelination and patient is NOT diagnosed with MS do the following within 14 days of decreased vision:
- IV methylpred 1g/day IV for 3 days
- Then pred 1 mg/kg/day po over 11 days
- Then taper prednisone over 4 days (20 mg day 1, 10 mg days 2-4)
- Omeprazole 20 mg po daily for prophylaxis
ONTT found that steroid treatment reduced progression to CDMS for 3 years
ONTT found that steroid therapy increases rapidity of visual recovery but does NOT improve final visual outcome
ONTT found that using oral pred ONLY without IV methylpred increases risk of recurrence
If MRI shows 2+ demyelinating lesions and patient has not been diagnosed with MS, treat as above and refer to neurologist for possible treatment with interferon-beta, fingolimod, etc.
- Patients with 1+ lesions on MRI have 72% chance of developing CDMS over 15 years
With a negative MRI, the risk of MS is low, repeat MRI at 3-6 months then periodically
If patient has a prior diagnosis of MS or optic neuritis, observation is appropriate
Follow up in 4-6 weeks after presentation, then every 3-6 months
Pituitary Tumor
Junctional scotoma - compression of anterior knee of the chiasm
Bitemporal more dense above - compression from underneath chiasm
Bitemporal more dense below or macular bitemporal - compression of posterior chiasm
Order formal HVF, order CT/MRI with coronal, sagittal, and axial scans
Order endocrine workup with assistance of endocrinologist
Surgical debulking may be performed by an ENT or neurosurgeon
Prolactinomas may be treated with bromocriptine or cabergoline
Consult submitted to endocrinologist
Educate patient on symptoms of acute apoplexy - severe headache, nausea, altered consciousness, ophthalmoplegia, facial numbness, vision loss, stroke symptoms
- Life threatening complication of pituitary apoplexy is adrenal crisis
- May start immediate steroids or emergent surgical decompression
Follow annually if there is no compression
- After treatment, perform visual field at 3 months and then every 6-12 months after that
- Periodic neuroimaging is essential, recurrence is not uncommon
Pseudotumor Cerebri/Idiopathic Intracranial Hypertension (IIH)
OCT and FAF of the optic nerves
Evaluate for SVP
Check BP
Emergent MRI with gadolinium and MRV of the head are preferred over CT
- If MRI/MRV are unremarkable order lumbar puncture with CSF analysis and opening pressure measurement
- Opening pressure is often >25cm H2O
Visual field is the most important test for monitoring these patients
Weight loss of 5-10% is shown to improve symptoms
Acetazolamide 250 mg po QID building up to 500-1000mg if tolerated and no sulfa allergy
Discontinue any causative meds, neurosurgical shunt may be recommended
Optic nerve sheath decompression is effective if vision is threatened
Follow up with neurology emergently for MRI/MRV and possible lumbar puncture
If acute and no other cause of swelling is determined, then monitor every 3 months in the absence of visual field loss
If vision decreases, follow more urgently
Retrobulbar Optic Neuritis with or without Multiple Sclerosis
MS is unlikely if vision is NLP, no pain is present, disc edema is present, or peripapillary hermes or exudates are present
MRI of the brain and orbits with gadolinium and fat suppression in ALL cases
Check BP
Consider CBC, ESR, ACE, Lyme antibody, FTA-ABS, RPR/VDRL, Chest X-ray or CT, FBG, and A1c
If MRI shows one area of demyelination and patient is NOT diagnosed with MS do the following within 14 days of decreased vision:
IV methylpred 1g/day IV for 3 days
Then pred 1 mg/kg/day po over 11 days
Then taper prednisone over 4 days (20 mg day 1, 10 mg days 2-4)
Omeprazole 20 mg po daily for prophylaxis
ONTT found that steroid treatment reduced progression to CDMS for 3 years
ONTT found that steroid therapy increases rapidity of visual recovery but does NOT improve final visual outcome
ONTT found that using oral pred ONLY without IV methylpred increases risk of recurrence
If MRI shows 2+ demyelinating lesions and patient has not been diagnosed with MS, treat as above and refer to neurologist for possible treatment with interferon-beta, fingolimod, etc.
Patients with 1+ lesions on MRI have 72% chance of developing CDMS over 15 years
With a negative MRI, risk of MS is low, repeat MRI at 3-6 months then periodically
If patient has a prior diagnosis of MS or optic neuritis, observation is appropriate
Follow up in 4-6 weeks after presentation, then every 3-6 months
Toxic/Metabolic Optic Neuropathy
Etiology includes tobacco/alcohol abuse, severe malnutrition with thiamine (B1) deficiency, pernicious anemia (B12 malabsorption), chloramphenicol, ethambutol, isoniazid, digitalis, streptomycin, chlorpropamide, disulfiram, amiodarone, and lead
Order formal HVF
Order CBC with diff, serum B1, B12, and folate (B9) levels
Consider heavy metal screen
If disc is swollen, consider blood test for Leber hereditary optic neuropathy
Treat with thiamine 100 mg BID PO, folate 1 mg daily po, multivitamin tablet daily, eliminating the causative agent, or 1000mg B12 IM monthly for pernicious anemia
Every month at first then every 6-12 months when stabilized
Vertebrobasilar Artery Insufficiency
Check BP of both arms to rule out subclavian steal syndrome
CBC to rule out anemia and polycythemia vera
Immediate ESR, CRP, platelets if GCA is suspected
Electrocardiogram, echocardiogram, and holter monitor to rule out dysrhythmia
- Consider carotid ultrasound
- Order MRA, CTA, or vertebral artery doppler ultrasound to evaluate posterior cerebral blood flow
Coordinate care with internal medicine or neurology with initiation of antiplatelet therapy. Control risk factors of HTN, HLD, DM
Follow up with urgent testing, further follow-up is dictated by the underlying condition at the recommendation of neurology/cardiology
Chlamydial Inclusion
1g azithromycin po 1 time OR 100 mg doxycycline BID po x1-2wk
Topical erythromycin 0.5% ung BID x2-3 weeks
Follow up in 2-3 weeks. Patient and sexual partners should be evaluated by medical doctors for other STIs
Rheumatoid Arthritis
(+) HLA-DR4, (+) RF, (+) anti-CCP
Episcleritis: Artificial tears if mild
- Topical ketorolac 0.5% QID or loteprednol 0.5% QID
- Consider oral NSAID ibuprofen 600 mg TID-QID po
- Follow up every 2-3 weeks until symptoms resolve then steroid is tapered
Scleritis
- Omeprazole 20 mg po daily
- Naproxen 250-500 mg BID po
- If no improvement, prednisone 60-80 mg daily po for 1 week with a taper to 20 mg po over one week then a slower taper
** Calcium and Vitamin D supplementation to reduce osteoporosis
- If long term control is not achieved with less than 10 mg per day, immunosuppressive therapy is indicated (cyclophosphamide, methotrexate, cyclosporine, azathioprine)
- Eye shield if there is significant thinning and risk of perforation
- Referral to rheumatology and uveitis specialist may be indicated
- Follow up within 1 week depending on amount of scleral thinning and symptoms
Monitor for signs of hydroxychloroquine toxicity, contact prescribing physician if they develop.
Systemic Lupus Erythematosus
(+) ANA, (+/-) antiphospholipid antibodies, (+) anti-dsDNA, meeting 4/17 separate clinical elements for diagnosis
Treat discoid skin lesions with 0.5% hydrocortisone ointment
- Monitor as needed
See every 3 months if retinopathy is present
Treat optic neuritis with IV methylpred followed by oral pred as discussed in optic neuritis section
- Follow up in 4-6 weeks, then every 3-6 months in chronic stage
If optic neuritis develops in SLE, over half of patients have permanent central scotoma and eventual optic atrophy
Monitor for signs of hydroxychloroquine toxicity, contact prescribing physician if they develop
Follow as indicated for individual condition. Patient should be followed by rheumatology
Episcleritis (Recurrent)
Artificial tears if mild
Topical ketorolac 0.5% QID or loteprednol 0.5% QID
Consider oral NSAID ibuprofen 600 mg TID-QID po
Follow up every 2-3 weeks until symptoms resolve then steroid is tapered
Graves Ophthalmopathy
Stop smoking and refer to an internist or endocrinologist for systemic management
Treat dry eye and exposure keratopathy
Order T3, T4, TSH
Cold compress in the morning and head elevation at night for lid edema
Orbital decompression in cases of optic neuropathy, recalcitrant keratopathy, globe luxation, uncontrolled high IOP, or severe proptosis
Tepezza: Insulin like growth factor receptor blocker, decreases orbital fibroblast stimulation
Order of surgical intervention is always: orbital decompression, strabismus surgery, lid surgery
Follow up for immediate treatment of optic nerve compression
- See restrictive strabismus patients every 3 months
- Minimal exposure and mild proptosis may be seen every 3-6 months
- Return immediately with worsening vision or diplopia or significant ocular irritation
- Offer smoking cessation resources
Leukemia (retinopathy in 50%)
Treatment for leukemia includes chemotherapy, immunotherapy, or radiotherapy
Acute lymphoblastic leukemia (ALL) treatment includes prednisone
Leukapheresis and bone marrow transplant may be necessary
Intravitreal methotrexate may show improvement in inflammation and tumor cell infiltration in the eye
Coordinate care with neurology/oncology as needed
Follow up every 3 months for retinopathy, refer to ophthalmology if neovascularization develops or retinopathy is severe
Lyme Disease
Intermediate uveitis is the most common form of uveitis in lyme disease
(+) borrelia burgdorferi antibody (ELISA), (+) western blot for lyme
Doxycycline 100 mg bid x2-3 weeks
Amoxicillin 500 mg TID x2-3 weeks
Azithromycin 500 mg po QD x2-3 weeks
Ceftriaxone 2g IV x2-3 weeks if neuro signs
Treat uveitis with topical steroid and cycloplegic
Follow up every day until improvement is noted, then weekly until resolved
Marfan Syndrome
Beta blockers may be prescribed systemically for aortic root dilation
Lens extraction if refraction is not possible, lens dislocation into the vitreous cavity, anterior lens displacement with secondary glaucoma, and cataract formation
Follow up annually unless complications develop
Myasthenia Gravis
(+) acetylcholine receptor autoantibodies, (+) anti-muscle specific kinase antibodies
Ice pack test for 2 min relieves ptosis by 2 mm or more
Order TSH, T3, T4, CT of chest to rule out a thymoma
Refer to neurologist familiar with MG. May consider oral pyridostigmine
If patient is having difficulty breathing, hospitalize for plasmapheresis and IV immunoglobulin
If systemic steroids are started, patient should be hospitalized for risk of respiratory crisis
Azathioprine or cyclosporine may be helpful
Follow ocular myasthenia every 6 months
If muscular weakness is present, monitor every 1-4 days by neurologist until improved
Ocular Ischemic Disease
Carotid ultrasound, IVFA for diagnostic purposes
Consider PRP and anti-VEGF if neovascularization is present
Perform gonioscopy at each visit
Refer to cardiologist
Refer to neurosurgeon for carotid endarterectomy or stent placement
Follow up for carotid ultrasound urgently
Ocular manifestations of pregnancy
Loss of accommodation, decreased corneal sensitivity, occlusive vascular disorders, aggressive meningioma growth, cavernous sinus syndromes, IIH/pseudotumor cerebri, migraines, worsening of diabetic retinopathy, central serous chorioretinopathy, ocular adnexal chloasma, ptosis, Purtscher-like retinopathy due to complement cascade or emboli after delivery
Preeclampsia/eclampsia/HELLP syndrome
Preeclampsia-Eclampsia Hypertensive Posterior Encephalopathy Syndrome (PEHPES)
Control blood pressure and electrolyte imbalances
Prompt delivery is ideal if preeclampsia/eclampsia develops
Refer systemic complications to obstetrics/gynecology specialist
Follow up as indicated by the ocular condition
Orbital Cellulitis
Order sagittal/coronal/axial CT of the orbits with contrast before wound exploration
Order CBC with diff
Admit patient to hospital with consult to infectious disease or ENT
Ampicillin-sulbactam 3g IV q6h
Vancomycin 15 mg/kg q12-24h if MRSA suspected
Ceftriaxone 2g IV daily and metronidazole 500 mg IV q6h if allergic to penicillin
See twice daily in the hospital for the first 48 hours, if condition worsens consider subperiosteal abscess and re-order CT of orbits
Scleritis
Omeprazole 20 mg po daily
Naproxen 250-500 mg BID po
If no improvement, prednisone 60-80 mg daily po for 1 week with a taper to 20 mg po over one week then a slower taper
Calcium and Vitamin D supplementation to reduce osteoporosis
If long term control is not achieved with less than 10 mg per day, immunosuppressive therapy is indicated (cyclophosphamide, methotrexate, cyclosporine, azathioprine)
Eye shield if there is significant thinning and risk of perforation
Referral to rheumatology and uveitis specialist may be indicated
Follow up within 1 week depending on amount of scleral thinning and symptoms
Sickle Cell Disease
Sickle cell retinopathy is most common with HbSC and HbSThal genotypes
Order sickledex, hemoglobin electrophoresis, sickle cell preparation
Neovascularization with vitreous hemorrhage may be treated with PRP
Retinal detachment and vitreous hemorrhage may be treated with vitrectomy
Anti-VEGF may or may not be beneficial
Systemic hydroxyurea, L-glutamine, or pain relievers may be prescribed
Blood transfusions and stem cell transplants may be considered
If no retinopathy, follow annually
Follow retinopathy every 3-6 months and refer to ophthalmology if neovascularization is present
Sjogren Syndrome with severe dry eye/Filamentary Keratitis
Order RF, ANA, SS-A anti-Ro, and SS-B anti-La antibodies
Negative serology should be followed by salivary gland biopsy when suspicion is high
3 of 4 of the following should be present:
1. Abnormally low schirmer test with rose bengal or fluorescein staining
2. Objective evidence of decreased salivary gland flow
3. Evidence of lymphocytic infiltration of the salivary glands on biopsy
4. Evidence of systemic autoimmune process by (+) RF, ANA, SSA, or SSB
Treat dry eye
Systemic treatment may include methotrexate, hydroxychloroquine, or cyclophosphamide
Treat filaments with topical acetylcysteine 10% TID x2-3 weeks
Follow up every 6 months or sooner if symptoms or signs warrant
Stevens Johnson Syndrome
Consult with internal medicine and dermatology
Hospitalization in a burn unit (hydration, wound care, and systemic antibiotics), remove the inciting factor.
Treat dry eyes, iritis, and bacterial keratitis if present.
Peel pseudomembranes, symblepharon lysis
Possible amniotic membrane therapy
Systemic or topical vitamin A and IV immunoglobulin.
Follow daily in hospital with infection surveillance, once released, weekly follow-ups
Transient vision loss (TVL) /Amaurosis Fugax
Current AHA guidelines suggest MRI with diffusion weighted imaging, urgent carotid and cardiac studies (carotid ultrasound and echocardiogram), and neuro consult
Immediate ESR/CRP/platelets if GCA is suspected
Cardiac and carotid auscultation
Order CBC with diff, FBG, A1c, and lipid profile
Cardiologist may prescribe aspirin 81-325 mg po daily
- Consult vascular surgery in patients with high grade carotid stenosis for stent or endarterectomy
- For thrombus, consider hospitalization and heparin therapy
Follow up is immediate diagnostics for possible therapeutic intervention
See at least every 6 months or at recommendation of cardiology
