Ophthalmology: Current Topics in Questions and Answers - PDF document

Ophthalmology: Current Topics in Questions and Answers Ophthalmology With help from: Jacque Duncan, MD Stephen D. McLeod, Professor and Professor, Clinical Ophthalmology Chair, UCSF Department of UCSF Ophthalmology Primary Care Medicine: Ayman Naseri, Professor and Vice Principles and Practice Chair for Graduate Medical Education, UCSF Department of October 30, 2013 Ophthalmology Disclosures: Common Questions:  I have nothing to disclose 1. What does my patient need before undergoing cataract surgery? 2. Are vitamins really helpful in preventing vision loss? 3. What do I need to do for patients on Plaquenil? 1

Common Questions: Cataract Surgery  Most commonly performed ambulatory 1. What does my patient need before undergoing cataract surgery? surgery in the US 2. Are vitamins really helpful in preventing  Numbers will increase as population ages vision loss?  Should I do an extensive medical evaluation 3. What do I need to do for patients on to ensure my patient is safe to undergo Plaquenil? surgery? – True – False No : Cochrane Review Should I do routine medical  Routine pre-operative testing does not testing (EKG, CBC, renal increase the safety of cataract surgery panel) to ensure my patient is – Intraoperative events (OR 1.02, 95% CI 0.85 to 1.22) safe to undergo surgery? – Postoperative adverse events (OR 0.96, 95% CI 0.74 to 1.24). – Costs estimated to be 2.55 times higher in those with 1. Yes preoperative medical testing compared to those without 2. No preoperative medical testing.  91.4% one year survival rate among VA pts with high disease burden Keay L, et al. Cochrane Database of Systematic Reviews 2012, Issue 3. Art. No.: CD007392 Schein O et al. NEJM 2000; 342:168-75 Greenberg PB et al. J Cataract Refract Surg 2011; 37:970-71 2

Answer: NO Should I discontinue my  Most cataract surgery is done without any patient’s anticoagulant or injections antiplatelet medications before  May increase medical morbidity cataract surgery?  Ophthalmologists need to communicate with primary care providers for patients 1. Yes with severe systemic disease, or when more 2. No invasive ocular surgery is planned. American Academy of Ophthalmology Cataract in the Adult Eye. Preferred Practice Patterns, 2006. Chen CK, Tseng VL, Wu W-C, Greenberg PB. J Cataract Refract Surg 2010; 36:1239-40. Ong-Tone L, Paluck EC, Hart-Mitchell RD. J Cataract Refract Surg 2005;31:991-6. Age-Related Macular Common Questions: Degeneration 1. What does my patient need before  Leading Cause of Severe Central Vision Loss among undergoing cataract surgery? people over 50 in U.S. 2. Are vitamins really helpful in preventing – 6 million cases in U.S. vision loss? – 1.75 million over age 50 have advanced AMD 3. What do I need to do for patients on  Prevalence increasing as population ages Plaquenil?  Population >60 will double by 2030  Number with advanced AMD will increase 50% to 2.95 M by 2020 Eye Diseases Prevalence Research Group , Arch Ophthalmol 2004;122:564-72 3

Normal Retina Normal AMD Milam AH, John SK. The Human Retina in Heath and Disease CD-ROM. 2001 Drusen Geographic Atrophy Milam AH, John SK. The Human Retina in Heath and Disease CD-ROM. 2001 Milam AH, John SK. The Human Retina in Heath and Disease CD-ROM. 2001 4

Choroidal Neovascularization Disciform Scar 10% of patients, 90% of severe vision loss Milam AH, John SK. The Human Retina in Heath and Disease CD-ROM. 2001 Milam AH, John SK. The Human Retina in Heath and Disease CD-ROM. 2001 Nutritional Supplements in Risk of Developing Advanced AMD AMD 50 Placebo Antioxidants Zinc 40 Antioxidants+Zinc Percent with Advanced AMD  Age Related Eye Disease Study (AREDS) Double-masked, placebo-controlled, multicenter, – 30 randomized clinical trial 3,640 patients, followed at least 5 years (average – 20 6.3 years) Randomly assigned to high doses of: – 10 1. Antioxidants Vit C 500mg, Vit E 400 IU,  -carotene 15mg • 0 0 1 2 3 4 5 6 7 2. Zinc=80mg Zn oxide + 2mg cupric oxide Years 3. Antioxidants + Zinc 4. Placebo AREDS Research Group, Arch Ophthalmol 2001;119:1417-36 5

Age Related Eye Disease Common Questions: Study (AREDS)  Recommend: 1. What does my patient need before – All people > 55 years old should have dilated eye undergoing cataract surgery? examinations – If patients have medium to high-risk AMD in either 2. Are vitamins really helpful in preventing eye, or advanced AMD in 1 eye: vision loss?  Consider supplemental vitamin C, E, zinc +copper  Add  -carotene if not a smoker 3. What do I need to do for patients on  Quit smoking if a smoker!  AREDS 2 Plaquenil?  No additional benefit to adding lutein and omega-3 fatty acid supplementation AREDS Research Group, Arch Ophthalmol 2001;119:1417-36 AREDS Study 2 Research Group, JAMA 2013:309:2005-15 63 year old woman Visual fields: 2003  PMH: Lupus with Sjogren’s syndrome  Meds: Treated with hydroxychloroquine 400 mg daily for 25 years (lifetime dose of 3,650 grams). Weight of 135 lbs = 6.52 mg/kg/d  Complained of vision loss, but her ophthalmologist records visual acuity of 20/20 OU.  She was told her vision was fine and not to worry.  Stopped taking hydroxychloroquine in 2005  Monitored with serial Humphrey visual field tests: 6

Visual fields: 2007 Visual fields: 2009 Retinal Toxicity and Hydroxychloroquine Fundus Photos: 2009  Rare relative to the many thousands/millions of individuals treated  Of concern because even after drug cessation there is little if any visual recovery and sometimes progression of vision loss  Mechanism not clearly understood  Early symptoms: paracentral vision loss with foveal sparing  Moderate: bull’s eye maculopathy  Late: loss of peripheral visual field, night vision, widespread fundus changes  Toxicity can be prevented if the drug is discontinued before advanced macular outer retinal damage has occurred Marmor MF et al, Ophthalmology 2002; 109: 1377-82 7

Retinal Toxicity and Screening Protocol Hydroxychloroquine  Patient counseling re: risk of permanent vision loss and  Risk factors: need for periodic exams – Daily dose greater than 6.5 mg/kg/d IBW  Baseline exam, then annually after 5 years – Obesity: drug is not retained in fat  Visual field testing : Sensitivity losses 2-6 degrees from – Duration of therapy greater than 5 years fixation  After 7 years: risk increases to 1% – White: red is sensitive but not specific – Cumulative dose > 1000 g – Renal or hepatic dysfunction – Even the most subtle change should prompt objective – Age greater than 60 years testing and referral to an ophthalmologist! – Macular or retinal disease at baseline (AMD) Ideal body weight: women = 100 lbs + 5 lbs for each inch over 5 feet men = 110 lbs + 5 lbs for each inch over 5 feet Marmor MF et al, Ophthalmology 2011; 118: 415-22 Hydroxychloroquine/Chloroquine Hydroxychloroquine/Chloroquine Screening recommendations Screening recommendations  Baseline:  Follow up: – Dilated Eye Exam and Visual Field Testing – Consider annual undilated visual fields and where available, SDOCT photos: sensitive and widely available – Look for pre-existing disease that could contraindicate use or complicate interpretation of screening tests – Take any visual field changes seriously and evaluate with objective tests – Consider baseline referral to optometry or ophthalmology – Refer to ophthalmology with any subjective or visual  Routinely check for toxic daily dosing: > 6.5 mg/kg field changes for more advanced objective testing ideal body weight – Require at least 2 methods (1 objective) to confirm  No additional ophthalmic testing for the first 5 years toxicity before recommending drug discontinuation for routine patients in absence of visual symptoms, renal or hepatic disease Browning DJ, Am J Ophthalmol 2013: 155: 418-28 Browning DJ, Am J Ophthalmol 2013: 155: 418-28 Marmor MF, Am J Ophthalmol 2013; 155: 413-14 Marmor MF, Am J Ophthalmol 2013; 155: 413-14 8