Monday, February 25, 2008

Flaxseed oil/Dry eye supplements

- AT
- MGD/blepharitis
warm compresses/lid scrubs bid
Zylet qid x 1 week, bid x 1 week
- oral antibiotics
- nutritional supplements
- dry mouth therapies
Hydrate (OcuSoft)
BioTears fish oil supplements
Lovaza (omega-3)

1,000-1,500mg per day of each
4-6 weeks before response (including better skin and hair)

TheraTears nutrition supplements for patients with intestinal sensitivities

Alodox convenience kit (doxy 20mg + ocusoft lid scrubs), take with water, don't take with calcium (negates drug)

Sjogren's syndrome

  • most age >40
  • women 9x > men
  • dry eye, dry mouth, autoimmune disorder
  • lid hygiene/massage for MGD, AT, Restasis, steroids
  • oral Minocycline 50mg bid x 2 weeks then 50mg qd x 1 month, then taper (usually 8 weeks to work); side effects: stained teeth, vaginitis, photosensitivity
  • or Doxycycline 50mg bid x 1-2 months then qd x 1 month (side effects: photosensivitiy, sensitivity to dair products/antacids)
  • or Periostat (20mg doxy) bid x 1-2 months then qd x 1 month
  • Salagen and Evoxac (30mg tid) drugs that stimulate the salivary glands to produce saliva
Classification system:

1. Ocular symptoms:
  • daily, persistent, troublesome dry eyes >3 months
  • recurrent sensation of sand or gravel in the eyes
  • use AT more than tid
2. Oral symptoms:
  • daily feeling of dry mouth for >3 months
  • recurrent or persistently swollen salivery glands
  • need to drink liquids to aid in swallowing dry food
3. Ocular signs:
  • Schirmer's test w/o anesthesia (<5>
  • Rose bengal or other dry eye findings
4. Histopathology:
  • focal lymphocytic sialoadentitis in minor salivary glands, evaluated by histopathologist
5. Salivary gland involvement (send to rheumatologist):
  • unstimulated whole salivary flow (<1.5>
  • parotid sialography showing diffuse sialectasias without evidence of major duct obstruction
  • salivary scintigraphy showing delayed uptake, reduced concentration and/or delayed excretion of tracer
6. Autoantibodies
  • presence of antibodies to Ro(SSA) or La(SSB) antigens or both
For primary Sjogren's:
  • any 4 of the 6 items as long as item 4 or 6 is positive
  • presence of any 3 of 4 objective criteria items (3 thru 6)
For secondary Sjogern's:
  • in patients with a potentially associated disease (e.g. connective tissue disease, RA, lupus) with the presence of item 1 or 2 plus any two from items 3-5

Ocular/Oculodermal melanocytosis (Nevus of Ota)

most common in Asians/Blacks
women>men
10% have POAG

Posner-Schlossman sydrome (glaucomatocyclitic crisis)

  • repeated attacks of a mild cyclitis with significantly elevated IOP, usually unilateral
  • asymptomatic or may have symptoms of sudden onset of blurred vision, mild pain and haloes around lights
  • signs: mild anterior uveitis and high IOP (40-60), may have KPs w/ corneal edema, gonio open angle, mild degree of iris heterochromia and anisocoria (involved pupil larger)
  • usually occurs b/w age of 20-50
  • unknown etiology (possible allergy, viral infection such as CMV or herpes simplex, stress-induced)
  • inflammatory material or precipitates on the TM reduce aqueous outflow or trabeculitis causes decreased outflow
  • acute and self-limiting (resolves or without treatment), lasting hours to weeks
  • associated with POAG and NAION in patients with small, crowded optic nerves
  • treatment: control inflammation -- topical corticosteroid may be used alone or with IOP med (e.g. PF 1% qid qid with alphagan tid); don't use miotics or prostaglandins; no need for medication b/w episodes
  • medical work-up: Chest x-ray, bilateral plain radiographs of ankles, feet and sacroiliac joints (to check for joint abnormalities), CBC with differential, ESR, TSH, HLA-B27, CRP, RF, ANA, Chorionic gonadotropin, RPR, Lupus

Reis-Buckler's dystrophy

  • bilateral
  • causes photophobia, corneal erosions and subepithelial and anterior stromal scarring
  • multiple subepithelial ring-shaped opacities (honeycomb apperance) in the centre of the cornea corneal surface is irregular with ferritin deposition

EBMD

  • 10% of patients will have painful recurrent epithelial errosions
  • moderate presentations may require hypertonic drops and ointments (NaCl 5%), Q3H to QID, for a minimum of six months

ICD-9 codes website

http://icd9data.com/

http://icd9cm.chrisendres.com/index.php?action=child&recordid=3125

Band keratopathy

Precipitation of calcium salts, subepithelial

Due to:
  • hypercalcemia 2^ hyperparathyroidism, excessive vitamin D intake,
    renal failure, hypophosphatasia, milk-alkali syndrome, Paget disease,
    sarcoidosis
  • topical medications that contain phosphates (steroid phosphates,
    pilocarpine)
  • chronic ocular inflammation (uveitis, end stage glaucoma) causes elevation
    of the surface pH out of the physiologic range which changes the solubility
    product and favors precipitation
  • compromised endothelial function and corneal edema (2^ silicone oil from RD surgery)
Lab studies:
  • serum calcium and phosphate level
  • if sarcoid is suspected, an angiotensin-converting enzyme (ACE) should be obtained
  • parathyroid hormone levels

Salzman's Nodular Degeneration

  • peripheral elevated subephithelial nodules and irregular astigmatism
  • needs smaller diameter GPs to try to keep the leses away from the peripheral nodules

Terrien's Marginal Degeneration

  • progressive thinning of the peripheral corneal (usually S/T)
  • increases regular and irregular against-the-rule astigmatism
  • needs larger GP lens diameters to prevent decentration

Nutrition in AMD

Pharmacologic treatments for wet AMD


  • verteporfin(Visudyne)
  • pegaptanib (Macugen)
  • Lucentis
  • Avastin
Natural history of AMD progression


  • 10% rate of conversion from dry to wet AMD
  • nutritional supplementation decreases risk
  • oxidation hypothesis: breakdown of antioxidant systems and generation of free radicals damages lipid membranes; antioxidant deficiency may predispose patient to disease

AMD and cardiovascular disease

  • shared risk factors: elevated lipids, cholesterol, CRP, arteriosclerosis, cigarette smoking, inflammatin, HTN
AREDS


  • category 1 or 2 (little-to-no AMD or few small drusen): risk of developing wet AMD at 5 years = 1.5%
  • category 3 (large intermediate-size drusen or nonvoeal geographic atrophy): risk of developing wet AMD at 5 years = 20%
  • category 4 (at least 1 eye with wet AMD or foveal geographic atrophy)
  • if wet AMD present in one eye, risk to the fellow eye is 45%
  • risk for vision loss at 5 years: antioxidant + zinc = 20% reduction in risk
  • risk for progression to wet AMD at 5 years: antioxidant + zinc or zinc alone = 25% reduction in risk
  • recommendations: patients with intermediate to advanced AMD (category 3 or 4) should take daily supplemental theraphy
  • people who smoke should avoid beta carotene due to increased risk of lung cancer
AREDS II


  • study of lutein, zeaxanthin, omega-3 fatty acids
  • lutein and zeaxanthin are natural carotenoids found in macula; antioxidants; filters of UV light; play role in structural signal transduction; macular pigment decreases with age; decrease predisposes patient to increased rsik for AMD
  • zeaxanthin can increase macular pigment
  • 6m lutein associated with reduced risk for develping AMD by up to 43%
Dietary fat


  • higher body mass index associated with greater AMD risk
  • high intake of fat in prcessed baked gods increases odds for developing wet AMD by 2.4
  • other sources of fat (nuts) protective
Omega-3 fatty acids


  • lutein, zeaxanthin, and omega-3 fatty acids not produced by body
  • high intake of omega-3 fatty acids protects against wet AMD (dose-dependent)
  • omega-3 fatty acids in broiled or baked fish: dose-dependent decrease in risk for AMD progression

Side-effects/interactions

  • high levels of beta-carotene linked to increased incidence of lung cancer among heavy smokers
  • high volumes of zinc linked with genitourinary and GI disorders

Tuesday, February 19, 2008

Dosing guides

Topical anti-infective medications:
http://pconsupersite.com/pdfs/0709guide.pdf

Topical allergy medications:
http://pconsupersite.com/pdfs/0802guide.pdf

Topical glaucoma medications:
http://pconsupersite.com/pdfs/0705guide.pdf

Tuesday, February 12, 2008

Pellucid marginal degeneration

  • bilateral asymmetric focal ectasia of the corneal stroma 1-2mm above the inferior limbus b/w 5 & 7 o'clock w/o evidence of scarring, vascularization or lipid infiltration
  • progressive ectasia results in the development of ATR astigmatism
  • can lead to corneal hydrops
  • advanced cases show "kissing doves" or "crab claw" topography with superior flattening and a small island of inferior central flattening

Keratoconus

  • Munson's sign (lower lid bulge on downgaze)
  • Rizzuti's sign (loss of normal corneal reflectance in the slit lamp)
  • retinoscopy scissors reflex
  • Charleaux oil droplet sign (retroillumination)
  • Vogt's striae (folds in Descemet's membrane)
  • Fleischer's ring (iron in corneal epithelium)
  • stromal thinning
  • stromal scarring
  • prominent corneal nerves
  • swirl SPK staining
  • pseudo-reduced IOP
  • loss of BCVA
  • asymmetric (>1D) astigmatism
  • elevated total higher-order aberrations
  • elevated vertical coma (> 0.53 um)
  • elevated topography I/S values (>1.4)
  • apical elevation over best fit sphere on anterior and posterior elevation maps
  • corneal thinning
  • corneal irregularity

Cornea ectasia

two theories:
  • certain patietns have a genetically different type of collage composition of their cornea that predisposes them to ectasia (external factors such as eye rubbing, RGP wear and refractive surgery may trigger the process of thinning)
  • insult to collagen corneal fibrils via surgery, trauma, RGP wear or eye rubbing causes the corneal matrix to lose structural integrity

Rosacea treatment

Periostat (2mg doxycycline) QD

Oracea (30mg immediate release, 10mg of slow release doxycycline) -- QAM on empty stomach or at least 1 hour prior or 2 hours after meals

MetroCream 0.75%


-use sunscreen to prevent sunburns

-can cause GI distress

Monday, February 11, 2008

My Love Remix (Glaucoma Suspect)

http://www.youtube.com/watch?v=OJMEfGFbFMI

AzaSite "pink eye" drop

AzaSite 1% ophth soln (azithromycin)

recommended dosage: BID x 2 days, QD x 5 days (total of 9 drops vs. 21 other brands)

demonstrated prolonged high levels in ocular tissue

good for bleph/bacterial conjunctivitis/dry eye patients (exerts anti-inflammatory activity along with antibacterial activity)

Acetaminophen dosages

Age:
>2 mo. (5kg): 80mg per dose
>4 mo. (6.5 kg): 100mg per dose
>6mo. (8kg): 120mg per dose
>12mo. (10kg): 160 mg per dose
>2 years (13kg): 200mg per dose
>3 years (15kg): 240mg per dose
>5 years (19kg): 280mg per dose

well-hydrated child: 15 mg/kg q4-6hrs
dehydration risk: 10 mg/kg q4-6hrs
maximum: 90 mg/kg/day (up to 4 grams daily)

Thursday, February 7, 2008

Pyogenic granuloma

  • benign vascular lesion of the skin and mucosa
  • appear as a fleshy red mass with relatively rapid growth
  • Histology: mixed acute and chronic inflammatory cells, with capillary proliferation in a lobular pattern (capillary hemangioma)
  • occurs most often in children and pregnant women and may occur close to the site of a minor injury
  • causes: usually associated with some inflammatory process such as a chalazion, severe blepharitis and meibomianitis, as a foreign body reaction or trauma such as surgery (pterygium excision, chalazia incision and drainage, placement of orbital implants, nasolacrimal duct probing with silicone tube placement, insertion of silicone punctal plugs, blepharoplasty, and eye muscle surgery).
  • in most cases, these lesions will resolve with topical steroid administration x2-3 weeks
  • surgical excision may be required for those lesions that fail to resolve after topical treatment
  • in rare cases malignant neoplasms such as Kaposi’s sarcoma may mimic pyogenic granuloma
  • recurrence following excision is extremely rare

CRAO

Symptoms:

  • abrubt, painless vision loss (pain = OIS)
  • amaurosis fugax precedes visual loss in 10% of patients
  • men:woman = 2:1; mean age = 60; bilateral involvement = 1-2%

Findings:

  • VA 20/800 to LP (NLP = ophthalmic artery obstruction or temporal arteritis)
  • +APD
  • anterior segment normal (except if OIS, can have NVI)
  • ischemic whitening of the retina
  • cherry red spot at macula
  • ONH pallor with splinter retinal hemorrhages
  • 20-25% demonstrate visible emboli

Differential diagnoses:

  • mild, nonischemic CRVO
  • neuroretinitis
  • hypertensive retinoathy

Sequelae:

  • after 4-6 weeks, retinal whitening dissipates, leaving optic nerve pallor
  • arterial collaterals
  • absent foveal reflex
  • RPE hyperplasia from stress to the RPE
  • NVI/NVG = 18% (make referal for panretinal laser photocoagulation)
  • after >100 minutes, complete irreversible loss

Causes:

  • Blood conditions: coagulopathies or poor blood flow, antiphospholipid antibody syndrome, protein S deficiency, protein C deficiency, antithrombin III deficiency
  • Systemic disease: 60% of patients have HTN, 25% have DM, 50% no cause identified
  • Heart disease: 30% have carotid artery disease; Refer patients (especially those <50> 50 y/o
  • Optic neuritis
  • Local trauma producing damage to the optic nerve
  • Radiation exposure
  • Behcet disease
  • Migraine
  • Syphilis
  • Optic disc drusen
  • Prepapillary arterial loops

Management:

  • 350mg ASA, agressive digital ocular massage, topical beta blocker, oral Diamox 2 x 250mg (attempt to lower IOP to decrease resistance to nerve and retinal blood flow), breath into brown paper bag (stimulate rtinal arterials)
  • Labs:
  • CBC w/ differential and platelets
  • blood pressure
  • fasting BS
  • lipid panel
  • cholesterol
  • ESR (if yes, requires high-dose corticosteroid treatment)
  • CRP
  • HLA-B27
  • FTA-Abs
  • HIV
  • electrocardiogram with 2-D echo
  • transesophageal electrocardiogram
  • carotid doppler
  • MRI

Tuesday, February 5, 2008

msd Mini-Scleral Design (from Blanchard CL company)

  • designed to vault the cornea and fit on the sclera/conjunctiva, reducing the net-vault of the contact lens over the cornea
  • reduction in the chance of irritation and better centering
  • keratoconus fits that dont center or dislodge with eye mvmt
  • irregular cornea fits
  • GP-intollerant patients (chronic awareness)
  • sagital depth of the CL
  • trial fit progressively deeper vaults until corneal clearance achieved
  • compression ring on conjunctiva after full day wear is ok
  • if mid-peripheral or limpal touch exists, increase the mid-peripheral zone of the lens to move the surface of the lens off the cornea
  • if mid-peripheral space b/w lens and cornea is too great (causing an air bubble), which may cause epithelial desiccation, decreasing the mid-peripheral zone will minimize these issues
  • small air bubbles in periphery that move during lens wear don't interfere with vision or cause epithelial surface drying

Tears Again Hydrate

  • for dry eye, blepharitis, MGD
  • Rx only
  • omega-3 fatty acid, flaxseed oil, evening primrose oil, omega-6, bilberry extract
  • anti-inflammatory properties
  • 4 soft gels daily, directly or during meals/snacks
  • avoid taking at the same time with other medications or supplements, or if pregnant/nursing
  • possible side effects: intestinal blockage, thyroid problems, may reduce blood vessel platelet aggregation (if you're taking ASA or blood thinners have your clotting time checked, may lower the seizure threshold in patients taking seizure meds

Saturday, February 2, 2008

Visual Fields - documenting progression

Glaucoma Progression Analysis (GPA)
  • change in the total deviation values over time may be due to factors other than glaucoma such as advancing cataract or decreased pupillary size.
  • by using the pattern deviation values, the GPA software specifically targets the localized change associated with glaucoma
  • If there were a diffuse component to the glaucomatous change, it would not be reflected in the GPA result, but the more likely localized component due to the formation of new glaucomatous defects or the expansion and deepening of existing defects would be characterized
  • change needs to be present in 3 consecutive visual fields before progression can be confirmed
  • if progression has occurred and there is a resultant change in therapy, the clinician should
    establish a new baseline so that any additional progression can be found
  • if the patient undergoes ocular surgery or develops another ocular condition, new baseline
    tests after he stabilizes should be selected for use in evaluating subsequent examinations
Mean deviation plot
  • gives the slope associated with change in the mean deviation
  • this change will include anything that affects the subject’s visual sensitivity, including advancing cataract, and that it may not reflect change due to glaucoma.
  • The GPA software will automatically assess the next visual field (and the next) to determine if that change is repeatable.
  • If it is present on two consecutive tests, a half-filled triangle will appear at the location
  • For repeatable change on three consecutive tests, a closed triangle will appear.
  • The GPA software then assesses the repeatability of three or more points and gives a plain-language report of “possible progression” if two consecutive fields show that
  • the same three or more points changed from baseline or “likely progression” if three consecutive fields show change at the same three or more points.