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    Chronic Visual Loss: UBC Ophthalmology Club 2012

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    Marini Yusufina Lubis
    This document discusses common causes of chronic visual loss and the role of primary care physicians in screening for them. It addresses four main conditions: open-angle glaucoma, age-related macular degeneration, cataracts, and diabetic retinopathy. For each, it covers features, risk factors, examination findings, management options, and referral criteria to ophthalmologists. The key message is that early detection by primary care screening is important, as these conditions can often be managed or slowed if caught early, preventing irreversible vision loss. Primary care physicians should know when to refer patients with suspected chronic visual loss for specialist evaluation and treatment.

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    Chronic Visual Loss: UBC Ophthalmology Club 2012

    Uploaded by

    Marini Yusufina Lubis
    28 views24 pages
    This document discusses common causes of chronic visual loss and the role of primary care physicians in screening for them. It addresses four main conditions: open-angle glaucoma, age-related macular degeneration, cataracts, and diabetic retinopathy. For each, it covers features, risk factors, examination findings, management options, and referral criteria to ophthalmologists. The key message is that early detection by primary care screening is important, as these conditions can often be managed or slowed if caught early, preventing irreversible vision loss. Primary care physicians should know when to refer patients with suspected chronic visual loss for specialist evaluation and treatment.

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    This document discusses common causes of chronic visual loss and the role of primary care physicians in screening for them. It addresses four main conditions: open-angle glaucoma, age-related macular degeneration, cataracts, and diabetic retinopathy. For each, it covers features, risk factors, examination findings, management options, and referral criteria to ophthalmologists. The key message is that early detection by primary care screening is important, as these conditions can often be managed or slowed if caught early, preventing irreversible vision loss. Primary care physicians should know when to refer patients with suspected chronic visual loss for specialist evaluation and treatment.

    Copyright:

    © All Rights Reserved
    Download as PPTX, PDF, TXT or read online from Scribd
    Download as pptx, pdf, or txt
    28 views24 pages

    Chronic Visual Loss: UBC Ophthalmology Club 2012

    Uploaded by

    Marini Yusufina Lubis
    This document discusses common causes of chronic visual loss and the role of primary care physicians in screening for them. It addresses four main conditions: open-angle glaucoma, age-related macular degeneration, cataracts, and diabetic retinopathy. For each, it covers features, risk factors, examination findings, management options, and referral criteria to ophthalmologists. The key message is that early detection by primary care screening is important, as these conditions can often be managed or slowed if caught early, preventing irreversible vision loss. Primary care physicians should know when to refer patients with suspected chronic visual loss for specialist evaluation and treatment.

    Copyright:

    © All Rights Reserved
    Download as PPTX, PDF, TXT or read online from Scribd
    Download as pptx, pdf, or txt
    of 24

    Chronic Visual Loss

    UBC Ophthalmology Club


    2012
    Approach
     History, physical, tests
     Patient population tends to be the elderly, but 2% of
    adults in the US over age 40 have vision <20/40 (Congdon et
    al. 2004. Arch Ophthalmol 122(4):477-85.)
     Prevalence increases with age
     Early detection may lead to early intervention and
    preservation of vision
     Primary care is the first screen, know when to refer
    Case 1
     55M comes to GP for  Exam:
    routine physical  OD 20/30 OS 20/30
     Has HTN, currently on (both 20/25 2 years
    thiazide ago)
     Denies visual loss, eye pain,  Pupils equal reactive
    headaches  No RAPD
     Sister was taking an eye  EOM full
    drop but not sure what  Confrontational VF
    that’s for grossly intact
    Case 1
     Management:
     A. This pt needs urgent
    treatment to lower his IOP
     B. Refer pt to
    ophthalmologist 1-2 weeks
     C. Reassess pt in 3 months
     D. Increase his thiazide
    dose and consider adding a
    second antihypertensive

    Photo courtesy Dr. Fred Mikelberg


    Transillumination defect. (Kuo &
    Noecker, AAO 2009)

    Pseudoexfoliation. (Shaw, AAO 2003)


    Primary Open Angle Glaucoma
     Progressive optic neuropathy of unknown etiology with
    persistent VF defect
     Risk factors incl. elevated IOP, family hx, race, age, myopia
     Sx incl. gradual loss of peripheral visual field
     Further tests:
     VF testing of this pt reveals nasal step defect
     IOP: OD 29mmHg, OS 23mmHg
     Retina tomography shows moderate thinning of nerve fibre
    layer
     AAO recommends refer pt when:
     disc:cup >0.5 or one cup significantly larger than the other
     IOP > 21mmHg or >5mmHg difference between the eyes
     Sx of acute glaucoma
    Common Rx for glaucoma
     The only pharmacological target is lowering IOP
     Alpha agonists(↑drain, ↓aq): clonidine, brimonidine
     Beta blocker (↓aq): timolol
     CA inhibitor (↓aq): acetazolamide (Diamox)
     Prostaglandin analog (↑drain): latanoprost (Xalatan)
     SE of PG analog- iris color change and longer eye lashes
    Case 2
     70M c/o decreasing vision in both eyes over last 6 months
    to GP
     This is particularly bothersome as he is having more
    trouble reading and watching TV
     No eye conditions in the past
     Hx significant for obesity and 50 pkyr smoking, quit 5
    years ago
     Family history unremarkable
    Case 2
     OD 20/80, OS 20/100
     (last 2 years decreased)
     Pupils equal reactive
     EOM full
     CVF intact
     IOP within normal limits
     Fundoscopy:
     Amsler grid:

    (Khanifar et al. Retinal Physician, 2007)


     What do you tell this patient?
     A. he has missed the window for effective intervention
     B. he needs immediate antioxidant and zinc supplement
     C. his children are at increased risk of this disease
     D. his condition probably won’t cause complete blindness
    Age Related Macular Degeneration
     2 forms: atrophic (dry) and exudative (wet)
     Leading cause of blindness in adults >75 yr, mostly from
    exudative form
     Multifactorial disease, see characteristic drusen
     Early diagnosis enables detection of exudative form, which
    can be effectively treated with anti-VEGF agents
     Screening in primary care:
     Visual distortions, especially in central vision
     Presence of drusen in macula, retinal pigment breakdown
     Refer to ophthalmologist for full evaluation
    Wet AMD

    Monthly
    injection,
    $1600 per
    shot
    Case 3
     68F comes to GP with c/o decreased vision in her L eye
     She denies double vision or glares, in fact she said she can
    read better with her L eye than her R eye now; she wants
    to know if her reading glasses are still necessary
     No eye disease or trauma
     No family hx of eye diseases
     Meds include prednisone 20 mg daily for last 2 months
    for RA flare
    Case 3
     OD 20/30, OS 20/50
     Pupils equal reactive no
    RAPD
     EOM full
     Confrontational VF full
     Fundus visualized,
    unremarkable

    (Espandar, AAO 2009)


    Management
     What’s your course of action?
     A. Inform pt that her cataract is the result of her
    prednisone use
     B. This pt needs to see an ophthalmologist STAT because
    of risk of irreversible visual loss
     C. This pt’s presbyopia is improving so she should be
    followed up in 6 months at your office
     D. Referral to ophthalmologist for evaluation and
    treatment options
    Cataract
     Etiology: opacified lens
     Most commonly associated with increasing age, but also
    congenital, DM, steroid use, trauma, radiation
     Pt complain of painless gradual unilateral vision decrease
     “Second sight” refers to myopic shift as cataract increases
    power of lens; this is temporary
     Referral to ophthalmologist when decrease in vision
    becomes symptomatic and/or interfere with function
     Cataract removal+IOL implant is one of the most
    frequently-performed and successful procedures in all of
    surgery
    Other types of cataracts

    Cortical cataract Posterior subcapsular cataract

    Implantable IOL
    Case 4
     63M with 17 yr hx of Type 2 DM comes to GP to c/o
    decrease in vision in both eyes
     Denies pain, distortions, double vision
     Hb A1c 7.5% despite being on metformin and gliclazide
     Also has dyslipidemia, on atorvastatin
     No previous eye complaints
    Case 4
     OD 20/40, OS 20/60
     Pupils equal reactive, red
    reflex present
     EOM full VF intact
     AC deep and quiet
     Fundoscopy:

    (AAO, 2012)
    Diagnosis
     What is the cause of this pt’s decreased vision?
     A. Non-proliferative diabetic retinopathy
     B. Age related macular degeneration
     C. Proliferative diabetic retinopathy
     D. Branch retinal vein occlusion
    Diabetic retinopathy
     Microvascular complication of DM
     Most common cause of vision loss in adults 25-74 yr
     In NPDR, vision loss arise from macular edema
     In PDR, vision loss can be rapid, secondary to scarring
    and vitreous hemorrhage
     Ophthalmologist referral when:
     Newly diagnosed DM patient
     Eye exam every 1-2 years after
     Patient who develop rapid vision change
     Glycemic control is the cornerstone of systemic
    management. DR is managed with laser and anti-VEGF
    PDR

    Proliferative disease, characterized by Pan-retinal photocoagulation uses laser


    formation of new and fragile vessels to destroy ischemic retina in order to
    that form a tangle on the disc and prevent neovascularization and
    elsewhere. preserve the macula.
    Summary
     4 most common causes of chronic visual loss and their
    features:
     Open angle glaucoma- insidious, treat IOP
     Age related macular degeneration- distortions, most common
     Cataract- often unilateral, good result with surgery
     Diabetic retinopathy- check in all DM pt, bilateral visual loss
     All are either reversible or can be managed well
    (slow/stop vision loss) if detected early
     Therefore, primary care’s role is vital in screening of
    chronic eye diseases
    Questions?

     Edited by: Steven Schendel, PGY-4


     Reviewed by: Drs. Fred Mikelberg, David Maberley, Francis
    Law

     Contact:
     R Tom Liu
    [email protected]

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