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Chapter 1

TOPICAL OCULAR MEDICATIONS
Stick to what works best; avoid obsolete drugs.

A) Antibiotic drops

Polytrim 10 mL: for mild to moderate bacterial infections: effective, inexpensive, generic
Vigamox 3 mL, Zymar 5 mL: 4th generation fluoroquinolone, most effective topical antibiotics for severe infections (although only labeled for conjunctivitis so far)

B) Antibiotic ointment

Bacitracin: for all abrasions, lid margin staph, and any chronic use
Polysporin: for acute use, broader spectrum but may get toxic reaction with long term use
Ciloxan: for serious pediatric bacterial infections when frequent drop instillation is a problem

C) Antivirals

Viroptic 7.5 mL: for herpes simplex keratitis

D) Steroid drops

FML 1, 5, 10, 15 mL: episcleritis, epidemic keratoconjunctivitis, allergies, etc.
Pred Forte 1, 5, 10, 15 mL: for all iritis: most likely to cause posterior subcapsular cataracts and intraocular pressure (IOP) rise with long term use. Do not substitute generic if bad inflammation
Lotemax 2.5, 5, 10 mL: less IOP rise than Pred Forte, but use 1½ – 2x the dosing. Do not use for acute iritis

E) Antibiotic steroid combination drops

Tobradex 2.5, 5, 10 mL: combination tobramycin and 0.1% dexamethasone. Convenient combination treatment of staph marginal infiltrates
Zylet 2.5, 5, 10 mL: combination tobramycin and loteprednol for more safety and steroid potency

F) Antibiotic/steroid ointment

Tobradex ointment: convenient treatment of inflammatory blepharitis

G) Topical analgesia

Voltaren 2.5 or 5 mL or Nevanac 3 mL: NSAID pain reduction
Proparacaine 0.5% 15 mL or tetracaine 0.5% 15 mL for short term topical anesthesia for most topical procedures
Lidocaine 4% used topically is the most effective drop for painful procedures. Use with 2.5% phenylephrine to increase duration

H) Non-preserved bottled artificial tears: Gen Teal, Refresh Tears, Refresh Liquigel, Systane, Optive

Do not cause preservative sensitivity
Are less expensive and more convenient than single dose drops
Use if will need chronic dosing >four times per day (qid), will save having to sort out a worsening dry eye vs. preservative sensitivity later
All other tears can be used for less frequent dosing. There is little clinical difference
Restasis (cyclosporine 0.05%): an immunomodulator eye drop to treat many of the underlying inflammatory causes of dry eye. Topical steroids such as Lotemax are also helpful (very expensive and improvement takes months)

I) Anti-rosacea: MetroGel, MetroCream or MetroLotion

Labeled to apply to affected skin, not eyes
Published evidence that it works on ocular rosacea also, with no side effects

J) Anti-allergy drops

Mild to moderate symptoms (Sx): Similasan Allergy Eye Relief 10 mL tid – qid, works well instilled while wearing contacts (unlabeled use)
Acute Sx: Naphcon A 15 mL or equivalent, not for chronic use
Moderate to severe acute or chronic Sx: Pataday 2.5 mL once per day, more frequent dosing may cause irritation
For severe Sx, use FML qid with Pataday for a short course

K) Dilating drops

Mix 1, 15 mL bottle of 1% Mydriacyl with 1, 5 mL bottle of 10% phenylephrine for quicker drop instillation and better views
Must maintain sterile conditions; you are potentially liable if there is a problem
Paramyd gives good dilation with less cycloplegia side effect

L) Celluvisc: to cushion a contact fundus or gonio lens, or to lubricate an abrasion

M) 1% Cyclogyl 2, 5, 15 mL: for small abrasions or iritis, lasts 3 – 4 hrs

N) 5% homatropine 5 or 15 mL: for abrasions and foreign bodies, cycloplegia lasts 2 – 4 days

O) 1% atropine 5 or 15 mL: for non-acute iritis, kids with ciliary spasm, cycloplegia lasts 3 – 5 days

P) Glaucoma: see glaucoma chapter for use recommendations

Once per day beta blockers
1. Timoptic XE 0.25% and 0.5%, 2.5 and 5 mL
2. Betagan 0.5%, 2, 5, 10, 15 mL
Twice per day beta blockers

Timoptic, Betimol 0.25% and 0.5%, 5, 10, 15 mL
Betagan 0.25%, 5 and 10 mL
Betoptic S 0.25%, 2.5, 5, 10, 15 mL
Ocupress 1%, 5 and 10 mL
OptiPranolol 0.3%, 5 and 10 mL

Other medications

Alphagan P 0.15%, 5, 10, 15 mL
Trusopt 2%, 5 and 10 mL
Xalatan 0.005%, 2.5 mL
Lumigan 0.03%, 2.5 and 5 mL
Travatan Z 0.004%, 2.5 and 5 mL
Azopt 0.5%, 5 mL

Combinations

Cosopt: 0.5% timolol with Trusopt, 5 and 10 mL
Xalcom: 0.5% timolol with Xalatan
Combigan: 0.5% timolol with Alphagan 0.2%
Extravan: 0.5% timolol with Travatan. Available soon

Chapter 5

RED EYE MISCELLANEOUS

A) Lids and margins

Subjective: from no Sx to itching and burning lids to intense pain
Objective

Blepharitis: flakes to heavy crusting with lid redness and swelling, foam along lid margin
Meibomian gland disease (MGD)

Telangiectasia: look carefully at lid margins and note facial rosacea
Express meibomians on all 4 lids. Note capping

Hordeolum (stye) or chalazion: note and draw size and location

Assessment

Blepharitis: grade for reference as you follow improvement
MGD grading scale

Grade 0: light, clear, oily secretion easily expressed
Grade 1: “milky” secretion easily expressed
Grade 2: “chunky, greasy” secretions are expressed, also see chunks floating in tear film after expression
Grade 3: “toothpaste” squeeze expressed with resistance
Grade 4: “toothpaste” squeeze expressed with high resistance or not at all (use 2 opposing cotton tipped applicators)

Hordeolum: note if it is erupting or pointing
Chalazion: long standing, non-painful, not red, lump. R/O skin cancer

Plan

Blepharitis: soak and scrub bid OU

Very warm compresses every 5 – 10 min
Thorough scrubbing of lid margins with lid scrub soap, preferably anti-bacterial
Rinse
Severe cases will benefit from bacitracin ung bid on margins
If marked lid margin inflammation, use Tobradex ung
RTC in 2 weeks

Soak and scrub tid if possible. Hot soaks are even more important
Squeeze out the meibomian glands in a milking action
Topicals are little help
In severe cases, Rx doxycycline 100 mg bid po (unless pregnant or growing child) until improves and then 50 – 100 mg qd for long term maintenance
RTC in 2 weeks

Hordeolum

Cannot excise until it quiets
For lots of heat delivery, boil an egg or microwave a potato and wrap in a damp washcloth and apply to the lid
If painful, Rx doxycycline with heat
If pointing: express, open if necessary (only if pointing!)
RTC in 2 – 4 days

Chalazion

Inject 0.2 – 1 mL of Kenalog unless darkly pigmented (this may depigment the skin)
Excision is the most common procedure. If recurrent, send to pathology to R/O cancer
RTC prn if no procedure done

B) Dry eye

Subjective

History of dry, scratchy or foreign body sensation, or transient blur improving with blink
In teen, ask about Accutane use
Possible Sjögren’s Sx such as dry mouth
Sx may wax and wane according to environmental conditions such as humidity, air conditioning, etc.
8% of women >age 50 affected

Objective

May have blepharitis or meibomianitis which may be contributing to a dry eye, or the entire cause for Sx
Corneal and/or conjunctival staining with fluorescein
Minimal tear prism
Poor tear quality or break up time <5 sec

Assessment

R/O lid disease
R/O epithelial basement membrane disease (EBMD), foreign bodies, and other corneal problems
Determine if it is a tear quality problem (matter or greasy chunks in tears, poor break up time) or a tear volume problem (small tear prism or reduced Schirmer’s with anesthetic)

Plan

Tear quality problems are usually caused by meibomianitis

Mild to moderate: Rx hot soaks and lid scrubs bid or more with tears prn
Severe: oral tear quality treatment for meibomianitis and rosacea. Beware of causing or aggravating cholesterol problems with the oils. Always use non-preserved tears, hot compresses and lid scrubs concurrently

Flaxseed oil 1 gram bid po with meal
Fish oil 1 – 2 grams per day
Doxycycline 100 mg po bid for 1 month then qd for 2 months

Tear volume problems, a staged approach

Mild: preserved tears 1 – 3x/day
Moderate: non, or minimally preserved tears such as Genteal, TheraTears, Refresh Liquigel, Systane, Refresh Plus, or Optive, if dosing of 4x or more is needed to prevent confusion with solution sensitivity problems later. Overnight protection with Refresh Plus gel may also be needed
Advanced

Punctal plugs with non-preserved lubrication as needed
Restasis (cyclosporine 0.05%) bid or topical FML qid as inexpensive trial. Expect 1 – 3 month delay in Sx improvement, especially if inflammatory component suspected

Severe tear volume problem or Sjögren’s

Use topical anti-inflammatory treatment in addition to plugs and lubrication and possibly goggles
Add oral treatment: Salagen (oral pilocarpine) 5 mg bid to start, then qid. Half fail due to GI upset though

C) Conjunctiva: itchy-scratches/red eye differential

Subjective: history is very important

If history of exposure to someone with a red eye, probably viral etiology and is contagious
Ask if recent upper respiratory infection (URI) symptoms such as sore throat or rhinitis
For subconjunctival hemorrhage ask about lifting, straining, constipation, blood thinners, aspirin, and supplements such as garlic, ginger, ginseng, ginkgo biloba
Ask about itching vs. burning, stinging, scratchiness
Ask if lids are matted shut or have purulent discharge. Is there ropy mucus or slippery tears?

Objective

Palpable or tender pre-auricular nodes (PAN): sometimes helpful, document
Look at margins and meibomians
Grade the amount of, and color of, injection
Grade the chemosis
Note any follicles: rarely helpful but document
Note presence of and quality of mucus
Draw subconjunctival heme
R/O iritis and angle closure

Always take BP with subconjunctival heme

Assessment

Allergic conjunctivitis: itchy, ropy mucus, slippery tears, mild injection, more chemosis, environmental correlation
Viral conjunctivitis: much more common than bacterial, burning, prominent mucus including matting shut is possible, “pink” injection, follicles and PAN may (or may not) be present. History usually indicates contagious exposure and infection starting in one eye followed by the other eye
Bacterial conjunctivitis: bacterial conjunctivitis without blepharitis is actually quite rare and usually over diagnosed. Beefy redness and prominent mucus are common
Subconjunctival hemorrhage: pooling of blood in an asymptomatic eye

Plan

Allergic

Mild to moderate: Similasan Allergy Eye Relief
Moderate to severe: Pataday qd – bid may be necessary (note, higher doses may cause burning and dryness)
Severe may need FML or Alrex qid until controlled enough for Patanol
RTC in 1 – 2 weeks

Viral

Counsel about hygiene, frequent hand washing, personal wash cloths, clean pillowcases
Counsel that the patient is likely to be contagious as long as the eye is tearing
Rx vasoconstrictors or tears as needed
FML if serious subjective and objective findings (such as infiltrates in the visual axis)
RTC in 1 week

Bacterial

Treat lids with scrubs even if they look clean; this will reduce the bacteria reservoir around eye where drops are not effective
Rx Polytrim qid – q2h
RTC in 2 – 5 days

Subconjunctival hemorrhages

Do not blow them off!
Take BP!

Systolic >220 or diastolic >115 with end organ damage (subconjunctival heme) is an emergency. If the medical doctor cannot see the patient immediately, send to the emergency department
If hypertensive, do at least direct ophthalmoscopy to check for papilledema or other retinopathy
RTC prn unless eye pathology is found

D) Contact lens associated red eye (CLARE)

Subjective

History of contact lens wear recently or presently, especially soft or overnight wear (even with silicone hydrogel), dirty lenses, non-compliance with lens replacement schedules
Red eye, epiphora
Pain or foreign body sensation
Photophobia
Blur

Objective

VA may be normal or reduced
If the lens is still in, it may be fitting tightly
Conjunctival injection, local, limbal, or diffuse
Mattering possible
Corneal edema, infiltration, staining, and ulceration are all possible
AC cell, flare, or pigmentation are all possible

Assessment

Is there only epithelial edema or stromal striae?
Is there white blood cell infiltration, especially near the limbus?
Is there epithelial staining and cell death?
Is there a frank ulcer with cloudy infiltration of the stroma vs. an anterior stromal reaction on the surface of the stroma?

Plan

For edema only, remove the lenses and use lubrication drops prn for comfort. RTC in 2 days. No lens wear for one month, re-check the fit, re-instruct on wearing schedules if necessary
For infiltration, stop lens wear and Rx Tobradex qid. RTC in 1 day to be sure not progressing to ulceration or HSV
For subepithelial infiltrates with staining, stop lens wear and Rx Vigamox q2h. After re-epithelialization, add Pred Forte qid. Alternatively, Tobradex q2h if there is no suspicion of ulceration. RTC daily until improvement noted
For a true corneal ulcer with white blood cells (WBC) or infiltrates in the stroma, striae, AC reaction, but not large or central

Remove contacts
Rx Vigamox q5 min for 1 hr then q30 min during the day and q1h at night. Alternatively Polysporin ung hs can be used for the nighttime dosing
Rx 5% homatropine bid for pain
RTC in 1 day

Large or central true ulcer

Do Gram stain and culture on blood, chocolate, thioglycolate broth and Sabouraud’s or refer to be done. If using culturette, be sure to moisten swab first by breaking vial
Refer for fortified antibiotics. Vigamox and Zymar may be as effective, but are not FDA approved for ulcers yet

E) Cornea

Subjective: from scratchy, foreign body sensation to intense pain
Objective

Look carefully with a good slit lamp and white light for epithelial erosions, filaments, epithelial basement membrane disease, striae, infiltrates, endothelial loss or keratitic precipitates (KPs), AC reaction
Stain lightly with fluoro-strip and look for the staining pattern. Fluress is too viscous and will hide light staining

Assessment

Punctate epithelial erosions (PEE): only see after stain. Mild damage
Punctate epithelial keratitis (PEK): see white defects before stain. May cause positive or negative stain. More damage. This grading system will allow you to more closely follow healing or deterioration
Superficial punctate keratitis (SPK): this term is only correct in Thygeson’s disease
Overall pattern: virus, dry eye, eye drop sensitivity
Inferior 13 stain line pattern: assume staph marginal keratitis or lagophthalmos
Note if diffuse or confluent stain pattern, draw
Do not use too much fluorescein; look carefully for negative stain, indicating an elevated area (epithelial basement membrane disease, HSV keratitis or Thygeson’s)
AC reaction up to hypopyon is possible: look at the inferior angle!
Striae
WBC or infiltrate in stroma vs. “anterior stromal reaction”
Is the stain pooling in a depression or is it staining cells (dendrite vs. pseudo-dendrite, staining Lasik flap vs. normal flap gutter)?

Form a fine strand of cotton on a cotton tip applicator
Wick away fluorescein; if pooling, it will disappear, if staining it will stay stained

Deep achy pain and photophobia
Prepare slide for Gram stain, culture on blood, chocolate, thioglycolate broth and Sabouraud’s. Use sterile spatula or spud

Plan

Filaments

Remove by rotating a sterile cotton tipped applicator moistened with anesthetic
Rx topical antibiotics and aggressive non-preserved tear application
Avoid ointments
Consider temporary disposable CL with antibiotic use; it will melt filaments beneath the lens
Treat the cause of the filaments
RTC in 2 days

Subepithelial infiltrates: epidemic keratoconjunctivitis

Lubricate and counsel if few Sx
Probably not infectious at this stage, but wash your hands anyway!
Instill topical anesthetic
Instill 1 drop of ophthalmic Betadine
Irrigate well
Rx FML or Tobradex qtt qid
RTC in 2 – 4 days

Bacterial keratitis

Simple bacterial keratitis

Polytrim qid – q2h
Lid hygiene
RTC in 2 days unless CL related, pain increases or vision decreases

Staph marginal infiltrates without AC reaction

Tobradex q2h or Vigamox qid with Pred Forte qid
Lid hygiene
RTC in 2 days unless CL related, pain increases, or vision decreases

True corneal ulcers or CL related

Start on Vigamox q5 min for 1 hr then q30 min during day and q1h at night if bad. Polysporin ung hs if less worrisome. Tobradex ung hs can be used later if need steroid for scarring
Rx 5% homatropine bid for pain
RTC in 1 day
Pred Forte qid after ulcer is healing and sterile

Large or central true corneal ulcer

Refer or do stain and culture, and then refer for fortified antibiotics
Vigamox and Zymar may be as effective as fortified antibiotics without the toxicity for most pathogens, but they are not FDA approved for ulcers yet

Fungal ulcer

History (Hx) of vegetative abrasion or a chronically sick eye
Gray feathery infiltrate, satellite lesions
Very painful, little pus
Does not respond to antibiotics
REFER!

Acanthamoeba

Ring stromal infiltrate around the ulcer
Usually a CL wearer or a swimming Hx
Unusually painful!
Non-responsive to antibiotics
REFER!

EBMD

If the epithelium is loosely attached

Debride it back to healthy margins with a spud, forceps
Lightly abrade Bowman’s membrane with an Alger brush to facilitate epithelial attachment

Instill cyclopentolate or 5% homatropine for ciliary spasm
Instill Voltaren for comfort
Instill bacitracin ung and pressure patch for up to 24 hrs, then Rx bacitracin ung tid
Alternatively, insert a bandage lens and Rx Polytrim gtt qid
RTC in 2 days
Use 5% NaCl ung hs for 2 months
If recurrent, try stromal micropuncture
If still recurrent, consider excimer PTK

F) Herpes simplex virus (HSV)

Subjective: usually unilateral, red, photophobic, tearing
Objective

May have lid or skin involvement
May have tender or palpable pre auricular nodes
Look for dendrites with end bulbs
Compare corneal sensitivities with cotton wisp
Look for cells and flare
Measure IOP

Assessment: R/O pseudo-dendrite (a healing abrasion line) by

History: ask how it felt yesterday. If it was a lot worse, it is a healing abrasion. If pain is worse today, it is a likely HSV dendrite
Pseudo-dendrites do not have end bulbs that stain with rose bengal or lissamine green
If you are still unsure of diagnosis, lubricate with bacitracin ung and RTC in 1 day. If worse, treat as HSV

Plan

Be sure patient is off of any steroid
Consider gentle debridement of dendrite with sterile cotton tipped applicator to reduce viral load (experts disagree)
Rx Viroptic 1% 9x/day (q1h – q2h)
Pediatric use: if the child is uncooperative with drops and tearing is diluting the Viroptic, co-manage with pediatrician to Rx acyclovir, Valtrex, or Famvir. 2 or more yrs of slow taper may be necessary
Instill 5% homatropine (or atropine 1% if severe)
RTC in 2 days, draw and monitor ulcer size
Viroptic 5 – 9x/day for 2 weeks then taper for 1 week, lubricate with bacitracin ung
If there is still a remaining defect, need to discontinue Viroptic because it becomes toxic and it may be the reason for the defect. If no rose bengal stain, probably no active virus; lube aggressively and watch
If you need further viral coverage, Rx oral acyclovir 200 mg po 5x/day or Valtrex 500 mg po bid, or Famvir 125 mg po bid. Consult with an internist if kidney problems or pregnancy
Stromal reaction under dendrite, watch carefully, should fade gradually
Stromal disease: REFER!

Disciform: disk shaped stromal edema with intact epithelium, local KPs, possible mild iritis
Necrotizing interstitial: multiple or diffuse infiltrates with thinning, neovascularization, inflammation. Possible hypopyon, iritis and glaucoma
Neurotrophic ulcer: a sterile, melting ulcer

G) Herpes zoster (HZO) (shingles)

Subjective: pain, usually intense on one side of the face
Objective

VA and pinhole or best corrected VA
External: note and draw vesicles and note if they are wet or dry
Versions to R/O extra ocular muscles (EOM) palsy
IOP: glaucoma is a common side effect of HZO
Slit lamp: conjunctivitis, diffuse corneal staining, pseudo-dendrites from mucus plaques, and iritis may be present
DFE: important to R/O rare but devastating retinitis or vitritis

Assessment: HZO respects the midline (vs. HSV)
Plan

Treat any IOP rise, iritis or corneal staining in the usual way
Treat IOP without prostaglandins if iritis is present
Be sure the patient is on antivirals or you will need to Rx acyclovir 800 mg 5x/day or Valtrex 1000 mg bid (if not pregnant or renal failure) for 10 days
Tylenol 3 and Zostrix may be needed for skin neuralgia (keep out of the eye), very painful
If the eye is unaffected, RTC in 1 month and repeat exam for late onset ocular complications

H) Episcleritis

Subjective: red eye with painless to moderate pain or tenderness
Objective

Sectorial or diffuse deep injection of episclera. Nodules are possible, often with pingueculae
R/O iritis

Assessment

R/O conjunctivitis by clinical examination. Also 2.5% Neo-Synephrine will blanch conjunctivitis quickly, but not episcleritis
R/O scleritis: scleritis pain is usually deep, severe and radiating. Scleritis causes extreme sensitivity to touch or pressure through the closed lid. Scleritis redness will not blanch with 10% phenylephrine, episcleritis will

Plan

Mild: tears prn
Moderate: FML qid
Severe: Pred Forte qid or more, ibuprofen 400 mg po qid
RTC in 1 week
Consider other connective tissue disease

I) Scleritis

Subjective: may be deep, severe, radiating pain, red eye, very sensitive to touch through the closed lid
Objective

Injection of deep vessels and purple or blue tinge of sclera observed with normal room lighting
Nodules may be present

Assessment

Vessels are not mobile with cotton swab
Vessels do not blanch with 10% phenylephrine
Pain is usually intense
Iritis, corneal, lens, retinal changes may co-exist; do a dilated fundus exam
Many have connective tissue disease

Plan

Internal medicine or rheumatology consult
Oral prednisone 80 mg po in divided doses until improvement, then slow taper
Ibuprofen 600 mg qid po
RTC in 2 days
Refer if no improvement in 1 week

Chapter 8

GLAUCOMA - LONG TERM MANAGEMENT

A) Subjective: usually no subjective signs or symptoms

B) Objective

Age: treat younger patients more aggressively (lower target pressure). They will probably gradually lose some field regardless

0.1% incidence in Australians 40 – 45 yrs old
10% incidence in Australians >80 yrs old

Race: treat black patients more aggressively. They are 4x more likely to develop glaucoma than whites and are more likely to progress
Medical history

Encourage compliance in treating cardiovascular diseases such as diabetes, hypertension, high cholesterol, heart disease, etc.
Systemic beta blockers will cause 2 – 4 mmHg IOP lowering and may make topical beta blockers ineffective. The IOP can go up if a systemic beta blocker is discontinued
History of significant blood loss (bleeding ulcer or major surgery) can account for optic nerve damage. Treat as possible low tension glaucoma (LTG), and monitor nerve and fields for progression to determine goal IOP
History of migraine is a risk factor for LTG

Family history

How many family members have glaucoma? Maternal Hx is worse. A 10% risk of primary open angle glaucoma (POAG) if close relatives have it (4x – 8x increased risk)
At what age did they develop glaucoma?
Did they have LTG? Indicates increased risk

Find out pretreatment IOPs
Start a glaucoma flow sheet listing dates, IOPs, CDs, meds used
Set initial target IOPs; some rules of thumb

LTG with pretreatment IOP in mid teens: goal 8 – 12
Advanced POAG field loss and <0.1 rim or notched out, goal: low teens (10 – 13)
Moderately advanced POAG field loss and at least a 0.1 rim through 360°, goal <15
Common early POAG, goal = 18
Ocular hypertension or POAG with pretreatment IOP 28 or higher, goal = 21

In one major study of primary open angle glaucoma, no patients with stable IOP ≤ 14 mmHg progressed. 4% of those with IOPs ≤ 17 had progression
Update and lower target IOPs by at least 2 – 3 mm if

Increasing CDs according to stereo photos or careful disk drawings
Confirmed field progression (repeat)

Do serial tonometry to get a reliable baseline: a variable high IOP is more damaging than a stable high IOP

Initially if LTG
Initially if variable IOP Hx
If you later question the accuracy of the glaucoma diagnosis, or the efficacy of medications, stop drops for 2 weeks and do serial IOP
If fields or nerves progressively deteriorate despite meeting target IOP, do serial tonometry while on medications
Take the first IOP by 8:00 a.m. if possible, then every 1 – 2 hrs until the end of the day. To bill serial tonometry you need 5 readings.

Get accurate, reproducible applanation readings. No other method is acceptable for treating glaucoma

Align tonometer axis with corneal toricity if it is highly toric
Ask the patient to breathe normally and relax
Measure right eye (OD), left eye (OS), OD; if OD readings are consistent, stop; if subsequent readings are lower, keep repeating measurements until consistent
A 10% or 2 mm error is possible with a single reading. Repeat until consistent, then allow 1 – 2 mm variance from goal IOP
Most error factors artificially elevate readings. Your lowest reading is usually the accurate one
Corneal thinning such as caused by excimer laser refractive surgery lowers applanation readings by approximately 3 mmHG
Goldmann tonometer calibrated for a 520 micron cornea. Pachymetry is very helpful here

For each 20 microns >520, reduce your reading by 1 mmHg for true IOP
For each 20 microns <520, increase your reading by 1 mmHg for true IOP

Gonioscopy

Do initially as part of a glaucoma workup and yearly thereafter
Be sure the angle is not occluded or occludable. Record the most posterior structure seen without depressing the cornea
A Posner lens is less likely to cause striae in the cornea while viewing than a Zeiss lens. A Goldmann lens should give the truest view of the angle but takes longer
Only the posterior half of the trabecular meshwork drains aqueous
Record the amount of pigment in the meshwork
Heavy pigment with a concave iris may be a clue to pigment dispersion caused by a reverse pupil block. This may be treated with a peripheral iridectomy if
Look for pigment clumping, inflammatory debris and exfoliative debris in inferior angle
Look carefully for rubeosis if there is a history of diabetes or vein occlusion
Look for angle recession if a history of ocular trauma
Repeat yearly; initially open angles can close over time and cause combined mechanism glaucoma
Do after applanation; it only takes a minute with a Zeiss or Posner (the cornea is already anesthetized)

Monitor optic nerves carefully

Recommend 90 D or 78 D fundus lens
Contact lens or gonio lens view is also excellent
Direct and binocular indirect ophthalmoscope (BIO) view is not acceptable to treat glaucoma
Do not use Superfield or 60 D unless you are aware when you lose binocularity. These lenses need a large dilation to get binocularity, often impossible in elderly. When viewing binocularily they give an enhanced view of depth and contour
Catching nerve head changes is most important in ocular hypertension and early glaucoma when the nerve is relatively healthy and there is not enough damage to cause a visual field defect for your perimeter to track
Stereo photos highly recommended

Nidek stereo photos are best, standardized, enhanced stereopsis
35 mm stereo slides or digital photos also good; need a stereo viewer
Non-myd and Polaroid cameras do not have enough resolution
Repeat photos when the disk changes
Progression of peripapillary atrophy indicates glaucoma progression

Disk drawings are necessary, especially if you have no camera

Recommend a 10×10 grid circle, stamp or preprinted
Record horizontal and vertical CD on all routine exams
If CD >0.7, look at the rim, not the cup
Memorize the rim thickness at the actual 12:00, 3:00, 6:00, and 9:00. Then mark your grid at those locations. Sketch the cup margin, note pallor and slope. Draw contour. Do not be fooled by color change. Use stereopsis to see the edge; search the rim methodically
ISNT rule: in a healthy optic nerve the inferior rim is usually thickest, followed by the superior, nasal, and the temporal rim is the thinnest
Consider a direct ophthalmoscopy view at each IOP check to catch disk hemorrhages. Assuming no other causes such as diabetes or vein occlusion, hemorrhages may indicate progression of the glaucoma. Lower the IOP if feasible; watch for a future notch and field loss here

Nerve fiber layer analysis

Use a direct ophthalmoscope with a red free filter
Look for a darker, slit shape defect in the shiny superior and inferior NFL reflection or a relative difference in appearance between superior and inferior NFL
Very difficult, clear media are necessary
Get an automated nerve fiber layer analysis done if in doubt and you need the information to make the diagnosis

Computerized nerve head and nerve fiber layer analysis: in early questionable glaucoma, access to an automated nerve fiber layer analyzer can be valuable. Once the field loss is established, careful visual fields are the most accurate way to follow progression. In advanced age or senility, yearly nerve fiber analysis may have to take the place of yearly fields
Estimate nerve size: a 0.7 cup in a small nerve is more significant than a 0.7 cup in a large nerve. This information is very helpful in borderline cases

Direct ophthalmoscopy

Shine spot on the nerve head with a dilated pupil
Record nerve size as normal or as a percentage of normal size
Sizes usually range from 80% – 130% of normal size

Indirect ophthalmoscopy

Use a 66 D superfield lens
Adjust the width of your beam to match the width of the nerve head
Read the scale for the beam width on the slit lamp
1 mm = 1000 microns (very small)
1.5 mm = 1500 microns (normal)
2.0 mm = 2000 microns (very large)

Very useful in making the initial diagnosis in borderline cases

Peripapillary atrophy is a minor risk factor, but progression of atrophy may be a sign of glaucoma progression

Automated visual fields

FDT or Matrix: frequency doubling technology by Humphrey-Zeiss

An effective, rapid visual field screener
Not a substitute for traditional automated fields when diagnosing or following glaucoma
Can miss small scotomas

Humphrey-Zeiss (see Chapter 9)

Fovea thresholds are important for long term care
Overview and statistical analysis are best for long term care
Humphrey is the dominant field analyzer
It is not important that all medical doctors use Humphrey. It may be important to use what your glaucoma tertiary care doctor uses so you can directly compare fields
Humphrey Field Analyzer II (HFA II) is worth upgrading to if you need a new machine because of new features

Swedish interactive thresholding algorithm (SITA Standard): the new standard of care

½ the time of a full threshold
Defects show as less deep
Probably represents visual function better than a full threshold because of less fatigue

SITA Fast

Takes about as long as a screening field, but it gives some threshold information for the elderly or inattentive
It is not acceptable to use for routine glaucoma care

Short wavelength automated perimetry (SWAP) (blue-yellow) perimetry can detect field loss earlier, but

A very difficult test for patients to take. Use only on experienced alert patients with clear media
Ignore mild defects because of false positives. A cluster of 4 points at P<5% or 3 points at P<1% yield sensitivity of 95% and specificity of 75%
Repeat the test to increase confidence

If you have a series of fields on a patient and you are worried about possible deterioration, repeat the same strategy for an apples to apples comparison. If you are confident the patient is stable, you can perform a SITA Standard for a new baseline, but expect the defects to be less deep. Humphrey claims the SITA result is actually a more accurate representation of the visual field
Recommendations

24-2 SITA Standard with fovea threshold: use on new glaucoma patients if time is a concern, 7 min
30-2 SITA Standard with fovea: use for suspected central nervous system disorders. Best for glaucoma in case the scotoma goes to the edge of a 24-2 field and other conditions, 9 min
24-2 SITA Fast without fovea threshold: no fluctuation data and less reliability. Use only when the patient is unable to do a longer test, 4 min
Choose a size V stimulus in advanced glaucoma when the field is mostly blacked out
Choose a central 10° field when that is all that is left or if there is paracentral loss so you can more closely track changes
Monitor fovea threshold, Snellen acuity, and count finger vision depending on the severity of the loss. Glaucoma does affect central vision eventually
Ask the patient how his/her vision is doing. Patients can tell when they are progressing in late stage disease

Write up instructions for dilation, lenses, strategy, etc. for staff
Do visual field (VF) interpretation, assessment, plan. Write interpretation in the chart. Describe the field loss and whether it is stable or progressing. Bill evaluations and management (E&M) if you do examine the patient (see Appendix — Medical Coding), and VF

C) Assessment

Review the total picture once a yr or whenever you suspect progression

Pretreatment IOP, treatment IOP, and current IOP
Pretreatment nerve appearance, progression, current nerve appearance
Pretreatment visual fields, progression, and latest field
Is the angle closing and causing combined mechanism glaucoma?
Has the patient’s general health changed substantially?
Review drop instillation
Review compliance
Review side effects

What is the patient’s life expectancy versus the rate of vision loss? We all lose some function naturally as we age (0.1 decibel (db) of mean deviation per yr)
Consider the benefit of very aggressive therapy versus the cost in time, money and quality of life for the patient. Take into consideration the patient’s life expectancy
When treating with multiple medications, consider stopping one or more of them to see if they are still effective
Always ask about side effects from the medications
Always set a new target IOP when you do a DFE or at least once a yr
You need to consider that there is a high risk of progression of vision loss with treated POAG over long periods of time

After 20 yrs of treatment, a 27% probability of legal blindness in one eye and a 9% probability of blindness in both eyes
Twice as many cases of blindness are due to visual field criteria as are due to central acuity loss. Patients are not functionally impaired by peripheral loss as much as by central loss

Risk analysis by Graham

Ocular hypertension risk analysis by Graham

Risk factors are thin corneas, large CD, IOP, age
Non-treated, 9.5% progress
Treated, 4.4% progress

Risk factors are female sex, migraine Hx, disk hemorrhages
Non-treated, 60% progress
Treated, 20% progress

Early glaucoma

Risk factors are exfoliation, IOP, VF loss, age, disk hemorrhages
Non-treated, 62% progress
Treated, 45% progress

Advanced glaucoma

Risk factors are IOP, age, IOP fluctuation
Non-treated, no data
Treated, 30% progress

D) Plan

POAG medications: we do not “treat glaucoma,” we treat a risk factor: pressures

First line medications: prostaglandins

Xalatan 0.005% (Lumigan 0.03%, Travatan 0.004%), Travatan Z 0.004% (no BAK preservative)

Qhs dosing helps compliance
Very effective, 25% – 30% IOP drop in patients for whom the drug is effective
These drugs are best at flattening the diurnal curve
Travatan: more effective in blacks
Warn about possible iris changes, especially in a hazel iris
Rare thickening and pigmentation of lashes
Iritis and CME also possible, but usually with preexisting risk factors such as pseudophakia, aphakia, a compromised retina, history of iritis, or recent eye surgery
May take >1 month to reach full effectiveness
Theoretically not additive with Pilo, but actually works sometimes
Due to uveo-scleral outflow mechanism of action, lower pressures are possible when treating LTG

Beta blockers have a longer track record, but must be used with caution in patients with heart or lung problems. Expect about a 25% IOP drop. Most require bid dosing

Cardioselective, less IOP drop but better nerve micro circulation in LTG

Betoptic S 0.25% (shake) preferred

Once a day dosing; use in the a.m. is more effective

Timoptic XE 0.25% and 0.5%
Betagan 0.25% and 0.5%

Neuroprotective? Less nocturnal systemic hypotension and less decrease in “good” HDL

Ocupress 1.0%
Betoptic S 0.25%

The rest: (Who will give you samples?)

Timoptic 0.25% and 0.5%
OptiPranolol 0.3%
Generics
Put p.m. dose in at supper time so hypotensive side effects can be noticed

Second line drugs

Trusopt 2%, Azopt

Topical versions of carbonic anhydrase inhibitors work about as well, without the side effects
Approximately 16 – 20% IOP drop
Bid gives as much effect as the recommended tid unless a dark iris color
Azopt should sting less, less expensive

Alphagan P 0.15%

A less toxic and less allergenic form of Iopidine
Bid as effective as tid
Approximately a 20% IOP drop expected
May be neuroprotective
Do not use

Cosopt bid: combination of 0.5% Timoptic and Trusopt 2%, very useful and potent. Could also combine with Alphagan if needed for neuroprotective effect
Combigan: combination of Alphagan 0.2% and timolol 0.5%, bid dosing
Xalcom: combination of 0.005% Xalatan and timolol 0.5% maleate. Once per day dosing, time so peak effect of timolol covers the diurnal peak. Available soon
Extravan: combination of travoprost 0.004% and timolol 0.5%. Available soon

Third line drugs

Pilocarpine drops 1% – 4%

A last medical resort, but they are very effective and the symptoms are usually well tolerated in the elderly
Warn about miosis, brow ache, retinal detachment Sx
Tid dosing with punctal occlusion works as well as qid
Have the patient discontinue 2 days before a yearly dilated fundus exam
Inexpensive

Pilopine HS gel or Ocusert

Hs dosing is a more practical alternative for many

Limited value drugs

Epinephrine
Propine
Carbachol
Iopidine
Echothiophate Iodide
Diamox and Neptazane (except for angle closure)

Strategy

All glaucoma meds will fail in about 15% of patients due to ineffectiveness or allergy
Unless IOPs are very stable and reliable, start all new medications with a uniocular trial
Expect a 2 mm crossover effect with beta blockers
Give a sample to establish the efficacy of the drug before asking the patient to pay $20 – $80 for a bottle that may not work. RTC in 3 weeks before the sample runs out
If 1 drop only gives a minimal effect, stop it before trying another
Consider Timoptic XE or Betagan qam and Xalatan qhs for combination convenience
Cosopt or Combigan with a prostaglandin analog gives 3 powerful medications in 2 drops

LTG: special considerations

Prostaglandin analogs: will give the lowest pressure with no BP effect
Alphagan: possible neuroprotective effect and no lipid effect
Ocupress and Betoptic S: possible neuroprotective effect
Consider asking family medical doctor to Rx an oral calcium channel blocker to help nerve head perfusion
Exercise may be helpful to reduce IOP as well as being good for circulation
Ginkgo biloba may increase perfusion of nerve head

Argon laser trabeculoplasty (ALT) or selective laser trabeculoplasty (SLT)

SLT is newer and has the advantage of being repeatable and less damaging to the meshwork
Consider whenever compliance is a problem or the patient needs 3 or more drops to achieve target IOP
Less effective in angle recession
The biggest risk is a post-op IOP spike that Iopidine usually controls well
All current glaucoma meds are continued for 1 month, then try tapering back medications
ALT is equal in effect to about 1 topical medication
Steroid qid is typically prescribed
Taper the steroid after 3 – 4 days

Trabeculectomy with mitomycin C: hands-on experience with the surgeon is recommended before doing immediate post-op care

70 – 80% success rate
All glaucoma meds should have been discontinued initially after surgery, though they may be added back later
Goals of 8 – 12 mmHg are usually possible
Careful post-op follow up necessary to ensure good bleb formation and filtration

R/O Seidel’s sign
Bleb should be medium or large size
Bleb should be avascular or mildly vascular
Bleb should have elevation or a bubble formation
Microcysts should be visible on about 50% of the surface of the bleb

If the IOP rises and the above 5 factors are not present, action is needed to save the bleb

If a releasable suture was placed, remove it and see if the IOP decreases
Apply digital pressure in 10 sec increments to reduce the IOP to about 10

Have the patient look up
Push against the lower lid with your finger to raise the IOP to an estimated 40 – 50 mmHg for 2 sec
Remeasure the IOP
The bleb should be fuller looking and increase in size
Repeat as necessary to lower the IOP to the low teens

Increase topical steroids
When the bleb is functioning properly, more of the above 5 factors will be present and the IOP will be lower
Some patients need to do home digital pressure
Blebitis can rapidly lead to endophthalmitis. If blebitis is suspected, call the surgeon, culture, and start on 4th generation fluoroquinolone drops. Watch for these signs

Vascular bleb
Mild iritis
Pus or WBC in the bleb
Discomfort

Always look for choroidal folds and worry about Seidel’s sign and endophthalmitis. Continue topical antibiotics through the post-op period
Once the patient and the bleb are stable, there is low risk in comanaging if you keep the above points in mind
Trabeculectomy with mitomycin-C gives excellent long term reduction of IOP. Hypotony (IOP <6 mmHg) occurs in approximately 40% of eyes within 2 yrs, however. The incidence of hypotony maculopathy is about 9%. Younger whites are at greater risk for hypotony
Trabeculectomy accelerates cataract development

Chapter 10

AGE RELATED MACULAR DEGENERATION
A) Subjective

Painless, monocular or binocular loss of vision
Usually gradual onset, though a sudden loss in one eye could indicate exudative age related macular degeneration (ARMD)
History of smoking, obesity, white race, or high UV exposure are risk factors