THE INTERNIST AND THE EYE

1. Peter P. Balingit, MD Dennis W. Cope, MD, FACP Dieu-thu Nguyen, MD THE INTERNIST AND THE EYE

2. Babak Fardin, MD University of California, Irvine College of Medicine Department of Ophthalmology, Orange, CA Consultative Services Steven G. Ferrucci, OD, FAAO Chief of Optometry Sepulveda VA Ambulatory Care Ctr., Sepulveda, CA Consultative Services Acknowledgements

3. Introduction • What motivated you to attend this workshop?

4. Agenda Importance of the Eye Exam for the Internist Approach to Common Eye Problems in the Office Setting Clinical Findings and Ophthalmic Manifestations of Systemic Diseases Documenting Your Exam and Communicating With the Ophthalmologist Examination Skills Practice Open Discussion – Strategies for More Effective Teaching of Ophthalmology Exam Skills in Residency Education

5. THE INTERNIST AND THE EYE Importance of the Eye Exam for the Internist

6. Background

7. Background • Internists are many times called upon to evaluate patients who present with ophthalmologic complaints. • As the internist is frequently the initial physician rendering treatment for these concerns, a working knowledge of the eye exam is essential in clinical practice.

8. Background • UCLA San Fernando Valley Medicine Residency Program • Based at Olive View-UCLA Medical Center • County hospital population • 70 house officers for 2007 – 2008 • Representatives from 31 different medical schools

9. Primary Care Clinic • Primary Care Clinic chart review • Charts of 20 patients with diabetes mellitus selected • Patients seen in teaching firm, resident continuity, or attending continuity clinics • GIM faculty, internal medicine housestaff, psychiatry interns, third year medical students

10. Primary Care Clinic • A funduscopic exam was performed in the Primary Care Clinic within the preceding 12 months… • A) Never • B) < 5 patients • C) 5 – 10 patients • D) > 10 patients

11. Primary Care Clinic • A funduscopic exam was performed in the Primary Care Clinic within the preceding 12 months… • A) Never • B) < 5 patients • C) 5 – 10 patients • D) > 10 patients • ANSWER: B • 2 patients

12. Primary Care Clinic • These 2 out of 20 patients had their funduscopic exams performed by… • A) Attending physician • B) Medicine house officer • C) Psychiatry intern • D) Third year medical student

13. Primary Care Clinic • These 2 out of 20 patients had their funduscopic exams performed by… • A) Attending physician • B) Medicine house officer • C) Psychiatry intern • D) Third year medical student • ANSWER: D

14. Primary Care Clinic • An ophthalmology clinic referral for health maintenance screening was ordered within the preceding 12 months for these same 20 patients… • A) Never • B) < 5 patients • C) 5 – 10 patients • D) > 10 patients

15. Primary Care Clinic • A ophthalmology clinic referral for health maintenance screening was ordered within the preceding 12 months for these same 20 patients… • A) Never • B) < 5 patients • C) 5 – 10 patients • D) > 10 patients • ANSWER: D • 17 of 20 patients

16. Medicine Ward • Medicine Ward inpatient chart review • Charts of 8 patients diagnosed with bacterial endocarditis selected • Patients admitted to the ward service over two month period

17. Medicine Ward • A funduscopic examination was documented in the medical record… • A) Never • B) 2 patients • C) 4 patients • D) > 4 patients

18. Medicine Ward • A funduscopic examination was performed by a member of the ward team… • A) Never • B) 2 patients • C) 4 patients • D) > 4 patients • ANSWER: A • Never!

19. Medicine Ward • Of these 8 patients diagnosed with endocarditis, an ophthalmology consultation was ordered for… • A) Never • B) 2 patients • C) 4 patients • D) > 4 patients

20. Medicine Ward • Of these 8 patients diagnosed with endocarditis, an ophthalmology consultation was ordered for… • A) Never • B) 2 patients • C) 4 patients • D) > 4 patients • ANSWER: C

21. Urgent Care Clinic • Urgent Care Clinic chart review – 20 patients seen in the Medical Walk-In Clinic • Disorders of refraction and accommodation (ICD-9 367.xx) • Visual disturbances (ICD-9 368.xx) • Blindness and low vision (ICD-9 369.xx) • GIM faculty, internal medicine housestaff, third year medical students

22. Urgent Care Clinic • Visual acuity testing was performed during the Urgent Care Clinic visit… • A) Never • B) < 5 patients • C) 5 – 10 patients • D) > 10 patients

23. Urgent Care Clinic • Visual acuity testing was performed during the Urgent Care Clinic visit… • A) Never • B) < 5 patients • C) 5 – 10 patients • D) > 10 patients • ANSWER: D • All 20 patients • Visual acuity testing is a standing clinic nursing order for all patients with ocular symptoms

24. Urgent Care Clinic • A funduscopic exam was performed during the Urgent Care Clinic visit… • A) Never • B) < 5 patients • C) 5 – 10 patients • D) > 10 patients

25. Urgent Care Clinic • A funduscopic exam was performed during the Urgent Care Clinic visit… • A) Never • B) < 5 patients • C) 5 – 10 patients • D) > 10 patients • ANSWER: D • 18 of 20 patients

26. Urgent Care Clinic • 11,000+ patients seen in the Urgent Care Clinic from over six month period • 359 (3.1% of all patients) seen for an symptoms related to the eye • Disorders of the conjunctiva (ICD-9 372.xx) • Cataracts (ICD-9 366.xx), • Blindness and low vision (ICD-9 369.xx) • Other disorders of the eye (ICD-9 379.xx) • Inflammation of the eyelids (ICD-9 373.xx)

27. THE INTERNIST AND THE EYE Approach to Common Eye Problems in the Office Setting

28. Treat or Refer? • Which patients need urgent ophthalmology referral to prevent loss of vision? • When is it safe to initiate treatment in the office and defer ophthalmology referral? • To make this judgment you need to assess the presence of alarm or “red flag” symptoms and signs. • If “red flags” are elicited, often referral to ophthalmology is indicated.

29. Red Flags – Pertinent History • Visual acuity? Decreased vision is worrisome! • Foreign body sensation vs. scratchy feeling? Is patient able to keep eyes open? • Photophobia? • Trauma? Scratch vs. blunt vs. high velocity? • Contact Lens Wear? Keratitis risk!

30. Red Flags – Physical Exam • Observe for: • General patient discomfort • Ability to tolerate light • Erythema of periorbital structures • Purulent discharge (conjunctivitis or bacterial keratitis) • Eye tearing

31. Uncover Red Flags on Physical Exam Investigate • Visual acuity (Snellen or near vision card, best correction) • Flip lid if foreign body sensation • Penlight exam of pupils (Reaction to light? Fixed? Constricted? Dilated?) • Pattern of erythema (Conjunctival injection vs. ciliary flush?)

32. Uncover Red Flags on Physical Exam • Corneal exam with and without fluorescein (Opacity? Foreign body? Dye pooling due to ulcer or abrasion?) • Anterior chamber exam (Hypopyon, a layer of white cells in anterior chamber and hyphema, a layer of red cells ?) • Funduscopic exam? (Part of any thorough eye evaluation, especially if painless vision loss)

33. “Red” Flags • Consider urgent referral to an ophthalmologist if you evaluate a patient with an red eye associated with: • Deep or severe pain • Significant photophobia (rule out simple foreign body or corneal abrasion) • Cloudy cornea • Dilated fixed pupil • Markedly constricted pupil • Decreased vision • Increased intraocular pressure

34. Blepharitis

35. Pterygium

36. Subconjunctival Hemorrhage

37. Subconjunctival Hemorrhage • Benign ruptured superficial capillary • Reassure patient • Evaluate and treat hypertension • Recurrent hemorrhage may indicate need for blood testing • PTT, CBC, etc.

38. Conjunctivitis • Allergic • Chemical • Viral • Bacterial • Hyperacute bacterial

39. Allergic Conjunctivitis

40. Allergic Conjunctivitis • Symptoms – itchy, watery, red eyes, usually with history of allergies • Signs – conjunctival injection and chemosis, swollen lids, conjunctival papillae, no pre-auricular node

41. Allergic Conjunctivitis Treatment: • Eliminate causative factor • Cool compresses several times daily • Pharmacologic treatment • Mild – artificial tears qid, mast cell stabilizers • Moderate – vasoconstrictor/antihistamine (naphazoline) qid, systemic antihistamines • Severe – topical antihistamine such as olapatidine, mild topical steroid qid if keratopathy (would let ophthalmologist manage topical steroids)

42. Viral Conjunctivitis

43. Viral Conjunctivitis • AKA “pink eye” • Symptoms – watery discharge, red swollen eyelids, often bilateral • Signs – conjunctival injection, edema, and follicles, pre-auricular node common • Often preceded by upper respiratory tract infection or contact with someone with red eye

44. Viral Conjunctivitis • Treatment – palliative only • Cold compresses • Artificial tears • Erythromycin • Very contagious • Don’t share towels, etc. • No school

45. Bacterial Conjunctivitis

46. Hyperacute Conjunctivitis

47. Bacterial Conjunctivitis • Symptoms – irritation, yellow/green discharge, mattering of eyelashes • Signs – conjunctival papillae, injection, and chemosis; subconjunctival hemorrhage possible in severe cases • Treatment – topical antibiotics • Trimethoprim/polymyxin B or tobramycin qid x 4-7 days. Cover S. pneumoniae, H. influenzae, Moraxella, Staphylococcus. • Ciprofloxacin in contact lens patients? • Gram stain and culture if copious discharge or suspicion of STI? Neisseria gonorrheae is a possible cause. IV antibiotics if GC.

48. Corneal Abrasion

49. Corneal Abrasion • Treatment – topical antibiotic • Ointment vs. solution • Erythromycin ointment • Topical cycloplegic • Cyclopentolate 1% • Oral analgesics • Discontinue any contact lens wear • Do not pressure patch