Systemic Disease Straight Up…..with a Twist of Neuro! AOA’s definition of Optometry

Systemic Disease
Straight Up…..with a
Twist of Neuro!
Beth A. Steele, OD, FAAO
Caroline B. Pate, OD, FAAO
Optometry’s Meeting 2014
AOA’s definition of Optometry
approved Sept 2012
Doctors of optometry (ODs) are the independent primary health care professionals for the eye. Optometrists examine, diagnose, treat, and manage diseases, injuries, and disorders of the visual system, the eye, and associated structures as well as identify related systemic conditions affecting the eye. No disclosures
Driving Forces in Health Care Changes
 Affordable Care Act
Quality of
Patient Care
 Coding
 Risk Adjustment  Physician Quality Reporting PREVENTION From: 2014 Evidence-Based Guideline for the Management of High Blood
Pressure in Adults: Report From the Panel Members Appointed to the
Eighth Joint National Committee (JNC 8)
WELLNESS
COMMUNITY HEALTH
TREATING THE WHOLE PATIENT
MEDICAL
OPTOMETRY
CLINICAL
QUALITY
MEASURES
…..where do we fit in?
1
Is routine blood pressure part of your daily routine in patient care?
JNC 8 – What’s New?  Threshold for treatment of BP in ages ≥60
 150/90 vs. 140/90
HYPERTENSION
 Approximately 65 million people in  Recommendations for initial therapy
 Thiazide diuretics  ACE inh, ARBs, Ca2++ channel blockers
 NOT: β‐blockers, α‐blockers, loop diuretics
US
 30% of population unaware
 7.1 million deaths per year
 “Silent Killer”
 Stroke, MI, ESRD
Blood Pressure Classifications and Referral Guidelines
“Hypertensive Crisis”
(adapted from the Joint National Committee on Detection, Evaluation, and Treatment of High Blood Pressure – JNC 7, 2003)
Hypotensio
n
Systolic
< 90
Diastolic < 60
normal Pre‐ Htn
Stage 1
Stage 2
Stage 3
Stage 4
< 120
120‐139 140‐ 159 160‐179 180‐209 >210
< 80
80 ‐ 89
90‐99
 URGENT vs. EMERGENT
100‐109 110‐119 >120
Systolic
>180
Diastolic
>110
(>120)
Confirm
within 2
months
Evaluate or
refer to
PCP within
1 month
Evaluate or refer
immediately or
within 1 week
Evaluate or
refer
immediately
BP 190/112
 Feeling “fine”
 (+) “migraine”since yesterday
 Forgot his medicine today
 DFE: disc edema
 Denies H/A, etc
 DFE: crossing changes, blot heme
flame heme
“Evaluate and treat immediately or within 1 week depending on clinical situations and complications.”
 Systemic symptoms
 Ocular findings
Meetz RE, Harris TA. The optometrist's role in the management of
hypertensive crises. Optometry. 2011 Feb;82(2):108-16.
Hypotension
Same BP – 2 different situations
BP 190/112  JNC 7
 Low Blood Pressure
 Systolic < 90
 Diastolic < 60
 Poor perfusion of oxygen and nutrients to vital organs
 Common symptoms = fatigue, dizziness, fainting, confusion
 Risk of ocular manifestations
2
Proper methods = Accurate Results
Vitals Station
Meaningful Use Patient Vital Signs  Temperature – 96.4ͦ ‐ 99.1ͦ
 Blood Pressure – <120/<80
 Respiration Rate – 20 breaths/min
 Heart Rate – 50‐90bpm  Others
 Weight/height BMI<25
 Pain Stage 1 (Core Obj #8)
Record and chart changes in vital signs:  Height  Weight  Blood pressure  Calculate and display BMI  Plot and display growth charts (BMI) for ages 2‐20 years
Stage 2 (Core Obj #4)
Age (≥3)
only
For more than 50% of all unique patients
age ≥2, BP, height and weight are recorded
as structured data
Stage 1– Core Quality Care Measures (Core Objective #10) HTN ‐ BP measurement
BMI screening and follow‐up
(alt) Weight assessment and counseling for children and adolescents
Stage 2 – Quality Measures are separated from Meaningful Use 0-20
More
than 80%
Now with EOM involvement….??
BP 190/112  Feeling “fine”
 Forgot his medicine today
 Denies H/A, etc
 DFE: crossing changes, blot heme
http://cim.ucdavis.edu/EyeRelease/Interface/TopFrame.htm
2014 – must report on new CQMs
CMS 22v1 ‐ Preventive Care and Screening: Screening for High Blood Pressure and Follow‐Up Documented CMS69v1 ‐ Preventive Care and Screening: Body Mass Index (BMI) Screening and Follow‐Up 3
Cranial Nerve III Palsy
 EOMs – SO and LR are unopposed
 Levator  Parasympathetic pupillary fibers
 Will NOT constrict with WEAK pilocarpine Etiology – CN III Palsy
 Pain or pupil involvement
 Lesions that involve the pupil are most likely compressive in nature (80%
 Emergency imaging
 Patient may have headache or other neuro signs
 NO pain or pupil involvement
 77% that spare pupil are vasculopathic
 Resolution usually within 3 months  Follow closely  Imaging? Kanski. Clinical Ophthalmology, 4th Ed
double vision
double vision
• Head injury 3 months ago – Imaging in ER all negative • Vertical diplopia; worse when looking down – Right head tilt
• Medications
– Atenolol, lisinopril/HCTZ, Trazodone, WellButrin, Cymbalta
• Smokes ½ day :/
Double Maddox Rod??  MR over both eyes
 Place small vertical prism over one eye 1⁰ gaze – note head posture
Under‐action LSO  Cyclodeviated eye will report a “tilted” line
 Rotating MR toward the torsion of the eye will straighten image of line 4
Torsion noted on DFEs!
SO Palsy
 Very common with closed head trauma
 Blunt force to frontal area  May be least likely of EOM palsies to have underlying etiology, but….
 Microvascular disease
 Brain abnormality
 Imaging, careful follow‐up VI Palsy – Pearls Isolated EOM palsies
 Incomitant ET worse when gaze towards paretic eye
 Lab testing
 Microvascular disease, Giant Cell Arteritis  Compensatory head turn away from paretic eye  distance > near …. Think neuro cause  Imaging
 Tumor, aneurysm
 Children
 Frequently acquired and transient
 Trauma, Tumor, hydrocephalus
 Adults  22% ‐ brain tumor  26% = idiopathic  Do not assume true isolation!
Summary of CN Functions and Testing
Adapted from Muchnick, B. Clinical Medicine of Optometric Practice, 2nd Ed. Cranial Nerve
I – Olfactory
Test
CN Tes ng → involvement of VII and VIII
Identify odors
II - Optic
Visual acuity, visual field, color, nerve head
III - Oculomotor
Physiologic “H” and near point response
IV – Trochlear
Physiologic “H”
Summary Corneal
of Cranial
Nerve Functions and Testing
reflex; clench jaw/palpate
V - Trigeminal
(Adapted from Muchnick,
B. Clinical
Medicine in Optometric Practice, 2nd ed.)
Light touch
comparison
VI - Abducens
Physiologic “H”
VII - Facial
Smile, puff cheeks, wrinkle forehead, pry open closed lids
VIII - Vestibulocochlear
Rinne test for hearing, Weber test for balance
IX - Glossopharyngeal
Gag reflex
X - Vagus
Gag reflex
XI – Accessory
Shrug, head turn against resistance
XII - Hypoglossal
Tongue deviation
C
5
Ramsay Hunt Syndrome
 Varicella Zoster Virus reactivation in geniculate ganglion
 Symptoms: Pain, hearing loss, dizziness, tinnitus, nausea, vertigo
 Treatment with oral antivirals + oral prednisone
 Protect the cornea!
 Poorer prognosis than Bell’s palsy
 Recurrences are rare
Updated Clinical Practice Guidelines: Bell’s Palsy
 Recommends prescribing oral steroids within 72 hours of symptom onset for patients with Bell’s palsy 16 years and older
 Recommends offering oral antiviral therapy in addition to
oral steroids within 72 hours of symptom onset
 Other recommendations:
 Careful history and physical exam to rule out other causes
 Inclusion of eye care for impaired lid closure
 Against routine laboratory testing and imaging for new onset Bell’s palsy
Baugh R, Basura G, Ishii L, et al. Clinical practice guideline: Bell’s Palsy. Otolaryngol Head Neck Surg 2013; 149(suppl 3) S1-S27.
“Blood work‐up”….tests driven by differentials  CBC with differential
 Chem 7
 Lipid Profile
 C‐Reactive Protein
 ESR
 Uveitis testing Complete Blood Count  White Blood Count (WBC)
 Differential White Blood Count (Diff)
 Red Blood Count (RBC)
 Hematocrit (Hct)
 Hemoglobin (Hb)
 Platelet Count (PLT)
 Red Blood Cell Indices:
 Mean Corpuscular Volume (MCV)
 Mean Corpuscular Hemoglobin (MCH)
 Mean Corpuscular hemoglobin Concentration (MCHC)
Chem 7 / Basic Metabolic Panel 1.
Creatinine
2. Blood urea nitrogen (BUN)
3. Glucose
 Screens for
 Kidney disease  Liver Disease  Diabetes and other blood sugar disorders
4. Carbon dioxide
5. Chloride
6. Sodium
electrolytes
7. Potassium 8. (Sometimes Calcium)
6
NON‐GRANULOMATOUS CAUSE OF UVEITIS Etiology 46 year old AA female  Recurrent and recalcitrant uveitus
 KPs
 Conjunctival granuloma
 ROS
Sex
Race
History Questions Lab Tests Ankylosing spondylitis
M>F
W>B
Lower back pain?
HLA‐B27, back x‐ray, RF (‐),
ESR (+)
Reactive arthritis (formerly Reiter’s)
M>F
W>B
Arthritis? Pain when urinating?
HLA‐B27, ESR (+), ANA (‐).
RF (‐), Urethral swab
Juvenile RA
F>M
W=B
Knee pain?
Knee x‐ray, RF (‐), ANA (+)
Lyme disease
M=F
W=B
Rash? Fever? Recent tick bite?
ELISA + for antispirochetal
antibody titer
Herpetic Disease
M=F
W=B
Skin vesicles?
Skin biopsy/culture,
Consider HIV testing
Crohn’s
M=F
W=B
Stomach pain?
GI workup, Endoscopy,
HLA‐B27
GRANULOMATOUS CAUSE OF UVEITIS  Resp: “cough”
Sarcoidosis
F>M
Syphillis
M=F
Tuberculosis
M=F
B>W
Cough?
Chest X‐ray, ACE (elevated),
Lung biopsy, Serum Lysozyme
W=B
Rash? Fever? Chancre?
FTA‐ABS
VDRL or RPR
W=B
Cough?
PPD Chest X‐ray
Table adapted from: Muchnick B. Clinical Medicine in Optometric Practice 2008
Vs. Point of Care Laboratory Testing….
Procedure
CPT Code
Reimbursement
Erythrocyte Sed Rate 85652QW
$4.96
Chlamydia Culture
87110QW
$27.00
Dipstick Urinalysis 81002QW
$4.37
Pregnancy Urinalysis
81025QW
$8.74
Glucometry
82962QW
$3.42
HbA1C
83037QW
$13‐18
AdenoPlus Adenovirus 87809QW
Detection $17.52
InflammaDry
83516QW
$18.36
Tear Lab Osmolarity
83861QW
$24.30
Sjo Test
36416 (finger stick) + CPT codes for lab tests run
What’s New in Point of Care Testing??
 InflammaDry
 MMPs in tears
 Much like AdenoPlus
 Tests for classical and new makers for Sjögren’s
 Kits are free
 Requires finger stick In‐office Blood Glucometry and A1C
 Blood glucose  reading in ~5 seconds
 A1C Now+® (CHEK Diagnostics)
 99% lab accuracy
 Results in 5 minutes
 www.a1cnow.com
 Cost: ~ $12.00/test (available in sets of 10 or 20)
 cleared by FDA for home use
Genetically classifying AMD patients?  Based on known factors in AMD pathogenesis
1.
the complement system 2.
cholesterol metabolism
3.
extracellular matrix remodeling .
 Simple cheek swab  No CLIA certification required  Macula Risk PGx
 RetinaGene AMD (Nicox)
4. oxidative stress
7
CLIA Certificate of Waiver (CMS‐116)
 42 AA female
 FHx glaucoma
 IOP 21, 20
10‐2
5 months later –
patient reporting arm weakness 8
MRI – Imaging of Choice  T1 weighted imaging ‐‐ Fat is bright, fluid is dark
 Quicker capture → Better resolution  Add Fat suppression – will enhance ON
 T2 weighted – fluid is bright  Detects edema  FLAIR ‐‐ Fluid‐attenuation inversion recovery
 CSF appears dark, while inflammatory fluid/edema is bright  DWI – Diffusion Weighted Imaging  can be added if ischemic event is suspected
If it’s a tumor….
If it’s a stroke….
 MRI
 MRA
 CT
 Angiogram
The terrifying truth about diabetes… By 2050….. 1 in 3 adults will be diabetic
WHY???? 9
The terrifying truth …  86% of Type 1 diabetics
40% of Type 2 diabetics
have clinically
evident
diabetic
retinopathy
Current ADA Diagnostic Criteria for DM
 HbA1c ≥ 6.5%
 Random plasma glucose ≥ 200mg/dL + symptoms (polyuria, thirst, wt loss, blurred vision)
 1/3 to ½ of diabetic patients do not receive an annual eye examination
 Fasting plasma glucose ≥ 126mg/dL
 OGTT 2 hour post‐load glucose ≥ 200mg/dL
 By 2050, the number of patients with diabetic retinopathy will triple
American Diabetes Association. Standards of Medical Care in Diabetes 2014.
Related Conditions
 Pre‐Diabetes
 Impaired glucose tolerance
 A1C of 5.7% ‐ 6.4%
 Fasting BS of 100‐125 mg/dl
 OGTT 2 hour blood glucose of 140 ‐ 199mg/dl
 Metabolic Syndrome – 25% of population
 Pre‐diabetic
 Abdominal obesity
 HTN
 High cholesterol
AOA Clinical Practice Guidelines
 January, 2014
 Evidence‐based vs. “consensus‐based”
 Stimulated by the new process established by the Institute of Medicine (IOM) of the National Academy of Sciences – evidence and outcome driven  576 papers reviewed, critiqued and referenced by 18 peer experts AOA Clinical Practice Guidelines
 Covers the basics…
 When to refer undiagnosed patient with symptoms to PCP
 How often to perform DFE
 Recommendations for f/u of macular edema
 Treatment of neovascularization Communicate with patient’s PCP regardless of retinopathy status
 And beyond…
 Use of OCT
 Rapid‐acting carbohydrates – need in office for hypoglycemic events 10
After all these years….
 Diabetic Retina Study (DRS) – 1971‐75
 Efficacy and timing for PRP and focal laser to prevent vision loss  Early Treatment Diabetic Retinopathy Study The Use of OCT
 Detection and monitoring response to treatment
(ETDRS) – 1979‐90  Efficacy and timing for PRP and focal laser to prevent vision loss  Classification of stages of retinopathy and CSME
 Routine macular OCT NOT indicated
 Central macular thickness – not the only factor in the return of visual function Management of DR
Pregnancy and Diabetic Retinopathy
 Main risk factor for DM  PRP
 May be considered for severe NPDR when high risk of progression  Vitrectomy
 The sooner the better for vitreous hemes
 Small gauge – less complications, better outcomes
 ERM, VMT
 Macular edema  Anti‐VEGF +focal laser when central and 20/30 or worse 2014 ADA Guidelines
For pregnant patients
with pre-existing
diabetes (Type I or II):
worsening during pregnancy is baseline severity of diabetic retinopathy
 2.5 x increased risk  Recommend A1C <6% in pregnant patients with pre‐existing Type 1 or 2 DM
Gestational Diabetes
 5‐10% of pregnancies
 Diagnosed 2nd – 3rd trimester
•DFE once per
trimester
•Retinopathy
counseling
 Glucose tolerance typically returns to normal 6 weeks post‐partum
 Due to short/temporary duration → GDM does not typically lead to development of diabetic retinopathy
11
Earlier Detection ??  autofluorescence
of lens
 AGEs
Crystalline lens autofluorescence
 Advanced glycation end products (AGEs)
 Highly correlated with uncontrolled blood glucose  An increase in AGEs is linked to autofluorescence
 Linked to diabetic cataract formation  Present up to 7 years earlier than other diabetic complications  Identification of risk factors for retinopathy?
 Closer follow‐up?
Creativity in blood glucometry…
Patient Education  ABCs of diabetes
A –A1C /blood glucose is “individualized” B –140/80 or less
C –LDLs 100 or <70 if CVD
S – smoking increases risk of retinopathy  Weight loss
 Exercise – 150 min per week Nutrition for Diabetics
 Dietary Advice
 Glycemic index
 Supplements
 Benfotiamine
 Pycnogenol
Nutritional Supplementation??
 Believed to
 Control glucose levels
 Inhibit diabetic induced retinal oxidative damage
 Protective effect against retinopathy
 Some include:
 Vitamin D, E
 Benfotiamine
 Pycnogenol
12
Ocular signs of carotid artery disease
 Ocular Hypoperfusion
 Hollenhorst Plaque
 CRAO
 Amaurosis Fugax
 4/5 strokes are causes by athersclerotic disease at carotid bifurcation  leading causes of death in US
 1/3 of cases are fatal
 Survivors usually have irreversible damage
Landwehr P, et al
Atypical/differentials?? Pearls and Prognosis
 Other clues
 Attenuated arterioles
 Look for (+)SAP  Or….. How easily can you collapse the arterial tree?  5 year mortality rate – 40%  90% blockage – CRA perfusion pressure ↓ 50%
Carotid Bruit
 Usually ≥70% blockage before ocular manifestations
13
Management of intra‐arteriolar plaque
 Acute care
 Symptoms?  Antiplatelets? Blood thinners? 
Eliquis (apixaban)
 Determining and Caro d Artery Dissec on → Horner’s Syndrome
 3rd order neuron defect along sympathetic pathway
 Imaging treating underlying etiology
 Doppler
 EKG/Angiography
http://www.cmaj.ca
Caro d Artery Dissec on → Horner’s Syndrome
 Dx of Horner’s
 10% cocaine – will NOT dilate
 0.5% apraclonidine – WILL dilate
 1% phenylephrine – WILL dilate  1% hydroxyamphetamine –
 Helps to localize lesion  What else can help us localize the lesion????

This patient has a 3rd order neuron lesion – sweating unaffected
Atrial Fibrillation
 Most common cardiac arrhythmia  Increased risk of stroke and MI
 Many undiagnosed
 History
 ECG (no P wave)
 Linked to retinopathy in diabetics
*Starting proven medications and therapy within 24 hours of symptom onset reduces the risk of having a stroke within 3 months by 80%
Dennis M, et. al. Prognosis of transient ischemic attack in the Oxfordshire Community Stroke Project. Stroke.
1990 Jun; 21(6): 848-53.
Rothwell PM et al. Effect of urgent treatment of transient ischemic attack and minor stroke on early recurrent
stroke (EXPRESS study): a prospective population-based sequential comparison. Lancet. 2007; 370(9596):
1432-42.
14
Risk of stroke after TIA
Johnston WC, Rothwell PM, Nguyen‐Huynh MN, et al. Validation and refinement of scores to predict very early stroke risk after transient ischaemic attack. Lancet. 2007; 369: 283‐292.
 Consider your risk factors in patients with TIA!
 ABCD2 rule
 Age>60 (1 point)
 BP ≥140/90 on first assessment after TIA (1 point)
 Clinical features of TIA (unilateral weakness=2 points or speech impairment without weakness=1 point)
 Duration of TIA (≥60 minutes=2 points; 10‐59 minutes=1point)
 Diabetes (1 point)
Blood in the retina….
What else can
cause blood
in the retina?
End Stage Renal Disease
 Medical History
 Recent cough?
 Severe kidney disease?
 Anemia?  Blood dyscrasias?  Social/employment history
 Heavy lifting Factor V Leiden??? What’s that?!!
 Factor V – clotting protein
 genetic mutation: ↑clotting in veins  Caucasians of European descent
 Often undiagnosed, however….
 Complications
 Miscarriage and clots in pregnancy  deep vein thrombosis
 pulmonary embolisms  CRVO Fegan CD et al, Eye (2002) 15
Revised Recommendations on Screening for Chloroquine and Hydroxychloroquine
Retinopathy Plaquenil ‐‐ What to look for on OCT…
Marmor MF, et al. Ophth Feb 2011.  Risk of toxicity increases sharply towards 1% after 5‐7 yrs of use, or cumulative dose of 1000 g HCQ
 Initial baseline exam, then annual screenings after 5 years
Marmor MF, et al. Ophthalmology. AAO Revised Recommendations on Screening for Chloroquine and
Hydroxychloroquine Retinopathy. Feb 2011.
 Screening:
 Regular exams with DFE
 10‐2  SD OCT, FAF or mfERG
 Outer retina
 Loss of IS/OS line (PIL); thinning of PR layer  Thickening of outer band of RPE  Inner retina
 Parafoveal thinning of GCL, IPL
 1.0mm (but not 0.5mm) from foveal center
But WAIT!!  10% of patients with a ring scotoma do NOT show damage with SD‐OCT!
Coding for high risk meds
• Code systemic disease which is the reason for the medication
Marmor MF, Melles RB. Ophthalmology. 2014 Jan 15. pii: S0161‐
6420(13)01174‐3. doi: 10.1016/j.ophtha.2013.12.002. Disparity between Visual Fields and Optical Coherence Tomography in Hydroxychloroquine Retinopathy.
– Long term (current) use of high risk medication– V58.69 – SLE – 695.4
• ICD‐10 codes…..October 1,2015!!!
– Z79.899 : “other long term (current) drug therapy”
Talc Retinopathy Differential Diagnoses of refractile
deposits in the retina

Drug Related
1.
2.
3.
4.
5.
1. Tamoxifen
2. Canthaxanthine
3. Nitrofurantoin
4. Ritonavir 5. Talc

Embolic Diseases
1.
2.
 Primary Ocular Disorders
1.
 Genetic Disorders
1. Primary Hyperoxaluria
2. Cystinosis
3. Hyperornithinemia
4. Sjögren‐Larsson Syndrome
1. Calcium emboli
2. Cholesterol emboli
2.
3.
4.
Calcified macular drusen
Idiopathic parafoveal
telangiectasis
Bietti’s crystalline dystrophy
Longstanding retinal detachment
16
 Optical coherence tomography (both time domain and spectral domain) confirms talc particles are localized to the inner retinal layers (containing retinal vasculature)
 NFL, INL, Clinical Management
 Patients without retinal ischemia, NFL defects, and without ongoing IV drug use should be photodocumented and monitored on an annual basis with visual fields
 Consider referral to PCP to monitor for small vessel disease
 Talc retinopathy has been associated with pulmonary talcosis, which can result in respiratory dysfunction, pulmonary HTN, and possibly death
choriocapillaris
From: Vinay A. Shah, et al. Talc Retinopathy. Ophthalmology. 2008: 115(4). 755 - 755.e2 http://dx.doi.org/10.1016/j.ophtha.2007.10.043
PREVENTION WELLNESS
COMMUNITY HEALTH
TREATING THE WHOLE PATIENT
MEDICAL
OPTOMETRY
CLINICAL
QUALITY
MEASURES
…..where do we fit in?
Relate your advice to relevant ocular findings
 Weight Loss  Smoking Cessation
 Supplementation
 Vitamin D
 Advise with caution….
 AMD patients
 Blood thinners
17