AAPC April

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Common Ophthalmology

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gy

Surgical Procedures

AAPC April 2011 Eric J Poulsen MD Eric J. Poulsen, MD [email protected] 559 449 5050

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Overview

• How the eye works – Anatomy/PhysiologyAnatomy/Physiology • What can go wrong

Pathology – Pathology • How we fix it

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H th k How the eye works

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Why do we need glasses?

• Nearsightedness (Myopia) • Farsightedness (Hyperopia)Farsightedness (Hyperopia) • Astigmatism

P b i ( f 40)

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Farsightedness Farsightedness

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Farsightedness Farsightedness

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N i ht d

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N i ht d

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Astigmatism Astigmatism

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How are these treated?

• Eyeglasses

• Contact lensesContact lenses

• Refractive Surgery LASIK PRK

– LASIK, PRK – Lens Implants

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Refractive Surgery Refractive Surgeryg yg y Laser Laser RK 65771 RK 65771 Lens Implant Lens Implant LASIK

LASIK PRKPRK Phakic IOLPhakic IOL RLERLE 66999 65720? 66999 65720? 66999 66999 6699966999 6699866998

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What is a LASER? Light Amplification by Amplification by Stimulated E i i f Emission of Radiation

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Custom Excimer Laser Custom Excimer Laser

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PRK PRK

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LASIK LASIK

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LASIK Candidates

• Nearsighted, Farsighted, Astigmatic • Stable vision

• No chronic eye conditionsy • No diseases that affect eyes

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Potential Side Effects • Temporary irritation • Under correction • Under-correction • Over-correction • Infection • Displaced flapp p

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Visian Visian

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Verisyse Verisyse

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Pathology, or what goes wrong? • ExternalExternal • Infections O i • Opacity • Retina • Congenital

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Corneal Opacity Corneal Opacity

• Corneal Dystrophy • Corneal Dystrophy

– Fuchs’ Corneal Dystrophy

P d h ki B ll K h

– Pseudophakic Bullous Keratopathy • Corneal Degeneration – Keratocous – Ectatia • Corneal Scar – Injuryj y – HSV

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Corneal Foreign Bodyg y 65222

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C l T l t

Corneal Transplant Corneal Transplant

Lamellar

Lamellar Full ThicknessFull Thickness

DALK 65710 DALK 65710 DSEK 65756 +/-DSEK 65756 +/-Penetrating Keratoplasty Penetrating Keratoplasty 65710 65710 65757 65757 _65730/65755_65730/65755

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DSEK, DALK

• Transplanting only the needed layer of y cornea

• Faster recoveryFaster recovery • Fewer long-term

problems (?) problems (?)

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Cataract Cataract

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Cataracts are treated with… A) Laser B) Blade C) Eyedrops) y p D) Ultrasound E) Radiation E) Radiation

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Phacoem lsification Phacoemulsification

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Cataract Surgery Cataract Surgery Complex 66982 Complex 66982 Standard 66984 Standard 66984 66982 66982 6698466984 Pupil dil ti Pupil dil ti Capsule d Capsule d No extra No extra dilation

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Cataract Extraction Cataract Extraction

with Lens Implant

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Intraocular Lenses Intraocular Lenses

Premium

Premium StandardStandard

Multifocal Multifocal Toric M f l Toric M f l MonofocalMonofocal Multifocal Multifocal Monofocal

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Pt i E i i Pt i E i i Pterygium Excision Pterygium Excision Graft 65426 Graft 65426 No Graft 65420 No Graft 65420 65426 65426 6542065420 Conjunctival Autograft Conjunctival Autograft Amniotic Membrane Amniotic Membrane Mitomycin-C 65435? Mitomycin-C 65435? 68335 68335 6578065780 65435?65435?

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Age-related Macular Degeneration

• Dry • WetWet

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ARMD ARMD

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M l D ti M l D ti Macular Degeneration Macular Degeneration Wet (Exudative) Wet (Exudative) Dry (Non-d ti ) Dry (Non-d ti ) ( ) ( ) exudative) exudative) Intravitreal Injection Intravitreal Injection Laser 67220 Laser 67220 AREDSAREDS j 67028 j 67028 6722167221

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Nonproliferative Diabetic Retinopathy • Microaneurysms • Intraretinal hemorrhagesg – Dot/Blot – Flame • Cotton-wool spots • Venous dilation/beading • IRMA • Exudates • Macular edema

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Proliferative Diabetic Retinopathy • Retinal neovascularization • Iris neovascularization • Fibrovascular proliferation • Vitreous hemorrhage • Traction retinal detachment

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Retina Laser Treatment Retina Laser Treatment

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Optic Nerve

• Glaucoma

• Optic Neuritis--Multiple SclerosisOptic Neuritis Multiple Sclerosis • Ischemic Optic Neuropathy

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Glaucoma

• Damage to optic nerve • IOPIOP

• Types T

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Glaucoma Laser Surgery

Open Angle

Open Angle Narrow AngleNarrow Angle

ALT = SLT 65855 ALT = SLT 65855 Cyclo- Cyclo-Laser Iridotomy 66761 Laser Iridotomy 66761 65855 65855 y Destruction 66710/66711 y Destruction 66710/66711 66761 66761

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Glaucoma Surgery Glaucoma Surgery

Filter

Filter ValveValve

Trabeculectomy 66170 Trabeculectomy 66170 Ex-PRESSEx-PRESS Ahmed B ld Ahmed B ld 66170 66170 _Baerveldt Molteno 66180 Baerveldt Molteno 66180 66180 66180

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Eyelid Lesions

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Droopy Eyelids Droopy Eyelidspy ypy y Brow Droop Brow Droop • Direct • Endoscopic • CoronalCoronal Dermatochalasis • Blepharoplasty Ptosis • Levator Advancment, 67904 • Frontalis Sling, 67901

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Cosmetic Blepharoplasty Cosmetic Blepharoplasty

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Strabismus Strabismus Strabismus Strabismus

Esotropia

Esotropia ExotropiaExotropia

Bilateral

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The Red Eye

• Infection

• InflammationInflammation • Injury

I l l i

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Infection

• Eyelid

• Conjunctiva • Cornea

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HSV or HZV Epitheliitis HSV or HZV Epitheliitis

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Inflammation • Allergy • PingueculumPingueculum • Pterygium E i l i i • Episcleritis • Scleritis • Uveitis

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Seasonal / Perennial Allergic Conjunctivitis

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Vernal Keratoconjunctivitis (VKC) Vernal Keratoconjunctivitis (VKC)

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Nonproliferative Diabetic Retinopathy • Microaneurysms • Intraretinal hemorrhagesg – Dot/Blot – Flame • Cotton-wool spots • Venous dilation/beading • IRMA • Exudates • Macular edema

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Proliferative Diabetic Retinopathy • Retinal neovascularization • Iris neovascularization • Fibrovascular proliferation • Vitreous hemorrhage • Traction retinal detachment

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The Goofy Eye

• Strabismus—congenital, CN palsy, CNS lesion • Ptosis—involutional CN III palsy myastheniaPtosis involutional, CN III palsy, myasthenia • Proptosis—cellulitis, Grave’s disease, tumor

Bl h d h if i l

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Pseudostrabismus Pseudostrabismus

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CN VI Palsy CN VI Palsy

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Ptosis Ptosis

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Proptosis Proptosis

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Treat and Triage

• Therapeutic patching • Topical medicationsTopical medications • Diagnostic testing

R f l

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Eye Injuries Eye Injuries

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History • Mechanism • Blunt • Superficial • Penetrating • Mechanism mismatch • Prior ocular surgeryPrior ocular surgery

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Examine and Classify • Ocular vs peri-ocular • BluntBlunt • Superficial P i • Penetrating

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Vital Signs

• Visual Acuity • Pupil examPupil exam

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Visual Acuity Visual Acuity

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Blunt Trauma

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Fist B ttl • Bottle • Handlebar • Knee • Nightstand • Baseball • Non-accident

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