NBEO Part 3 - PEPS

Corneal Foreign Body - Testing

NaFl, Lid eversion, Retroillumination

Corneal Foreign Body - Treatment

Remove foreign body with cotton-tipped applicator, or instill Proparacaine and remove with instrument, remove rust ring with Alger brush, place BCL if large epithelial defect, Moxifloxacin 0.5% qid x1 wk, Ketorolac 0.5% qid if pain, frequent PFATs

Corneal Foreign Body - FU

1 day if BCL, otherwise 1 wk

Corneal Foreign Body - Education

You have a piece of metal in your that we have removed. We placed a bandage lens on your eye to help your cornea heal, so you need to return tomorrow so that we can remove it. We've given you an antibiotic to use 4x per day, and we also rcmnd using PFATs 6-8x throughout the next several days. In the future, it is important to remember to wear safety glasses when working with metal.

RCE/EBMD - Testing

NaFl, Lid eversion

RCE/EBMD - Treatment

Propraracaine and debride 1-2mm beyond lesion, Place BCL if not a previous CL wearer, Moxifloxacin 0.5% qid x1 wk, Nacl 5% soln qid x2 wk then taper to qhs for 3 months, frequent PFATs

RCE/EBMD - FU

1 day for BCL, Otherwise 3-4 weeks

RCE/EBMD - Education

You have a condition called EBMD, in which the top layer of your cornea does not adhere well to the bottom layers. Sometimes, this can lead to the top layer of the cornea being ripped off, leaving a large abrasion. (OR - Because of a past trauma to your eye, the top layer of your cornea has difficulty staying adhered to the bottom layers). We removed some of the top layer of your cornea so that it can heal properly, and placed a bandage lens to speed up the healing process. We also gave you an antibiotic to prevent any infection while this heals, and a drop that helps to dehydrate the cornea. This drop can help to prevent this from happening again, but may need to be continued for the next few months. If this recurs, you should return to our office.

Chemical Burn - Testing

Irrigation for 15 mins, lid eversion and irrigation/swabbing of fornices, Testing PH with litmus paper after 5 minutes (normal is 7-7.4), NaFl

Chemical Burn - Treatment

Debridement of any loose epithelium, Moxifloxacin 0.5% qid x1 week, Prednisolone Acetate 1% qid x1 week then taper, frequent PFATs

Chemical Burn - FU

1 day

Chemical Burn - Education

You have gotten a chemical into your eye which has burned a layer of your cornea. I've removed all of the loose corneal tissue to help the corneal heal better. I have given you an antibiotic drop to prevent any infection, as well as a steroid to help with swelling and inflammation. You should use PFATs 6-8x per day while this heals. I'd like to see you tomorrow to make sure your eye is healing well. In the future, it is important to use safety eye wear while dealing with dangerous chemicals.

IIH - Testing

RNFL OCT, VF (enlarged BS), FAF (r/o ONH drusen), Red cap, BP, Order urgent MRI/MRV and LP with CSF analysis

IIH - Treatment

MRI & MRV of brain and orbit ASAP, LP if MRI/MRV normal, and oral CAIs. Refer to PCP/OBGYN to discuss weight loss and d/c of birth control.

IIH - FU

3-4 weeks

IIH - Education

You have IIH, which is a condition in which there is increased pressure inside the brain. This also puts pressure on the optic nerve, causing it to swell and leading to visual changes, headaches and nausea. This increased pressure may be due to being overweight, or due to your birth control. First, it is important that we rule out any other causes of increased pressure in the brain, so I am referring you for an urgent MRI and LP. I am also referring you back to your PCP who can offer different treatments to help bring down the pressure and may recommend you d/c your birth control. I'd like to see you back in about a month to make sure your nerve swelling is returning to normal.

NAION - Testing

RNFL OCT, VF (altitudinal or central), Pupils (APD), Red cap (reduced), ESR/CRP/CBC with diff (r/o GCA), BP, EOM (r/o neuritis)

NAION - Treatment

Refer to PCP for management of BP/BS/Cholesterol

NAION - FU

1-2 months

NAION - Education

You have a condition called NAION, in which blood supply to your optic nerve has been cut off. This is often due to systemic issues like uncontrolled high BP, BS, or cholesterol. First, I want to refer you urgently for blood work to make sure that this was not caused by inflammation in the body. I also want to refer you to your PCP to help get your BP/BS under control as there is a risk of this happening to the other eye as well. Up to 40% of patients show mild improvement in vision over 3 to 6 months in some studies. I'd like to see you back in 1-2 months after you've seen your PCP.

AAION - Testing

RNFL OCT, VF (altitudinal or central), Pupils (APD), Red cap (reduced), Palpation of temporal artery, TA biopsy, ESR/CRP/CBC with diff

AAION - Treatment

Refer to ER for blood work and IV methylprednisolone, Switch to oral steroids if (+) TA biopsy and cont for 6-12 months

AAION - FU

3-4 wks

AAION - Education

You have AAION/GCA. This condition leads to inflammation of the medium and large blood vessels in the body, leading to your fever, headaches, and jaw pain. This inflammation is also affecting the blood supply to your optic nerve, leading to vision loss. Unfortunately, there is only a small chance the vision loss you are experiencing will return. The primary goal is to prevent this from happening in the other eye. I am referring you for urgent blood work, as well as steroids at the hospital. They will likely keep you on steroids for 6-12 months after this to keep inflammation in your body low. I'd like to see you back in about a month.

Optic Neuritis - Testing

RNFL OCT, VF (central or arcuate), Pupils (APD), Red cap (reduced), EOM (pain), Urgent MRI and LP

Optic Neuritis - Treatment

Refer for imaging, and oral steroids if within the first 1 -2 weeks of onset. Refer to neurology for MS management.

Optic Neuritis - FU

3-4 weeks. After that, q 3-6 mo

Optic Neuritis - Education

You have a condition called optic neuritis. This means that the optic nerve connecting your eye to your brain is swollen, leading to your blurry vision. Your vision will return after the swelling has gone down. However, this kind of swelling is often associated with MS. MS is an autoimmune disease in which your body's own immune system attacks your tissues and nervous system. It's important that we refer you for an MRI and to a neurologist to help make that diagnosis. I'd like to see you back in 1 month, and we'll check your vision every 3-6 months from here on out.

ONH Drusen - Testing

FAF (+), B-scan (hyper-reflective), VF (generalized depression), RNFL OCT

ONH Drusen - Treatment

Observation

ONH Drusen - FU

q 6-12 mo

ONH Drusen - Education

You have ONH drusen, which are calcified deposits within the optic nerve. Usually these are benign and will have no effect on your vision. Rarely, they can start to compress the nerve tissue and lead to loss of vision. I'd like to see you every 6-12 months to check on your visual field to make sure that they are not impacting your vision. There is no treatment for this condition.

Horner Syndrome - Testing

Pupil sizing, Near testing (no LND/ normal), MRD 1 (2mm ptosis), Old photos, 1% Apraclonidine testing (dilates Horner pupil), RTC 1 day for 1% Hydroxyamphetamine testing (dilates if pre-ganglionic), Order chest CT (Pancoast tumor), MRI/MRA of brain/neck (carotid artery dissection [esp if neck pain]), CBC w/ diff

Horner Syndrome - Treatment

Refer for neuroimaging

Horner Syndrome - FU

FU after imaging

Horner Syndrome - Education

You have a condition called Horner syndrome that leads to the lid droop and smaller pupil that you are experiencing. This can be caused by several things, but there is likely inflammation or compression of the nerve that connects parts of your eye to the brain. It may be due to headaches or migraines, or something more serious like a mass. I need to refer you for imaging to rule out that possibility. I will follow up with you after the imaging results.

Adie Tonic Pupil - Testing

Pupil sizes, Near testing (LND), Old photos, 0.125% Pilocarpine (constriction)

Adie Tonic Pupil - Treatment

0.125% Pilocarpine bid-qid to help with accommodation and cosmesis, Cosmetic CL, sunglasses

Adie Tonic Pupil - FU

1 year

Adie Tonic Pupil - Education

You have a condition called Adie tonic pupil. This is a benign condition in which one of your pupils is bigger than the other, and it does not focus as well up close. You may also be more light sensitive on that side since that pupil is bigger. I recommend wearing sunglasses when outside and I can prescribe you a drop that helps to constrict the pupil to make reading easier. This condition may occur in both eyes with time. We can monitor you annually.

Myasthenia Gravis - Testing

MRD1, MRD1 after 2 min sustained upgaze, Ice pack test or Tensilon test, pupils (normal), Bloodwork (T3, T4, TSH), Neck CT (r/o thymoma)

Myasthenia Gravis - Treatment

Refer to neurology for treatment (steroids may help if early in the disease course, pyridostigmine if trouble breathing), Prism for diplopia

Myasthenia Gravis - FU

4-6 mo

Myasthenia Gravis - Education

You have a condition called MG. This is an autoimmune condition in which your body's own immune system attacks your tissues, leading to a droopy eyelid and double vision towards the end of the day. It may also lead to difficulty breathing. We are referring you to a neurologist who can treat you. We also are ordering blood work, as this condition is often associated with thyroid and thymus issues. If the double vision is consistent and bothersome to you, we can also prescribe prism in your glasses to help. I'd like to see you back in 4-6 months.

Bell palsy - Testing

NaFL, TBUT, Urgent referral to ER for stroke workup

Bell palsy - Treatment

Perform stroke workup to R/O stroke, Refer to neurology, PFATs, Ointment at bed time, Lid taping or eye mask at night, Turn off fans while sleeping

Bell palsy - FU

1-3 months

Bell palsy - Education

You have a condition called Bell palsy. This is a condition where inflammation of an unknown cause, or due to a previous viral infection, leads to drooping on the whole side of your face. As this can often mimic a stroke, we need to refer you to the ER for a stroke workup. We are also referring you to neurology for further care. This condition is usually temporary and resolves in a few months. Since your eye can not close properly, it's important to make sure your eyes do not dry out. I recommend frequent PFATs throughout the day, an ointment at bed time, and wearing a sleeping mask at night. Turning off fans while sleeping can also help. I'd like to see you in 1-3 months.

OHTN - Testing

RNFL/GCC OCT, 24-2 VF, Pachymetry, IOP

OHTN - Treatment

Monitor if <24, consider tx if 24-30, tx if >30; Use any drop

OHTN - FU

RTC 4 weeks after starting med for IOP (esp PG or β-blocker), otherwise RTC 3-6 months for repeat IOP

OHTN - Education

You have OHTN. This means that the pressure inside your eye is higher than normal. This can be a risk factor for glaucoma, so we'd like to see you again in 3-6 months to recheck your eye pressure. If the pressure is still high, we may choose to give you a drop that helps reduce the eye pressure and prevent glaucoma from developing.

POAG - Testing

RNFL/GCC OCT, 24-2 HVF, Pachymetry, IOP, Red cap (normal)

POAG - Treatment

1st line - Latanoprost 0.05% qhs (CI in pregnancy; pigment changes, lash growth, hyperemia), Timolol .25-0.5% qAM (CI in CHF, bradycardia, COPD, asthma, MG), Brimonidine 0.2% bid (CI with MAOI and kids <5), or Dorzolamide 2% bid (CI with sulfa allergy or Fuch's) 2nd line - MIGS, SLT, Shunt sx

POAG - FU

3-4 weeks for IOP check. Monitor 6-12 months

POAG - Education

You have a condition called POAG. There are many risk factors for glaucoma, including (+) FOHx, eye pressure >24, C/D size, African/Hispanic, and PDS/PXS. Increased eye pressure applies pressure to the optic nerve, leading to nerve tissue loss and progressive peripheral vision loss. The only known way to tx glaucoma is through lowering the eye pressure. I am going to start you on an eye drop to use once per day before bed. This drop can lead to irritation, so use PFATs throughout the day. You may also notice a darkening of your iris color or growth of your eye lashes. I want to see you back in 1 month to re-check the eye pressure, then we can monitor you every 6-12 months with scans.

NTG - Testing

RNFL/GCC OCT, 24-2 VF, Pachymetry, IOP, Gonio

NTG - Treatment

1st line - Drops; Neuroprotective drops are preferred (Brimonidine 0.2% bid or Betaxolol 0.25-0.5% bid). 2nd line - Latanoprostene bunod 0.024% qhs (most effective drop in NTG; expensive)

NTG - FU

FU in 4-6 wks for IOP check. Monitor q 6-8 mo.

NTG - Education

You have a condition called NTG. When we look at the nerve in the back of your eye we can see nerve tissue loss, indicating you have glaucoma. Often, glaucoma is associated with high eye pressure. Even though your eye pressures today were normal, the only known way to treat glaucoma is to lower the eye pressure. I'm going to start you on a drop that you'll use twice a day and I want to see you back in 1 month to re-check your pressure. After that, I want to monitor you every 6-8 months.

AACG - Testing

Gonio with compression, Ant-seg OCT, IOP

AACG - Treatment

3 drops, 1 drop every 15 min (Apraclonidine 0.5%, Timolol 0.5%, Dorzolamide 2%) - &/OR - Acetazolamide 2 250mg po. Recheck IOP in 1 hour and repeat drops if still high. Once the cornea is clear, perform LPI. Send home on Acetazolamide 250mg bid and Timolol 0.5% bid

AACG - FU

1 day; RTO 2-7 days for LPI in fellow eye if narrow angles

AACG - Education

You are experiencing AACG. The drainage system in the eye that allows fluid to filter out is blocked, leading to increased eye pressure. This leads to the headache, eye pain, nausea and distorted vision you are experiencing. We are going to try to lower your eye pressure in-office using drops/pills, and may perform/refer out for an LPI surgery. This surgery prevents the drainage system from getting blocked again so that the eye pressure won't spike. If it goes well, we may choose to perform an LPI preventatively in the other eye as well. I'm also going to send you home with medicine to keep your eye pressure low. I'd like to see you tomorrow to re-check your eye pressure.

Diabetic Ret - Testing

Fundus photo, Mac OCT, IVFA (neo or perfusion abnormalities), Gonio, A1C, BP

Diabetic Ret - Grading

All stages may have CME. Mild - hemes. Moderate - more hemes, CWS, or exudate. Severe - 4 quadrants of hemes, 2 of beading, 1 of IRMA. Proliferative - NVD, NVE, NVI, or vitreous heme. High Risk Proliferative - NVD >1/4 size of the nerve, or any NVD/NVE associated with pre-retinal or vitreous heme

Diabetic Ret - Treatment

Refer for AntiVEGF for CME or NV, PRP for high risk NV, Vitrectomy for persistent vitreous heme. Otherwise, Monitor.

Diabetic Ret - FU

None - 12 mo. Mild - 6-9 mo. Moderate - 4-6 mo. Severe - 4-6 mo. Proliferative - 2-3 mo.

Diabetic Ret - Education

You have diabetic retinopathy. When your blood sugar is high or fluctuating, it makes the small blood vessels in the back of the eye leaky. Blood and protein start to leak out into the retina. It can also leak into the macula and cause swelling, leading to blurry vision. I'm going to refer you to a retinal specialist - OR - monitor. I'd like to see you in ___ months.

Hypertensive Ret - Testing

Fundus photo, BP, OCT-A, IVFA

Hypertensive Ret - Staging

1 - Attenuation. 2 - AV crossing. 3 - CWS, hemes, exudate, micro/macroaneurysms, VO/AO, neo, Elschnig spots. 4 - ONH edema, macular star, venous engorgement.

Hypertensive Ret - Treatment

Refer to PCP for better BP control. Refer to ER if malignant HTN. Focal laser if leaking macroaneurysm

Hypertensive Ret - FU

2-3 months

Hypertensive Ret - Education

You have hypertensive retinopathy. Uncontrolled high BP can lead to changes in the back of the eye such as bleeding, and can ultimately cause vision loss if this continues long term. I'm going to refer you back to your PCP to better control your BP.

RAO - Testing

IVFA, gonio, BP, ESR/CRP/CBC, Carotid doppler, ECG

RAO - Treatment

Refer for stroke workup, Refer to PCP for systemic management, Monitor monthly for neovascularization. If recent onset, attempt gonio massage, breathing into a paper bag, Acetazolamide 2 250mg tablets, Timolol 0.5% q15 minutes.

RAO - FU

q 3-4 weeks for next 6 mo to monitor for neovascularization if CRAO, 3-6 mo for BRAO

RAO - Education

You have a RAO. A blockage in an artery in the back of your eye has prevented blood flow and oxygen from reaching the retinal tissue. Without blood flow, that tissue dyes off, leading to permanent vision loss. This may have been caused by a blockage in your carotid artery or from heart valve disease. I want to send you for urgent blood work and a carotid doppler to check for any blockages; if there is an artery blockage in the back of the eye, there could also be one in the brain that could lead to stroke. I also want you to FU with your PCP. I want to see you back in 1 month to make sure there are no complications developing from this such as glaucoma.

RVO - Testing

Mac OCT, IVFA, Gonio, BP, Lipid panel

RVO - Treatment

Refer to PCP for cholesterol/BP management, Refer for AntiVEGF, Monitor annually for neovascularization. Sector laser for NVE, Sector laser and AntiVEGF for NVI, PPV for persistent vitreous heme.

RVO - FU

q 3-4 weeks for next 6 mo. to monitor for neovascularization

RVO - Education

You have a RVO. Due to either high blood pressure or cholesterol, your arteries can become hardened. In the retina, those hard arteries can compress a vein, leading to pooling of blood in the retina. It can also lead to swelling in the macula, causing blurry vision. Your vision can improve with treatment, so I am referring you for AntiVEGF injections to improve the swelling. I also want to refer you back to your PCP for systemic management. I want to see you back in 1 month to make sure there are no complications developing from this such as glaucoma.

OIS - Testing

Mac OCT, IVFA, Gonio, BP, Carotid doppler, Carotid auscultation

OIS - Treatment

Refer to PCP for systemic management. AntiVEGF for CME, PRP and AntiVEGF for NVE/NVI, PPV for persistent vitreous heme.

OIS - FU

q 3-4 weeks for next 6 mo. to monitor for neovascularization

OIS - Education

You have a condition called venous stasis retinopathy, or OIS. This is caused by a blockage in your carotid artery preventing adequate blood flow to the retina. It presents as bleeding in the back of the eye, and it can eventually progress to glaucoma. I need you to FU with your PCP to help manage your cholesterol/BP, and I'm going to refer you for a carotid doppler to assess the blockage. I'm going to have you follow up with me in 3-4 weeks for the next 6 months to make sure there are no lasting complications from this such as glaucoma.

Lattice - Testing

DFE with scleral depression

Lattice - Treatment

Monitor, Barrier laser if holes develop, laser photocoagulation, cryotherapy, or scleral buckle for RD

Lattice - FU

6-12 mo

Lattice - Education

You have some thinning and stretching of your retinal tissue called lattice. This is very common with high prescriptions. Although lattice is a common finding, it has a small risk of developing a hole or RD. You should watch out for any flashing lights, new floaters, or missing parts of your vision. If that occurs, FU with us immediately. Otherwise, we'll monitor you every 6-12 months.

ERM - Testing

Mac OCT, Fundus photo, Amsler

ERM - Treatment

Monitor, Amsler, Consider PPV with ILM peel if BCVA >20/40 or significant intraretinal cysts

ERM - FU

6 - 12 mo

ERM - Education

You have an ERM, which is a membrane growing over the macula. This can lead to distorted or wavy vision if it continues to grow. Rarely, the membrane may spontaneously resolve. You should check your vision at home using one eye at a time with an Amsler grid, at least once every week. If you notice any distortion in the grid or changes in your vision, RTO. Otherwise, we will monitor you every 6-12 mo

Mac Hole - Testing

Mac OCT, Amsler, Watzke-Allen testing

Mac Hole - Treatment

Impending hole - monitor. Full thickness hole - PPV with ILM peel and gas tamponade

Mac Hole - FU

Monitoring q 4-6 mo. If Sx, FU after release from retina

Mac Hole - Education

The jelly inside your eye called the vitreous is adhered to several different points, including the macula. It will naturally begin to detach over time, but it can start to pull on the macula tissue if it does not detach properly. In your case, the jelly pulled too hard on the retina and ripped the retinal tissue. In order to restore your vision, surgery is needed. I'll have you RTO for a FU after you are released from retina.

RP - Testing

Fundus photo, Mac OCT, FAF (ONH drusen), ERG, EOG, Goldmann VF, Genetic testing for RPE-65

RP - Treatment

10,000 IU Vitamin A Palmitate qd, Luxturna if (+) RPE 65 gene, Refer to LV for device evaluation, Refer to OT for mobility training, Refer to PCP for systemic management (hearing loss)