ICO International Clinical Guidelines: List of Guidelines Available

November 2010
ICO International Clinical Guidelines

This document contains 24 International Clinical Guidelines defined by the
International Council of Ophthalmology (ICO).
The Guidelines are designed to be translated and adapted by ophthalmologic

societies to help ophthalmologists assess how they are treating patients. They are
intended to serve a supportive and educational role and ultimately to improve the
quality of eye care for patients.
Below is a list of the Guidelines available with links to each Guideline in this
document, followed by the Preface to the Guidelines. Also see the Introduction to
the ICO International Clinical Guidelines
www.icoph.org/enhancing_eyecare/international_clinical_guidelines.html.
For the latest information on the ICO Clinical Guidelines and to download
individual Guidelines as separate PDF files, see the www.icoph.org resources
listings.
List of Guidelines Available

Age-Related Macular Degeneration (Initial and Follow-up Evaluation)
Age-Related Macular Degeneration (Management Recommendations)
Amblyopia (Initial and Follow-up Evaluation)
Bacterial Keratitis (Initial Evaluation)
Bacterial Keratitis (Management Recommendations)
Blepharitis (Initial and Follow-up Evaluation)
Cataract (Initial and Follow-up Evaluation)
Conjunctivitis (Initial Evaluation and Therapy)
Diabetic Retinopathy (Initial and Follow-up Evaluation)
Diabetic Retinopathy (Management Recommendations)
Dry Eye Syndrome (Initial Evaluation)
Dry Eye Syndrome (Management Recommendations)
Esotropia (Initial and Follow-up Evaluation)
Exotropia (Initial and Follow-up Evaluation)
Eye Disease in Leprosy (Initial Evaluation and Management)
Idiopathic Macular Hole (Initial Evaluation and Therapy)
Keratorefractive Surgery (Initial and Follow-up Evaluation)
Ocular HIV/AIDS Related Diseases (Initial and Follow-up Evaluation)
Posterior Vitreous Detachment, Retinal Breaks and Lattice Degeneration
(Initial and Follow-up Evaluation)
Primary Open-Angle Glaucoma (Initial Evaluation)
Primary Open-Angle Glaucoma (Follow-up Evaluation)
Primary Open-Angle Glaucoma Suspect (Initial and Follow-up Evaluation)
Primary Angle Closure (Initial Evaluation and Therapy)
Trachoma
Preface to the Guidelines

International Clinical Guidelines are prepared and distributed by the International
Council of Ophthalmology.
These Guidelines are to serve a supportive and educational role for
ophthalmologists worldwide. These guidelines are intended to improve the quality
of eye care for patients. They have been adapted in many cases from similar
documents (Benchmarks of Care) created by the American Academy of
Ophthalmology based on their Preferred Practice Patterns.
While it is tempting to equate these to Standards, it is impossible and inappropriate
to do so. The multiple circumstances of geography, equipment availability, patient
variation and practice settings preclude a single standard.
Guidelines on the other hand are a clear statement of expectations. These include
comments of the preferred level of performance assuming conditions that allow the
use of optimum equipment, pharmaceuticals and/or surgical circumstances.
Thus, a basic expectation is created and if the situation is optimum, the optimum
facets of diagnosis, treatment and follow up may be employed. Excellent,
appropriate and successful care can also be provided where optimum conditions
do not exist.
Simply following the Guidelines does not guarantee a successful outcome. It is
understood that, given the uniqueness of a patient and his or her particular
circumstance, physician judgment must be employed. This can result in a
modification in application of a guideline in individual situations.
Medical experience has been relied upon in the preparation of these guidelines,
and they are whenever possible, evidence-based. This means these Guidelines
are based on the latest available scientific information. The ICO is committed to
provide updates of these guidelines on a regular basis (approximately every two to
three years).
(Also see the Introduction to the ICO International Clinical Guidelines at
www.icoph.org/guide/guideintro.html and the list of other Guidelines at
www.icoph.org/guide/guidelist.html.)
ICO International Clinical Guidelines, 2010

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Age-Related Macular Degeneration
(Ratings: A: Most important, B: Moderately important, C: Relevant but not critical

Strength of Evidence: I: Strong, II: Substantial but lacks some of I, III: consensus
of expert opinion in absence of evidence for I & II)
Initial Exam History (Key elements)

Symptoms (metamorphopsia, decreased vision) (A:II)
Medications and nutritional supplements (B:III)
Ocular history (B:II)
Systemic history (any hypersensitivity reactions) (B:II)
Family history, especially family history of AMD (B:II)
Social history, especially smoking (B:II)
Initial Physical Exam (Key elements)

Visual acuity (A:III)
Stereo biomicroscopic examination of the macula (A:III)
Ancillary Tests
Intravenous fundus fluorescein angiography in the clinical setting of AMD is
indicated: (A:I)
o when patient complains of new metamorphopsia
o when patient has unexplained blurred vision
o when clinical exam reveals elevation of the RPE or retina, subretinal
blood, hard exudates or subretinal fibrosis
o to detect the presence of and determine the extent, type, size, and
location of CVN and to calculate the percentage of the lesion
composed of or consisting of classic CNV
o to guide treatment (laser photocoagulation surgery or verteporfin
PDT)
o to detect persistent or recurrent CNV following treatment
o to assist in determining the cause of visual loss that is not explained
by clinical exam
Each angiographic facility must have a care plan or an emergency plan and a
protocol to minimize the risk and manage any complications. (A:III)

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Follow-up Exam History
Visual symptoms, including decreased vision and metamorphopsia (A:II)
Changes in medications and nutritional supplements (B:III)
Interval ocular history (B:III)
Interval systemic history (B:III)
Changes in social history, especially smoking (B:II)
Follow-up Physical Exam

Stereo biomicroscopic examination of the fundus (A:III)
Follow-up Treatment after Neovascular AMD

Discuss risks, benefits and complications with the patient and obtain
informed consent (A:III)
Examine patients treated with ranibizumab intravitreal injections
approximately 4 weeks after treatment (A:III)
Examine patients treated with bevacizumab intravitreal injections
approximately 4 to 8 weeks after treatment (A:III)
Examine patients treated with pegaptanib sodium injection approximately 6
weeks following the treatment (A:III)
Examine and perform fluorescein angiography at least every 3 months for
up to 2 years after verteporfin PDT (A:I)
Examine patients treated with thermal laser photocoagulation approximately
2 to 4 weeks after treatment and then at 4 to 6 weeks (A:III)
Optical coherence tomography, (A:III) fluorescein angiography, (A:I) and
fundus photography (A:III) may be helpful to detect signs of exudation and
should be used when clinically indicated
Subsequent examinations should be performed as indicated depending on
the clinical findings and the judgment of the treating ophthalmologist (A:III)
Patient Education
Educate patients about the prognosis and potential value of treatment as
appropriate for their ocular and functional status (A:III)
Encourage patients with early AMD to have regular dilated eye exams for
early detection of intermediate AMD (A:III)
Educate patients with intermediate AMD about methods of detecting new
symptoms of CVN and about the need for prompt notification to an
ophthalmologist (A:III)
Instruct patients with unilateral disease to monitor their vision in their fellow
eye and to return periodically even in absence of symptoms, but promptly
after onset of new or significant visual symptoms (A:III)
Instruct patients to report symptoms suggestive of endophthalmitis,
including eye pain or increased discomfort, worsening eye redness, blurred
or decreased vision, increased sensitivity to light, or increased number of
floaters promptly (A:III)

Page 4
Encourage patients who are currently smoking to stop (A:I) because there
are observational data that support a causal relationship between smoking
and AMD (A:II) and other considerable health benefits of smoking cessation
Refer patients with reduced visual function for vision rehabilitation (see
www.aao.org/smartsight) and social services (A:III)
* Adapted from the American Academy of Ophthalmology Summary Benchmarks,

November 2010 (www.aao.org)

Page 5
(Management Recommendations)
Treatment Recommendations and Follow-up Plans for

Diagnoses Eligible for

Recommended Treatment Follow-up Recommendations
Treatment
Observation with no medical No clinical signs of AMD As recommended in the Comprehensive Adult
or surgical therapies (A:I) (AREDS category 1) Medical Eye Evaluation PPP (A:III)
Early AMD (AREDS Return exam at 6 to 24 months if asymptomatic or

category 2) prompt exam for new symptoms suggestive of CVN
(A:III)
Advanced AMD with
bilateral subfoveal No fundus photos or fluorescein angiography
geographic atrophy or unless symptomatic (A:I)
disciform scars
Antioxidant vitamin and Intermediate AMD Monitoring of monocular near vision

mineral supplements as (AREDS category 3) (reading/Amsler grid) (A:III)
recommended in the AREDS
reports (A:I) Advanced AMD in one Return exam at 6 to 24 months if asymptomatic or
eye (AREDS category 4) prompt exam for new symptoms suggestive of CVN
(A:III)
Fundus photography as appropriate
Fluorescein angiography if there is evidence of

edema or other signs and symptoms of CVN
Ranibizumab intravitreal Subfoveal CNV Patients should be instructed to report any
injection 0.5 mg as symptoms suggestive of endophthalmitis promptly,
recommended in ranibizumab including eye pain or increased discomfort,
literature (A:I) worsening eye redness, blurred or decreased
vision, increased sensitivity to light, or increased
number of floaters (A:III)
Return exam approximately 4 weeks after

treatment; subsequent follow-up depends on the
clinical findings and judgement of the treating
Monitoring of monocular near vision

(reading/Amsler grid) (A:III)

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Treatment
Bevacizumab intravitreal Subfoveal CNV Patients should be instructed to report any

injection as described in symptoms suggestive of endophthalmitis promptly,
published reports (A:III) including eye pain or increased discomfort,
worsening eye redness, blurred or decreased
vision, increased sensitivity to light, or increased
The ophthalmologist should
provide appropriate informed Return exam approximately 4 to 8 weeks after
consent with respect to the treatment; subsequent follow-up depends on the
off-label status (A:III) clinical findings and judgement of the treating

Pegaptanib sodium Subfoveal CNV, new or Patients should be instructed to report any
intravitreal injection as recurrent, for symptoms suggestive of endophthalmitis promptly,
recommended in pegaptanib predominantly classic including eye pain or increased discomfort,
sodium literature (A:I) lesions <12 MPS disc worsening eye redness, blurred or decreased
area in size vision, increased sensitivity to light, or increased
Minimally classic, or
occult with no classic Return exam with retreatments every 6 weeks as
lesions where the entire indicated (A:III)
lesion is <12 disc areas in
size, subretinal Monitoring of monocular near vision
hemorrhage associated (reading/Amsler grid) (A:III)
with CVN comprises
<50% of lesion, and/or
there is lipid present,
and/or the patient has
lost 15 or more letters of
visual acuity during the
previous 12 weeks
PDT with verteporfin as Subfoveal CNV, new or Return exam approximately every 3 months until
recommended in the TAP and recurrent, where the stable, with retreatments as indicated (A:III)
VIP reports (A:I) classic component is
>50% of the lesion and Monitoring of monocular near vision
the entire lesion is <5400 (reading/Amsler grid) (A:III)
microns in greatest linear
diameter
Occult CNV may be

considered for PDT with
vision <20/50 or if the
CVN is <4 MPS disc
areas in size when the
vision is >20/50

Page 7
Treatment
Thermal laser Extrafoveal classic CNV, Return exam with fluorescein angiography
photocoagulation surgery as new or recurrent approximately 2 to 4 weeks after treatment, and
recommended in the MPS then at 4 to 6 weeks and thereafter depending on
reports (A:I) May be considered for the clinical and angiographic findings (A:III)
juxtapapillary CVN
Retreatments as indicated

AMD = Age-related Macular Degeneration; AREDS = Age-related Eye Disease Study; CNV =
choroidal neovascularization; MPS = Macular Photocoagulation Study; PDT = photodynamic
therapy; TAP = Treatment of Age-related Macular Degeneration with Photodynamic Therapy; VIP =
Verteporfin in Photodynamic Therapy


Page 8
Amblyopia (Initial and Follow-up Evaluation)


Ocular symptoms and signs (A:III)
Ocular history (A:III)
Systemic history, including review of prenatal, perinatal, and postnatal
medical factors (A:III)
Family history, including eye conditions and relevant systemic diseases
(A:III)

Assessment of visual acuity and fixation pattern (A:III)
Ocular alignment and motility (A:III)
Red reflex or binocular red reflex (Brckner) test (A:III)
Pupil examination (A:III)
External examination (A:III)
Anterior segment examination (A:III)
Cycloplegic retinoscopy/refraction (A:III)
Funduscopic examination (A:III)
Binocularity/stereoacuity testing (A:III)
Care Management
Choose treatment based on patient's age; visual acuity; compliance with
previous treatment; and physical, social, and psychological status. (A:III)
Treatment goal is to achieve equalization/normalization of fixation patterns
or visual acuity. (A:III)
Once maximal visual acuity has been obtained, treatment should be tapered
and eventually stopped. (A:III)
Follow-up Evaluation
Follow-up visits should include:
o Interval history (A:III)
o Tolerance to therapy (A:III)
o Examinations and testing as indicated (A:III)

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Amblyopia Follow-up Evaluation Intervals During Active Treatment Period
(A:III)
High- Percentage Low-Percentage
Occlusion Occlusion Maintenance
Age
(70% or more of (<70% of waking Treatment or
(years)
waking hours/ 6 hours/<6 hours per Observation
hours per day) day) or Penalization
0-1 1-4 weeks 2-8 weeks 1-4 months
1-2 2-8 weeks 2-4 months 2-4 months
Patient Education
1 Discuss diagnosis, severity of disease, prognosis and treatment plan with
patient, parents and /or caregivers. (A:III)
2 Explain the disorder and recruit the family in a collaborative approach to
therapy. (A:III)


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Bacterial Keratitis (Initial Evaluation)

Initial Exam History

Ocular symptoms (A:III)
Contact lens history (A:II)
Review of other ocular history (A:III)
Review of other medical problems and systemic medications (A:III)
Current and recently used ocular medications (A:III)
Medication allergies (A:III)
Initial Physical Exam

General appearance of patient (B:III)
Facial examination (B:III)
Eyelids and eyelid closure (A:III)
Conjunctiva (A:III)
Nasolacrimal apparatus (B:III)
Corneal sensation (A:III)
Slit-lamp biomicroscopy
o Eyelid margins (A:III)
o Conjunctiva (A:III)
o Sclera (A:III)
o Cornea (A:III)
o Anterior chamber (A:III)
o Anterior vitreous (A:III)
Contralateral eye (A:III)
Diagnostic Tests
Manage majority of community-acquired cases with empiric therapy and
without smears or cultures. (A:III)
Indications for smears and cultures:
o Sight-threatening or severe keratitis of suspected microbial origin
prior to initiating therapy (A:III)
o A large corneal infiltrate that extends to the middle to deep stroma
(A:III)
o Chronic in nature (A:III)
o Unresponsive to broad spectrum antibiotic therapy (A:III)
o Clinical features suggestive of fungal, amoebic, or mycobacterial
keratitis (A:III)

Page 11
The hypopyon that occurs in eyes with bacterial keratitis is usually sterile,
and aqueous or vitreous taps should not be performed unless there is a
high suspicion of microbial endophthalmitis. (A:III)
Corneal scrapings for culture should be inoculated directly onto appropriate
culture media to maximize culture yield. (A:III). If this is not feasible, place
specimens in transport media. (A:III). In either case, immediately incubate
cultures or take promptly to the laboratory. (A:III)
Care Management
Topical antibiotic eye drops are preferred method in most cases. (A:III)
Use topical broad-spectrum antibiotics initially in the empiric treatment of
presumed bacterial keratitis. (A:III)
For central or severe keratitis (e.g., deep stromal involvement or an infiltrate
larger than 2 mm with extensive suppuration), use a loading dose (e.g.,
every 5 to 15 minutes for the first 1 to 3 hours), followed by frequent
applications (e.g., every 30 minutes to 1 hour around the clock). (A:III) For
less severe keratitis, a regimen with less frequent dosing is appropriate.
(A:III)
Use systemic therapy for gonococcal keratitis. (A:II)
In general, modify initial therapy when there is a lack of improvement or
stabilization within 48 hours. (A:III)
For patients treated with ocular topical corticosteroids at time of
presentation of suspected bacterial keratitis, reduce or eliminate
corticosteroids until infection has been controlled. (A:III)
When the corneal infiltrate compromises the visual axis, may add topical
corticosteroid therapy following at least 2 to 3 days of progressive
improvement with topical antibiotics. (A:III) Continue topical antibiotics at
high levels with gradual tapering. (A:III)
Examine patients within 1 to 2 days after initiation of topical corticosteroid
therapy. (A:III)


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Bacterial Keratitis

Frequency depends on extent of disease, but follow severe cases initially at
least daily until clinical improvement or stabilization is documented. (A:III)
Patient Education
Inform patients with risk factors predisposing them to bacterial keratitis of
their relative risk, the signs and symptoms of infection, and to consult an
ophthalmologist promptly if they experience such warning signs or
symptoms (A:III)
Educate about the destructive nature of bacterial keratitis and need for strict
compliance with therapy. (A:III)
Discuss possibility of permanent visual loss and need for future visual
rehabilitation. (A:III)
Educate patients with contact lenses about increased risk of infection
associated with contact lens, overnight wear, and importance of adherence
to techniques to promote contact lens hygiene. (A:III)
Refer patients with significant visual impairment or blindness for vision
rehabilitation if they are not surgical candidates (see
www.aao.org/smartsight). (A:III)

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Antibiotic Therapy of Bacterial Keratitis [A:III]
Organism Antibiotic Topical Subconjunctival
Concentration Dose
No organism identified Cefazolin with 50 mg/ml 9-14 100 mg in 0.5 ml
or multiple types of Tobramycin or mg/ml 20 mg in 0.5 ml
organisms gentamicin 3 or 5 mg/ml
or Fluoroquinolones Various**
Gram-positive Cocci Cefazolin 50 mg/ml 100 mg in 0.5 ml

Vancomycin*** 15-50 mg/ml 25 mg in 0.5 ml
Bacitracin*** 10,000 IU
Fluoroquinolones* Various**
Gram-negative rods Tobramycin or 9-14 mg/ml 20 mg in 0.5 ml

gentamicin 50 mg/ml 100 mg in 0.5 ml
Ceftazidime Various**
Fluoroquinolones
Gram-negative Ceftriaxone 50 mg/ml 100 mg in 0.5 ml

Cocci**** Ceftazidime 50 mg/ml 100 mg in 0.5 ml
Fluoroquinolones Various**
Nontuberculous Amikacin 20-40 mg/ml 20 mg in 0.5 ml
Mycobacteria Clarithromycin 10 mg/ml
Azithromycin***** 10 mg/ml
Fluoroquinolones Various**
Nocardia Sulfacetamide 100 mg/ml 20 mg in 0.5 ml
Amikacin 20-40 mg/ml
Trimethoprim/Sulfa
methoxazole: 16 mg/ml
Trimethoprim 80 mg/ml
Sulfamethoxazole
*Fewer gram-positive cocci are resistant to gatifloxacin and moxifloxacin than other
fluoroquinolones.
**Ciprofloxacin 3 mg/ml; gatifloxacin 3 mg/ml; levofloxacin 15 mg/ml; moxifloxacin 5mg/ml;
ofloxacin 3 mg/ml, all commercially available at these concentrations.
***For resistant Enterococcus and Staphylococcus species and penicillin allergy.
Vancomycin and Bacitracin have no gram-negative activity and should not be used as a
single agent empirically in treating bacterial keratitis.
**** Systemic therapy is necessary for suspected gonococcal infection.
***** Data from Chandra NS, Torres MF, Winthrop KL. Cluster of Mycobacterium chelonae
keratitis cases following laser in-situ keratomileusis. Am J Ophthalmol 2001; 132:819-30.


Page 14
Blepharitis (Initial and Follow-up Evaluation)

Time of day when symptoms are worse (A:III)
Duration of symptoms (A:III)
Unilateral or bilateral presentation (A:III)
Exacerbating conditions (e.g., smoke, allergens, wind, contact lens, low
humidity, retinoids, diet, alcohol consumption, eye makeup) (A:III)
Symptoms related to systemic diseases (e.g., rosacea, allergy) (A:III)
Current and previous systemic and topical medications (A:III)
Recent exposure to an infected individual (e.g., pediculosis) (C:III)
Ocular history (e.g., previous intraocular and eyelid surgery, local trauma,
including mechanical, thermal, chemical, and radiation injury) (A:III)
Systemic history (e.g., dermatological diseases, such as rosacea, atopic
disease, and herpes zoster ophthalmicus) (A:III)
External examination
o Skin (A:III)
o Eyelids (A:III)
o Tear film (A:III)
o Anterior eyelid margin (A:III)
o Eyelashes (A:III)
o Posterior eyelid margin (A:III)
o Tarsal conjunctiva (A:III)
o Bulbar conjunctiva (A:III)
o Cornea (A:III)
Measurement of IOP (A:III)
Diagnostic Tests
Cultures may be indicated for patients with recurrent anterior blepharitis with
severe inflammation as well as for patients who are not responding to
therapy. (A:III)
Biopsy of the eyelid to exclude the possibility of carcinoma may be indicated
in cases of marked asymmetry, resistance to therapy or unifocal recurrent
chalazia that do not respond well to therapy. (A:II)
Consult with the pathologist prior to obtaining the biopsy if sebaceous cell
carcinoma is suspected.(A:II)

Page 15
Care Management
Treat patients with blepharitis initially with a regimen of warm compress and
eyelid hygiene. (A:III)
For patients with staphylococcal blepharitis, a topical antibiotic such as
erythromycin can be prescribed to be applied one or more times daily or at
bedtime on the eyelids for one or more weeks. (A:III)
For patients with meibomian gland dysfunction, whose chronic symptoms
and signs are not adequately controlled with eyelid hygiene, oral
tetracyclines can be prescribed. (A:III)
A brief course of topical corticosteroids may be helpful for eyelid or ocular
surface inflammation. The minimal effective dose of corticosteroids should
be utilized and long-term corticosteroid therapy should be avoided if
possible. (A:III)
o Visual acuity (A:III)
o External exam (A:III)
o Slit-lamp biomicroscopy (A:III)
If corticosteroid therapy is prescribed, re-evaluate patient within a few
weeks to
determine the response to therapy, measure intraocular pressure, and
assess treatment compliance (A:III)
Patient Education
Counsel patients about the chronicity and recurrence of the disease
process. (A:III)
Inform patients that symptoms can frequently be improved but are rarely
eliminated. (A:III)
Advise patient that if warm compress and eyelid hygiene treatment is
effective, symptoms often recur if treatment is stopped so may be
necessary long term (A:III)


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Cataract (Initial and Follow-up Evaluation)

Symptoms (A:II)
Systemic history (A:III)
Assessment of visual functional status (A:II)

Visual acuity, with current correction (A:III)
Measurement of BCVA (with refraction when indicated) (A:III)
Ocular alignment and motility(A:III)
Pupil reactivity and function (A:III)
External examination (A:III)
Slit-lamp biomicroscopy (A:III)
Evaluation of the fundus (through a dilated pupil) (A:III)
Assessment of relevant aspects of general and mental health (B:III)
Care Management
Treatment is indicated when visual function no longer meets the patient's
needs and cataract surgery provides a reasonable likelihood of
improvement. (A:II)
Cataract removal is also indicated when there is evidence of lens-induced
diseases or when it is necessary to visualize the fundus in an eye that has
the potential for sight. (A:III)
Surgery should not be performed under the following circumstances: (A:III)
glasses or visual aids provide vision that meets the patient's needs, surgery
will not improve visual function; the patient cannot safely undergo surgery
because of coexisting medical or ocular conditions; appropriate
postoperative care cannot be obtained.
Indications for second eye surgery are the same as for the first eye. (A:II)
(with consideration given to the needs for binocular function)
Preoperative Care
Ophthalmologist who is to perform the surgery has the following responsibilities:
Examine the patient preoperatively (A:III)
Ensure that the evaluation accurately documents symptoms, findings and
indications for treatment (A:III)
Inform the patient about the risks, benefits and expected outcomes of

Page 17
surgery (A:III)
Formulate surgical plan, including selection of an IOL (A:III)
Review results of presurgical and diagnostic evaluations with the patient
(A:III)
Formulate postoperative plans and inform patient of arrangements (A:III)
High-risk patients should be seen within 24 hours of surgery. (A:III)
Routine patients should be seen within 48 hours of surgery. (A:III)
Frequency and timing of subsequent visits depend on refraction, visual
function, and medical condition of the eye.
More frequent follow-up usually necessary for high risk patients.
Components of each postoperative exam should include:
o Interval history, including new symptoms and use of postoperative
medications (A:III)
o Patient's assessment of visual functional status (A:III)
o Assessment of visual function (visual acuity, pinhole testing) (A:III)
o Measurement of IOP (A:III)
Nd:YAG Laser Capsulotomy

Treatment is indicated when vision impaired by posterior capsular
opacification does not meet the patient's functional needs or when it
critically interferes with visualization of the fundus. (A:III)
Educate about the symptoms of posterior vitreous detachment, retinal tears
and detachment and need for immediate examination if these symptoms are
noticed. (A:III)
Patient Education
For patients who are functionally monocular, discuss special benefits and
risks of surgery, including the risk of blindness. (A:III)


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Conjunctivitis (Initial Evaluation and Therapy)


Ocular symptoms and signs (e.g., itching, discharge, irritation, pain,
photophobia, blurred vision) (A:III)
Exacerbating factors (A:III)
Unilateral or bilateral presentation (A:III)
Character of discharge (A:III)
Recent exposure to an infected individual (A:III)
Trauma (mechanical, chemical, ultraviolet) (A:III)
Contact lens wear (e.g., lens type, hygiene and use regimen) (A:III)
Symptoms and signs potentially related to systemic diseases (e.g.,
genitourinary discharge, dysuria, upper respiratory infection, skin and
mucosal lesions) (A:III)
Allergy, asthma, eczema (A:III)
Use of topical and systemic medications (A:III)
Use of personal care products (A:III)
Ocular history (e.g., previous episodes of conjunctivitis (A:III) and previous
ophthalmic surgery) (B:III)
Systemic history (e.g., compromised immune status, current and prior
systemic diseases) (B:III)
Social history (e.g., smoking, occupation and hobbies, travel and sexual
activity) (C:III)

o Regional lymphadenopathy (particularly preauricular) (A:III)
o Skin (A:III)
o Abnormalities of the eyelids and adnexae (A:III)
o Eyelashes (A:III)
o Lacrimal puncta and canaliculi (B:III)
o Tarsal and forniceal conjunctiva (A:II)
o Bulbar conjunctiva/limbus (A:II)
o Cornea (A:I)
o Anterior chamber/iris (A:III)

Page 19
o Dye-staining pattern (conjunctiva and cornea) (A:III)
Diagnostic Tests
Cultures, smears for cytology and special stains are indicated in cases of
suspected infectious neonatal conjunctivitis. (A: I)
Smears for cytology and special stains are recommended in cases of
suspected gonococcal conjunctivitis. (A:II)
Confirm diagnosis of adult and neonate chlamydial conjunctivitis with
immunodiagnostic test and/or culture. (A:III)
Biopsy the bulbar conjunctiva and take a sample from an uninvolved area
adjacent to the limbus in an eye with active inflammation when ocular
mucous membrane pemphigoid is suspected. (A:III)
A full-thickness lid biopsy is indicated in cases of suspected sebaceous
carcinoma. (A:II)
Care Management
Avoid indiscriminate use of topical antibiotics or corticosteroids because
antibiotics can induce toxicity and corticosteroids can prolong adenoviral
infections and worsen herpes simplex virus infections (A:III)
Treat mild allergic conjunctivitis with an over-the-counter
antihistamine/vasoconstrictor agent or second-generation topical histamine
H1-receptor antagonists. (A:III) If the condition is frequently recurrent or
persistent, use mast-cell stabilizers (A:I)
For contact lens-related keratoconjunctivitis, discontinue contact lens wear
for 2 or more weeks (A:III)
If corticosteroids are indicated, prescribe the minimal amount based on
patient response and tolerance (A:III)
If corticosteroids are used, perform baseline measurement of intraocular
pressure (A:III)
Use systemic antibiotic treatment for conjunctivitis due to Neisseria
gonorrhoeae (A:I) or Chlamydia trachomatis. (A:II)
Treat sexual partners to minimize recurrence and spread of disease when
conjunctivitis is associated with sexually transmitted diseases and refer
patients and their sexual partners to an appropriate medical specialist.
(A:III)
Refer patients with manifestation of a systemic disease to an appropriate
medical specialist. (A:III)
o Visual acuity (A:III)
If corticosteroids are used, perform periodic measurement of intraocular

Page 20
pressure and
pupillary dilation to evaluate for cataract and glaucoma (A:III)

Page 21
Patient Education
Counsel patients with contagious varieties to minimize or prevent spread of
diseases in the community (A:III)
Inform patients who may require repeat short-term therapy with topical
corticosteroid of potential complications of corticosteroid use (A:III)
Advise patients with allergic conjunctivitis that frequent clothes washing and
bathing/showering before bedtime may be helpful (B:III)


Page 22
Diabetic Retinopathy

Duration of diabetes (A:I)
Past glycemic control (hemoglobin A1c) (A:I)
Medications (A:III)
Systemic history (e.g., obesity (A:III), renal disease (A:II), systemic
hypertension (A:I), serum lipid levels (A:II), pregnancy (A:I))

Visual acuity (A:I)
Gonioscopy when indicated (for neovascularization of the iris or increased
IOP) (A:III)
Dilated funduscopy including stereoscopic examination of the posterior pole
(A:I)
Examination of the peripheral retina and vitreous, best performed with
indirect ophthalmoscopy or with slit-lamp biomicroscopy, combined with a
contact lens (A:III)
Diagnosis
Classify both eyes as to category and severity of diabetic retinopathy, with
presence/absence of CSME.(A:III) Each category has an inherent risk for
progression.
Follow-up History
Visual symptoms (A:III)
Systemic status (e.g., pregnancy, blood pressure, serum cholesterol, renal
status) (A:III)
Glycemic status (hemoglobin A1c) (A:I)

Visual acuity (A:I)
Slit-lamp biomicroscopy with iris examination (A:II)
Gonioscopy (if neovascularization is suspected or present or if intraocular
pressure is increased) (A:II)

Page 23
Stereo examination of the posterior pole after dilation of the pupils (A:I)
Examination of the peripheral retina and vitreous when indicated (A:II)
Ancillary Tests
Fundus photography is seldom of value in cases of minimal diabetic
retinopathy or when diabetic retinopathy is unchanged from the previous
photographic appearance. (A:III)
Fundus photography may be useful for documenting significant progression
of disease and response to treatment. (B:III)
Fluorescein angiography is used as a guide for treating CSME (A:I) and as
a means of evaluating the cause(s) of unexplained decreased visual acuity.
(A:III) Angiography can identify macular capillary nonperfusion (A:II) or
sources of capillary leakage resulting in macular edema as possible
explanations for visual loss.
Fluorescein angiography is not routinely indicated as part of the
examination of patients with diabetes. (A:III)
Fluorescein angiography is not needed to diagnose CSME or PDR, both of
which are diagnosed by means of the clinical exam.
Patient Education
Discuss results or exam and implications. (A:II)
Encourage patients with diabetes but without diabetic retinopathy to have
annual dilated eye exams. (A:II)
Inform patients that effective treatment for diabetic retinopathy depends on
timely intervention, despite good vision and no ocular symptoms. (A:II)
Educate patients about the importance of maintaining near-normal glucose
levels and near-normal blood pressure and lowering serum lipid levels.
(A:III)
Communicate with the attending physician, e.g., family physician, internist,
or endocrinologist, regarding eye findings. (A:III)
Provide patients whose conditions fail to respond to surgery and for whom
treatment is unavailable with proper professional support and offer referral
for counseling, rehabilitative, or social services as appropriate. (A:III)
Refer patients with reduced visual function for vision rehabilitation (see
www,aao.org/smartsight) and social services (A:III)


Page 24
Diabetic Retinopathy
Management Recommendations for Patients with Diabetes
Follow-
Presence Panretinal Fluorescein Focal
Severity of up
of Photocoagulatio Angiograph and/or
Retinopathy (Months
CSME* n (Scatter) Laser y Laser
)
Normal or No 12 No No No
minimal NPDR
Mild to moderate No 6-12 No No No
NPDR Yes 2-4 No Usually Usually*^
Severe NPDR No 2-4 Sometimes Rarely No
Yes 2-4 Sometimes Usually Usually**
Non-high-risk No 2-4 Sometimes Rarely No
PDR Yes 2-4 Sometimes Usually Usually^
High-risk PDR No 2-4 Usually Rarely No
Yes 2-4 Usually Usually Usually**
Inactive/involuted No 6-12 No No Usually
PDR Yes 2-4 No Usually Usually
CSME = clinically significant macular edema; NPDR = nonproliferative diabetic

retinopathy; PDR = proliferative diabetic retinopathy
* Exceptions include: hypertension or fluid retention associated with heart failure,
renal failure, pregnancy, or any other causes that may aggravate macular edema.
Deferral of photocoagulation for a brief period of medical treatment may be
considered in these cases. Also, deferral of CSME treatment is an option when the
center of the macula is not involved, visual acuity is excellent, and the patient
understands the risks.
Adjunctive treatment that may be considered include intravitreal corticosteroids

or anti-vascular endothelial growth factor agents (off-label use). Data from the
Diabetic Retinopathy Clinical Research Network in 2010 demonstrated that, at one
year of follow-up, intravitreal ranibizumab with prompt or deferred laser resulted in
greater visual acuity gain and intravitreal triamcinolone acetonide plus laser also
resulted in greater visual gain in pseudophakic eyes compared with laser alone.
Individuals receiving the intravitreal injections of anti-vascular endothelial growth
factor agents may be examined one month following injection.
^ Deferring focal photocoagulation for CSME is an option when the center of the
macula is not involved, visual acuity is excellent, close follow-up is possible, and
the patient understands the risks. However, initiation of treatment with focal
photocoagulation should also be considered because although treatment with focal
photocoagulation is less likely to improve the vision, it is more likely to stabilize the

Page 25
current visual acuity. Treatment of lesions close to the foveal avascular zone may
result in damage to central vision and with time, such laser scars may expand and
cause further vision deterioration. Future studies may help guide the use of
intravitreal therapies including corticosteroids and anti-vascular endothelial growth
factor agents in these cases in which laser photocoagulation cannot be
administered safely. Closer follow-up may be necessary for macular edema that is
not clinically significant.
Panretinal photocoagulation surgery may be considered as patients approach

high-risk PDR. The benefit of early panretinal photocoagulation at the severe
nonproliferative or worse stage of retinopathy is greater in patients with type 2
diabetes than in those with type 1. Treatment should be considered for patients
with severe NPDR and type 2 diabetes. Other factors, such as poor compliance
with follow-up, impending cataract extraction or pregnancy, and status of fellow
eye will help in determining the timing of the panretinal photocoagulation.
** It is preferable to perform the focal photocoagulation first, prior to panretinal

photocoagulation laser-induced exacerbation of the macular edema.


Page 26
Dry Eye Syndrome (Initial Evaluation)


Exacerbating conditions (B:III)
Topical medications used and their effect on symptoms (A:III)
Ocular history, including
o Contact lens wear, schedule and care (A:III)
o Allergic conjunctivitis (B:III)
o Ocular surgical history (A:III) (prior keratoplasty, cataract surgery,
keratorefractive surgery)
o Punctal surgery (A:III)
o Ocular surface disease (A:III) (e.g., herpes simplex virus, varicella
zoster virus, ocular mucous membrane pemphigoid, Stevens-
Johnson syndrome, aniridia, graft-versus-host disease)
o Punctal surgery (A:III)
o Eyelid surgery (A:III) (e.g. prior ptosis repair, blepharoplasty,
entropion/ectropion repair)
o Bell palsy (A:III)
Systemic history, including
o Smoking or exposure to second-hand smoke (A:III)
o Dermatological diseases (A:III) (e.g., rosacea)
o Technique and frequency of facial washing including eyelid and
eyelash hygiene (A:III)
o Atopy (A:III)
o Menopause (A:III)
o Systemic inflammatory diseases (A:III) (e.g., Sjogrens syndrome,
graft-versus- host disease, rheumatoid arthritis, systemic lupus
erythematosus, scleroderma)
o Other systemic conditions (A:III) (e.g., lymphoma, sarcoidosis)
o Systemic medications (A:III) (e.g., antihistamines, diuretics,
hormones and hormonal antagonists, antidepressants, cardiac
antiarrhythmic drugs, isotretinoin, diphenoxylate/atropine, beta-
adrenergic antagonists, chemotherapy agents, any other drug with
anticholinergic effects)
o Trauma (A:III) (e.g., chemical)
o Chronic viral infections (B:III) (e.g., hepatitis C, human
immunodeficiency virus)
o Nonocular surgery (B:III) (e.g., bone marrow transplant, head and
neck surgery, trigeminal neuralgia surgery)

Page 27
o Radiation of orbit (B:III)
o Neurological conditions (B:III) (e.g., Parkinsons disease, Bell palsy,
Riley-Day syndrome, trigeminal neuralgia)
o Dry mouth, dental cavities, oral ulcers (B:III)

o Skin (A:III)
o Eyelids (A:I)
o Adnexae (A:III)
o Proptosis (B:III)
o Cranial nerve function (A:III)
o Hands (B:III)
o Tear film (A:III)
o Eyelashes (A:III)
o Anterior and posterior eyelid margins (A:III)
o Puncta (A:III)
o Inferior fornix and tarsal conjunctiva (A:III)
o Bulbar conjunctiva (A:III)
o Cornea (A:III)


Page 28
Dry Eye Syndrome
Care Management
Treat any causative factors that are amenable to treatment as patients with
dry eye symptoms often have many contributory factors (A:III)
Sequence and combination of therapies is determined based on the
patients needs and preferences and the treating ophthalmologists medical
judgment (A:III)
For mild dry eye, the following measures are appropriate:
o Education and environmental modifications (A:III)
o Elimination of offending topical or systemic medications (A:III)
o Aqueous enhancement using artificial tear substitutes, gels/ointments
(A:III)
o Eyelid therapy (warm compresses and eyelid hygiene) (A:III)
o Treatment of contributing ocular factors such as blepharitis or
meibomianitis (A:III)
For moderate dry eye, in addition to above treatments, the following
measures are appropriate:
o
Anti-inflammatory agents (topical cyclosporine (A:I) and
corticosteroids, (A:II) systemic omega-3 fatty acids supplements
(A:II))
o
Punctal plugs (A:III)
o
Spectacle side shields and moisture chambers (A:III)
For severe dry eye, in addition to above treatments, the following measures
are appropriate:
o Systemic cholinergic agonists (A:I)
o Systemic anti-inflammatory agents (A:III)
o Mucolytic agents (A:III)
o Autologous serum tears (A:III)
o Contact lenses (A:III)
o Correction of eyelid abnormalities (A:III)
o Permanent punctal occlusion (A:III)
Monitor patients prescribed corticosteroids for adverse effects such as
increased intraocular pressure, corneal melting, and cataract formation
(A:III)
Patient Education
Counsel patients about the chronic nature of dry eye and its natural history.
(A:III)

Page 29
Provide specific instructions for therapeutic regimens. (A:III)
Reassess periodically the patient's compliance and understanding of the
disease, risks for associated structural changes and realistic expectations
for effective management, and reinforce education. (A:III)
Refer patients with manifestation of a systemic disease to an appropriate
medical specialist. (A:III)
Caution patients with pre-existing dry eye that keratorefractive surgery may
worsen their dry eye condition. (A:III)


Page 30
Esotropia (Initial and Follow-up Evaluation)

Ocular history (date of onset and frequency of the deviation, presence or
absence of diplopia) (A:III)
Systemic history (review of prenatal, perinatal and postnatal medical
factors) (A:III)
Family history, including presence of strabismus, amblyopia, extraocular
muscle surgery, genetic diseases. (A:III)

Ocular alignment (at distance and near) and motility (A:III)
Extraocular muscle function (A:III)
Detection of nystagmus (A:III)
Sensory testing (A:III)
Fundoscopic examination (A:III)
Care Management
Consider all forms of esotropia for treatment and re-establish ocular
alignment promptly (A:III)
Prescribe corrective lenses for any clinically significant refractive error (A:I)
If optical correction does not align the eyes, then surgical correction is
indicated (A:III)
Start amblyopia treatment before surgery to reduce angle of strabismus or
increase likelihood of binocularity (A:III)
Periodic evaluations necessary until visual maturity reached (A:II)
Hyperopia should be assessed every 1 to 2 years (A:III)
More frequent cycloplegic examinations are indicated in cases with changes
in acuity, amblyopia, or unstable alignment (A:III)
If the examination has been stable, follow-up evaluations are appropriate
every 1 to 2 years during teenage years (A:I)

Page 31
Esotropia Follow-up Evaluation Intervals (A:III)
Age (years) Interval (months)

0-1 3-6
1-5 6-12
5 12-24
Note: More frequent visits may be necessary if amblyopia is present or if there is

a recent deterioration of alignment.
Patient Education
Discuss findings with the patient when appropriate and/or
parents/caregivers to enhance understanding of disorder and to recruit them
in a collaborative approach to therapy. (A:III)
Formulate treatment plans in consultation with the patient and/or
family/caregivers. (A:III)


Page 32
Exotropia (Initial and Follow-up Evaluation)

Ocular history (date of onset and frequency of the deviation, presence or
absence of diplopia) (A:III)
Systemic history (review of prenatal, perinatal and postnatal medical
factors) (A:III)
Family history, including presence of strabismus, amblyopia, extraocular
muscle surgery, genetic diseases (A:III)

Ocular alignment (at distance and near) and motility (A:III)
Extraocular muscle function (A:III)
Detection of nystagmus (A:III)
Sensory testing (A:III)
Fundoscopic examination (A:III)
Care Management
Consider all forms of exotropia for treatment and re-establish ocular
alignment as soon as possible if deviation is manifest a large percentage of
the time. (A:III)
Prescribe corrective lenses for any clinically significant refractive error.
(A:III)
Optimal modes of therapy are not well established.
Periodic evaluations necessary until visual maturity reached (A:III)
Intervals are reduced if strabismus is stable (A:III)
Includes interval history, tolerance to treatment (if any), and routine
examination and testing of ocular motility (A:III)

Page 33
Exotropia Follow-up Evaluation Intervals (A:III)
Age (years) Interval (months)

0-1 3-6
1-5 6-12
5 12-24
Note: More frequent visits may be necessary if patching therapy is being administered, or
if there is a recent deterioration of alignment.
Patient Education
Discuss findings with the patient when appropriate and/or parents/caregivers to
enhance understanding of disorder and recruit them in a collaborative approach to
therapy. (A:III)
Formulate treatment plans in consultation with the patient and/or
family/caregivers. (A:III)


Page 34
Eye Disease in Leprosy
(Initial Evaluation and Management)

Ocular symptoms (decreased vision, epiphora, symptoms of irritation) (A:III)
Duration of lagophthalmos (<or>6 months) (A:III)
Duration of leprosy (usually from date of diagnosis) (B:III)
Type of leprosy (A:III)
MDT treatment; what drugs and for how long (A:III)
History of leprosy reactions (B:III)

Eyelids and lid closure (A:III)
Corneal sensation (A:III)
Conjunctiva (A:III)
Sclera (A:III)
Pupil (A:III)
Nasolacrimal apparatus (A:III)
Slit lamp biomicroscopy
o Corneal epithelial integrity (A:III)
o Corneal nerve beading, stromal opacity (B:III)
o Iris atrophy (A:III)
o Iris "pearls" (B:III)
o Posterior synechiae (A:III)
o Cataract (A:III)
Care Management
The main important conditions (cataract, lagophthalmos, anterior uveitis) are
managed as for any patient, and people with leprosy should be integrated into the
normal eye care service, specifically:
Cataract should be removed when it adversely affects patient's visual
function (A:III)
IOL is not contraindicated as long as quality of surgery is good and eye is
quiet (A:III)
Chronic lagophthalmos should be treated surgically if cornea is
compromised or cosmesis is a problem, regardless of severity of
lagophthalmos, by whatever procedure the surgeon does best (A:III)
Special considerations in a person afflicted with leprosy include:

Page 35
o New onset lagophthalmos (duration <6 months) should be treated
with oral prednisolone 25-30 mg per day tapered over 6 months.
(A:III)
o Acute uveitis should be treated with intensive topical steroid;
associated systemic leprosy reaction must be ruled out or treated if
present with systemic steroid give dose) (A:III)
Patient Education
At the end of MDT all patients should be warned that lagophthalmos could
develop and understand the risks associated with this. (A:III)
Patients with residual lagophthalmos must be told about the risk form
exposure and specifically warned about development of red eye and
decreased vision. (A:III)
Patients should understand risks to eye during reaction and given explicit
instructions on where to report if reaction develops. (A:III)
All patients should be informed of significance of decreased vision and told
to report this to case worker for referral to higher level. (A:III)

Page 36
Idiopathic Macular Hole
(Initial Evaluation and Therapy)


Ocular history: glaucoma or other prior eye diseases, injuries, surgery, or
other treatments; prolonged gazing at the sun (A:III)
Medications that may be related to macular cysts (A:III)

Slit-lamp biomicroscopic examination of the macula and the vitreoretinal
interface (A:III)
Management Recommendations for Macular Hole
Stage Management Follow-up [A:III]

1-A Observation [A:II] Prompt return if new symptoms
Every 4 to 6 months in the absence of symptoms
[A:II]
1-B Observation Prompt return if new symptoms
Every 4 to 6 months in the absence of symptoms
2 Surgery [A:II] * 1 to 2 days postoperatively, then 1 to 2 weeks
Frequency and timing of subsequent visits varies depending
on the outcome of surgery and the patients symptoms
If no surgery, every 4 to 8 months
3 Surgery [A:I] 1 to 2 days postoperatively, then 1 to 2 weeks
4 Surgery [A:I] 1 to 2 days postoperatively, then 1 to 2 weeks
* Although surgery is usually performed, observation is also appropriate.

Page 37
Surgical and Postoperative Care if Patient Receives Treatment
Inform the patient about relative risks, benefits, and alternatives to surgery,
and the need for use of expansile intraocular gas or special patient
positioning postoperatively (A:III)
Formulate a postoperative care plan and inform the patient of these
arrangements (A:III)
Inform patients with glaucoma of possible perioperative increase in IOP
(A:III)
Examine postoperatively within 1 or 2 days and again 1 to 2 weeks after
surgery (A:III)
Patient Education
Inform patients to notify their ophthalmologist promptly if they have
symptoms such as increase in floaters, a loss of visual field, or a decrease
in visual acuity (A:II)
Inform patients that air travel, high altitudes, or general anesthesia with
nitrous oxide should be avoided until the gas tamponade is nearly
completely gone (A:III)
Inform patients who have had a macular hole in one eye that they have a
10% to 20% chance of macular hole formation in the fellow eye, especially if
the hyaloid remains attached (A:III)
Refer patients with functionally limiting postoperative visual impairment for
vision rehabilitation (see www.aao.org/smartsight) and social services (A:III)


Page 38
Keratorefractive Surgery


Present status of visual function (A:III)
Medications (A:III)

Visual acuity without correction (A:III)
Manifest, and where appropriate, cycloplegic refraction (A:III)
Computerized corneal topography (A:III)
Central corneal thickness measurement (A:III)
Evaluation of tear film (A:III)
Evaluation of ocular motility and alignment (A:III)
Care Management
Discontinue contact lenses before preoperative exam and procedure (A:III)
Inform patient of the potential risks, benefits, and alternatives to and among
the different refractive procedures (A:III)
Document informed consent process; patient should be given an
opportunity to have all questions answered before surgery (A:III)
For LASIK, residual stromal bed thickness should not be less than 250 um
(A:III)
Check and calibrate instrumentation before the procedure (A:III)
Surgeon confirms the identity of the patient, the operative eye, and that the
parameters are correctly entered into the excimer lasers computer (A:III)
Postoperative Care
Operating surgeon is responsible for postoperative management (A:III)
For surface ablation techniques, examine on the day following surgery and
every 2 to 3 days thereafter until the epithelium is healed (A:III)
For uncomplicated LASIK, examine within 48 hours following surgery, a
second visit 1 to 4 weeks postoperatively, and further visits thereafter as
appropriate (A:III)

Page 39
Patient Education
1Discuss the risks and benefits of the planned procedure with the patient. (A:III)
Elements of the discussion include the following:
Range of expected refractive outcomes
Residual refractive error
Reading and/or distance correction postoperatively
Loss of best-corrected visual acuity
Side effects and complications (e.g., microbial keratitis, sterile keratitis,
keratectasia
Changes in visual function not necessarily measured by Snellen acuity,
including glare and function under low-light conditions
Night vision symptoms (e.g., glare, haloes) developing or worsening; careful
consideration should be given to this issue for patients with high degrees of
ametropia or for individuals who require a high level of visual function in
low-light conditions
Effect on ocular alignment
Dry eye symptoms developing or worsening
Monovision advantages and disadvantages (for patients of presbyopic age)
Conventional and wavefront-guided ablations advantages and
disadvantages
Advantages and disadvantages of same-day bilateral keratorefractive
surgery versus sequential surgery. Because vision might be poor for some
time after bilateral same-day photorefractive keratectomy, the patient should
be informed that activities such as driving might not be possible for weeks
Postoperative care plans (setting of care, providers of care)


Page 40
Ocular HIV/AIDS Related Diseases
General - Initial Exam History

Age (B:III)
Ocular symptoms including laterality (A:III)
Systemic symptoms (A:III)
Complete review of systems (A:III)
Prior ocular history (A:III)
Prior medical history (A:III)
Prior surgical history (B:III)
History of other sexually transmitted diseases (A:III)
History of AIDS-defining illnesses or complications (A:III)
Method of HIV acquisition (B:III)
Duration of HIV infection (A:III)
Past and current risk factors sexual behavior, intravenous drug abuse,
transfusion history (A:III)
Current anti-HIV regimen duration and compliance (A:III)
Current medications (A:II)
Current CD4 count (A:II)
Current viral load (A:II)
Medication allergies (B:III)
General - Initial Physical Exam

General appearance (A:III)
External examination face, ocular adnexa (A:III)
Lymphatics preauricular and submandibular nodes (A:III)
Extraocular motility (A:III)
Confrontation visual fields (A:III)
Eyelids lid closure, interpalpebral fissure height (B:III)
Lacrimal gland (B:III)
Evaluation of tear film Schirmer, rose bengal and fluorescein staining
(A:III)
Nasolacrimal function (B:III)
Slit-lamp examination
o Sclera (A:III)
o Cornea (A:III)

Page 41
o Iris (A:III)
o Lens (A:III)
o Anterior vitreous (A:III)
Dilated ophthalmoscopic examination
o Vitreous cell/flare, blood, condensations (A:III)
o Optic disc (A:III)
o Retinal vasculature (A:III)
o Macula/fovea (A:III)
o Peripheral retina with scleral depression (A:III)
o Choroid (A:III)
General - Diagnostic Tests

HIV infection for increased risk populations and/or suspected infection
o Anti-HIV ELISA to screen for infection, followed by confirmation with
Western blot (A:II)
AIDS
o Presence of AIDS-defining illness(es) (A:III)
o CD4 (< 200 cells/l, per CDC criteria) (A:II)
Known HIV/AIDS patient
o CD4 count (A:II)
o Viral load (A:II)
General - Care Management

Management of HIV/AIDS should involve a multidisciplinary team, including
an infectious disease specialist and an ophthalmologist (A:III)
Anti-Retroviral Therapy (ART) or Highly Active Anti-Retroviral Therapy
(HAART), where available (A:II)
Emphasis on prevention of disease transmission (A:III)
Identification and treatment of HIV/AIDS associated illnesses/infections
(particularly tuberculosis and syphilis) (A:II)
HIV Retinopathy Initial Exam History

CD4 count (A:II)
Ocular symptoms usually asymptomatic (B:III)
HIV Retinopathy Initial Physical Exam

Slit lamp examination (B:III)
Dilated ophthalmoscopic examination (A:II)
Screen for other HIV/AIDS related illnesses/infections (B:III)
HIV Retinopathy - Care Management

Treat immune compromise with HAART (A:II)

Page 42
Consider corticosteroids (B:III) or focal laser (A:II) for macular edema
HIV Retinopathy Follow-up Evaluation

Lesions usually resolve over weeks to months (A:II)
Dilated ophthalmoscopic examination every 3 months for CD4 counts
persistently below 50 cells/l (A:II)
Cytomegalovirus (CMV) Retinitis Initial Exam History

Interval since AIDS diagnosis (A:II)
History of CMV related systemic complications (A:II)
Ocular symptoms blurred vision, floaters, photopsias, scotomata (A:II)
Cytomegalovirus (CMV) Retinitis Initial Physical Exam

Visual acuity (A:II)
Cornea for small endothelial deposits (B:III)
Anterior chamber for signs of inflammation (A:II)
Dilated ophthalmoscopic examination of both eyes including optic disc,
macula, and retinal periphery. The choroid should be examined to rule out
co-infection with other agents (A:II)
Cytomegalovirus Retinitis Diagnostic Tests

CD4 count typically less than 50 cells/l (A:II)
Cytomegalovirus Retinitis Ancillary Testing

Fundus photography may be useful to document disease progression or
response to treatment and fluorescein angiography as indicated to evaluate
for the presence of macular edema or ischemia (A:III)
Test for syphilis and vitreous biopsy for other causes of necrotizing retinitis
(varicella zoster virus, herpes simplex virus, toxoplasmosis) when diagnosis
uncertain (A:II)
Cytomegalovirus Care Management

Main objectives include direct treatment of CMV retinitis with anti-CMV
medications, and improvement of immune status with initiation/optimization
of HAART if not already taking anti-retroviral therapy (A:II)
To reduce the possibility of immune recovery uveitis, patients with newly
diagnosed CMV retinitis who are not on HAART should be treated with anti-
CMV medications until the retinitis is inactive, or at least less active. HAART
should then be initiated (A:II)
Also, in cases with expected persistent immune suppression, e.g. poor
response to or unavailability of ART, immediate treatment is indicated (A:II)
Local anti-CMV therapy, as might be achieved using intravitreal injection of
ganciclovir or foscarnet, may be used immediately when active CMV retinitis
either involves or threatens the optic disc or macula (A:II)
Induction followed by indefinite maintenance therapy in cases of persistent
immune suppression (A:II)

Page 43
Ganciclovir
o Intravenous 5 mg/kg every 12 hours for 2 to 3 weeks, then 5
mg/kg/day 5 to 7 times per week indefinitely. (A:I) Monitor for
leukopenia, the risk of which may be lessened by administering
leukocyte-stimulating factors such as granulocyte colony-stimulating
factor (A:II)
o Intraocular 2 to 2.5 mg/0.1 ml intravitreal injection twice per week
until inactive, then weekly (A:I)
o Intravitreal sustained-release implant (Vitrasert) 4.5 mg implant that
releases 1 g/hr for eight months. This should be combined with oral
valganciclovir therapy for systemic coverage (A:I)
Foscarnet
o Intravenous 60 mg/kg every 8 hours or 90 mg/kg every 12 hours for
14 days, then 90 to 120 mg/kg/day. Monitor for renal toxicity (A:I)
o Intraocular 1.2 mg/0.05 ml (or 2.4 mg/0.1 ml) (A:I)
Valganciclovir
o Oral 900 mg twice daily for 2 weeks, (A:I) then 900 mg daily
indefinitely. (A:II) Monitor for leukopenia (A:II)
Cytomegalovirus Follow-up Evaluation

Recurrence is very common, and patients being treated with anti-CMV
medications should be evaluated monthly (A:II)
Intervals may be extended when CD4 counts are elevated, anti-CMV
medications are discontinued, and the disease remains inactive in the
setting of immune recovery (A:II)
Visual symptoms (A:II)
CD4 count and HIV viral load (A:II)
Review of systems for CMV related systemic complications or drug-induced
side effects (A:II)
Cytomegalovirus Follow-up Examination

Slit lamp examination (B:II)
Ophthalmoscopic examination including the macula and peripheral retina
(A:II)
Serial fundus photography (B:II)
Cytomegalovirus Follow-up Management

No treatment can eliminate CMV from the eye (A:II)
Patient education about the symptoms of CMV retinitis is crucial (A:III)
For recurrences, first line is re-induction with the same therapy in the
absence of side effects or evidence of drug resistance (A:II)
Persistent or progressive retinitis after 6 weeks of induction-level therapy
implies resistance or incorrect diagnosis (A:II)
UL97 and UL54 mutations in CMV DNA are associated with relative
ganciclovir resistance (A:II)

Page 44
Anti-CMV drugs may be discontinued in patients on HAART with no signs of
active CMV retinitis in whom CD4 counts are above 100 to 150 cells/l for at
least three to six months (A:II)
Tuberculosis Initial Exam History

CD4 count (typically < 200 cells/l) (A:II)
Visual and ocular symptoms (A:II)
History M. Tuberculosis infection, systemic complications, or exposure (A:II)
Tuberculosis Initial Physical Exam

External examination including eyelids and adnexa (B:III)
Intraocular pressure (B:III)
Dilated ophthalmoscopic examination - optic disc, macula, retinal periphery,
and choroid (A:II)
Tuberculosis Diagnostic Tests

Presumptive diagnosis by clinical examination combined with PPD skin
testing and chest x-ray (A:II)
Requires a high index of clinical suspicion (B:III)
Consider leukocyte stimulation based assays where available, particularly
when PPD skin testing is unreliable (QuantiFERON -TB Gold Test; T.SPOT-
TB test) (A:II)
Definitive diagnosis requires biopsy with histopathologic examination (A:III)
Tuberculosis Ancillary Testing

Fluorescein angiography to evaluate suspected retinal vasculitis (A:III)
Indocyanine green angiography may be helpful to detect subclinical
choroidal involvement (A:III)
Optical coherence tomography to diagnose and monitor for cystoid macular
edema (A:III)
Tuberculosis Care Management

Systemic treatment is indicated with rifampin (500 mg/day for weight > 50
kg and 600 mg/day for weight < 50 kg), isoniazid (5 mg/kg/day),
pyrimethamine (25 to 30 mg/kg/day, and ethambutol (15 mg/kg/day) for 2
months then rifampin and isoniazid for another 4 to 7 months (A:II)
Oral prednisone (1 mg/kg/day), taper as directed by clinical response (A:II)
Initiate/optimize HAART if not already taking anti-retroviral therapy (A:II)
Coordinate care with an infectious disease specialist (A:III)
Tuberculosis Follow-up Evaluation

Monitor all patients for medication toxicity (A:II)
Examine patients monthly until there is significant clinical improvement
(A:III)

Page 45
Toxoplasmosis (T. gondii) Initial Exam History
CD4 count (typically < 200 cells/l) (A:II)
Visual and ocular symptoms (A:III)
History of T. gondii infection, systemic complications, or exposure (A:III)
Toxoplasmosis Initial Physical Exam

Intraocular pressure (B:II)
Slit lamp examination (C:II)
Toxoplasmosis Diagnostic Tests

Primarily a clinical diagnosis (A:III)
Serologic testing for anti-T. gondii IgM/IgG antibodies (A:II)
In unclear cases, can perform PCR on aqueous or vitreous for T. gondii
DNA (B:II)
Toxoplasmosis Care Management

Initial treatment involves oral antimicrobials for 4 to 6 weeks. Options
include:
o Trimethoprim/sulfamethoxazole (800/160) 500 mg PO twice daily
(A:II)
o Pyrimethamine (100 mg loading dose given over 24 hours, followed
by 25 to 50 mg daily) and sulfadiazine (1 g given four times daily) for
4 to 6 weeks. Should be given concurrently with folinic acid (3 to 5
mg twice weekly) to prevent leukopenia and thrombocytopenia (B:II)
o Clindamycin (300 mg orally every 6 hours) for 3 or more weeks (B:II)
o Atovaquone (750 mg orally four times daily) for 3 months (B:II)
o Consider use of Azithromycin in patients with sulfa-related allergy
(B:III)
Maintenance therapy with at least one of the above medications is
recommended for patients with ocular toxoplasmosis who remain severely
immunodeficient (A:III)
Oral corticosteroids may be considered when inflammation contributes to
vision loss (vitritis, vasculitis, serous retinal detachment, lesion involving or
threatening the optic disc or macula) - 0.5 mg/kg/day with taper, initiated
and ended concurrent with antimicrobial therapy (A:III)
Topical corticosteroids may be considered for significant anterior chamber
inflammation (A:III)
Toxoplasmosis Follow-up Evaluation

Initial follow-up should be one week after initiation of treatment, then as
indicated by examination and treatment response (A:III)
Lesions typically take several months to resolve (A:III)

Page 46
Syphilis Initial Exam History
CD4 count (often less than 200 cells/l). However, ocular syphilis in the
setting of HIV/AIDS may occur at any CD4 count. (A:II)
Visual symptoms and rapidity of onset (A:III)
Previous syphilis infection, related complications, or exposure (A:III)
History of other sexually-transmitted diseases (B:III)
Syphilis Initial Physical Exam

Intraocular pressure (B:II)
Syphilis Diagnostic Tests

Both non-treponemal (RPR or VDRL) and treponemal (MHA-TP or FTA-
ABS) testing should be obtained (up to one-third of patients with syphilitic
uveitis have a negative non-treponemal test) (A:II)
Patients with profound immune suppression may present with seronegative
syphilis (A:II)
CSF examination (RPR or VDRL) in all HIV/AIDS patients with ocular
syphilis (A:II)
Syphilis Care Management

Treat as neurosyphilis (A:II)
Involve an infectious disease specialist in coordinating systemic
management (A:III)
First-line treatment is with IV penicillin G, 18 to 24 million units for 14 days
(A:II)
Worsening ocular inflammation following the initiation of penicillin may be
indicative of a Jarish-Herxheimer reaction (A:II)
Syphilis Follow-up Evaluation

Serial serum and CSF antibody levels every month for 3 months, then every
6 months until CSF cell count normalizes and CSF VDRL/RPR becomes
non-reactive (A:III)
Serum quantitative nontreponemal testing every 3 months for one year, then
yearly (A:III)
Maintenance therapy is not necessary or recommended (B:II)

Page 47
Table 1. Adnexal Manifestations of HIV/AIDS (A:III unless otherwise indicated)
CD4 Diagnostic
Entity History Examination Key Findings Management Fol
count workup
Herpes Zoster < 200 Prior zoster Periorbita Vesiculobullous dermatitis in Clinical IV acyclovir 10 mg/kg every 8 hours for 7 days (A:II) Obs
Ophthalmicus cells/ infection (A:II) Eyelids CN V1 distribution (A:II) examination Alternatives: valacyclovir (1 gram PO 3 times daily) or pos
l (A:II) Age SLE Complications include Can confirm oral acyclovir (800 mg PO 5 times daily); close follow-up neu
Sclera keratitis, uveitis, scleritis, diagnosis for signs of disseminated infection including cerebritis Seri
AC retinitis, and optic neuritis with viral (A:II)
DOE (A:II) culture, Patient receiving high doses of valacyclovir should be
Hemorrhagic hypopyon Tzanck monitored for TTP/HUS (A:II)
(B:II) smear, PCR Maintain on oral acyclovir 800 mg, 3 to 5 times daily
(A:II) indefinitely (A:II)
Alternatively, can maintain on oral famciclovir or
valacyclovir
Topical corticosteroids for iridocyclitis and/or stromal
keratitis (A:II)
Kaposis Sarcoma < 200 Manner of HIV External Highly vascularized tumor Clinical Immune reconstitution (A:II) Rec
cells/ acquisition (sexual examination of the skin or mucous examination Indications for treatment: 1) loss of normal lid function, are
l (A:II) more common) Lymphatics membranes (A:II) Biopsy with 2) discomfort, 3) cosmesis (A:I
(B:II) Oral cavity May involve eyelids and/or histopatholog Treatment depends on the size and location of lesions
Dry eye symptoms SLE conjunctiva (A:II) y of (A:II)
(B:II) Eyelids Eyelid lesions may appear as suspicious Treatment options include intralesional vinblastine or
Pain (rare) (B:II) Lacrimal a purplish nodule (A:II) lesions (A:II) interferon-alpha, local radiation therapy, excision, and
Reduced vision gland Conjunctival lesions can cryotherapy (A:II)
(rare) (C:II) Skin of face mimic SCH (B:II) Systemic chemotherapy if disseminated disease (A:II)
and upper Reduce size of large lesions prior to excision
body
Molluscum Any History of Periorbita Papulonodular dermatitis of Clinical Immune reconstitution (A:II) Eye
Contagiosum (A:II) molluscum SLE the skin and mucous examination Topical agents: liquid nitrogen, trichloracetic acid, com
exposure (A:II) Trunk and membranes (A:II) cantharadin (A:II) recu
genitalia Multiple small umbilicated Incision with curettage, excision, or cryotherapy (A:II) to 8
(B:III) lesions (A:II) (A:I
Squamous Cell Any Geographic VA Papilliform, gelatinous, or Biopsy with Wide excision with cryotherapy for non-invasive lesions Rou
Carcinoma (SCC) (A:II) location higher External leukoplakic lesion at the histopatholog (A:II) and
and Conjunctival risk in Africa (A:II) examination interpalpebral limbus (A:II) ic Frozen section pathologic examination (A:II) ope
Intraepithelial History of HPV SLE SCC: lesion is more examination Alternatives include MMC, 5-FU, and interferon (A:II) exa
Neoplasia (CIN) infection (B:II) Gonioscopy extensive, feeder vessels (A:II)
more common (A:II)
Cutaneous or Any Presence/history VA Erythematous lesion of the Biopsy (A:II) Radiation (A:II) As d
Conjunctival (A:II) of systemic External eyelid or conjunctiva (A:II) Systemic Chemotherapy (A:II) by t
Lymphoma lymphoma (A:II) examination evaluation Involve an oncologist in
Ocular symptoms SLE (A:II) coo
DOE (C:III) with
onc
SLE = slit lamp examination, AC = anterior chamber, DOE = dilated ophthalmoscopic examination, PCR = polymerase chain reaction, PO = per os (by mouth), IV = intravenous, TTP/HUS = thrombotic
thrombocytopenic purpura/hemolytic uremic syndrome, HIV = human immunodeficiency virus, SCH = subconjunctival hemorrhage, HPV = human papilloma virus, VA = visual acuity, MMC = mitomyc
= 5-fluorouracil, FBS = foreign body sensation = visual acuity, MMC = mitomycin C, 5-FU = 5-fluorouracil, FBS = foreign body sensation

Page 49
Table 1. (continued) Adnexal Manifestations of HIV/AIDS (A:III unless otherwise indicated)
CD4 Diagnostic
Entity History Examination Key Findings Management Foll
count workup
Conjunctival Any Typically SLE Inferior perilimbus (A:II) Clinical Not indicated Unn
Microvasculopathy (A:II) asymptomatic DOE (B:III) Segmental vascular dilation examination
(B:II) and narrowing (A:II)
Comma-shaped vascular
fragments (A:II)
Microaneurysms (A:II)
Blood column granularity
(A:II)
Conjunctivitis Any Symptoms of VA Conjunctival erythema (A:II) Clinical Guided by results of gram stain and culture Eve
(A:II) irritation, SLE Watery, mucoid, or purulent examination Clinical examination should be used to initiate empiric day
discharge (A:II) discharge (A:II) Culture and treatment reso
gram stain of
discharge
(A:II)
Atopic dermatitis Any History of atopic External Pruritis and excematous Clinical Topical corticosteroids (i.e. hydrocortisone 0.5% cream) Ser
(A:II) triad: dermatitis, examination changes of the periorbital examination (A:II) exa
rhinitis, asthma Eyelids skin (A:II) Topical calcineurin inhibitors, Elidel (pimecrolimus) and s un
Typical Protopic (tacrolimus) are contraindicated in reso
symptomatology immunosuppressed patients (B:II)
(B:II)
Triggers (A:II)
Blepharitis Any Use of Indonavir External Crusting and erythema of Clinical Lid hygiene Eve
(A:II) (B:II) examination eyelid margins (A:II) examination Consider culture in high-risk patients wee
Itching, FBS, Eyelids
redness SLE
including tear
film and
cornea
SLE = slit lamp examination, AC = anterior chamber, DOE = dilated ophthalmoscopic examination, PCR = polymerase chain reaction, PO = per os (by mouth), IV = intravenous, TTP/HUS = thrombotic
thrombocytopenic purpura/hemolytic uremic syndrome, HIV = human immunodeficiency virus, SCH = subconjunctival hemorrhage, HPV = human papilloma virus, VA = visual acuity, MMC = mitomyc
FU = 5-fluorouracil, FBS = foreign body sensation = visual acuity, MMC = mitomycin C, 5-FU = 5-fluorouracil, FBS = foreign body sensation

Page 50
Table 2. Corneal and Anterior Segment Manifestations of HIV/AIDS (A:III unless otherwise indicated)
CD
4 Diagnostic
Entity History Examination Key Findings Management Follow-up
cou workup
nt
Keratoconjunctivitis sicca Any Typical history VA Lagophthalmos Clinical Artificial tears As dictated by examina
(A:I History of HIV Periorbita and reduced blink examination Long-acting lubricants
I) encephalopathy (B:III) (B:III) rate (B:II) Schirmer Consider punctual occlusion in
Duration of infection with Lacrimal Diminished tear testing (A:II) resistant cases
HIV (B:III) gland (C:III) meniscus (B:III) TBUT (B:II)
Eyelids Rapid TBUT (A:II) Rose bengal or
(A:II) Interpalpebral fluorescein
SLE with staining with rose staining (A:II)
fluorescein bengal or
fluorescein (A:II)
Viral VZV Any Reduced vision VA Dendritic epithelial Clinical Acyclovir 800 mg PO 5 times Every 1 to 7 days until
keratitis (B:I Ocular symptoms IOP keratitis (A:II) examination daily or 10 mg/kg IV tid (A:II) resolution, then every 6
I) Presence or recent history Periorbita Decreased corneal Corneal Foscarnet IV for resistant cases Observe for stromal and
of zoster dermatitis (A:II) Eyelids/lash sensation (A:II) sensation (A:II) neurotrophic keratitis a
Prior history of zoster or es Elevated IOP (B:II) (A:II) Consider maintenance dose of postherpetic neuralgia (
herpes infection (A:II) Corneal Iris atrophy (B:II) May confirm acyclovir (600 mg PO tid) (A:II)
sensation May present with a with viral Infectious dendrites can be
SLE with mild conjunctivitis culture, DFA, treated with oral (as described
fluorescein or anterior uveitis PCR (B:II) above) or topical antiviral
DOE with (B:II) medications (trifluridine 1% 9
scleral 1/3 develop times daily) (A:II)
depression stromal
involvement (B:II)
HSV Dendritic epithelial Topical trifluridine 1% 9 times Every 1 to 7 days until r
keratitis, which daily or Acyclovir ointment 5 HSV appears to recur m
may be larger in times daily (A:II) frequently in HIV/AID
HIV+ patients May treat with oral acyclovir (A:II)
(A:II) (400-800 mg PO 5 times daily)
Limbal alone (A:II)
involvement (B:II) Consider lesion debridement
(B:III)
Long term suppression with
acyclovir 400 mg PO bid for 1
year (A:I)
HIV = human immunodeficiency virus, VA = visual acuity, SLE = slit lamp examination, TBUT = tear film breakup time, VZV = varicella zoster virus, HSV = herpes zoster virus, IOP = intraocular pressure
dilated ophthalmoscopic examination, DFA = direct fluorescent antibody, PCR = polymerase chain reaction, PO = per os (by mouth), IV = intravenous, AIDS = acquired immunodeficiency syndrome, FBS =
body sensation, AC = anterior chamber, HAART = highly active antiretroviral therapy, CMV = cytomegalovirus

Page 51
Table 2. (continued) Corneal and Anterior Segment Manifestations of HIV/AIDS (A:III unless otherwise indicated)
CD4 Diagnostic
Entity History Examination Key Findings Management Follow-up
count workup
Bacterial or fungal Gonorrhea Any Reduced VA Epithelial defect Clinical Guided by culture results (B:II) Daily follow-up u
keratitis Syphilis (B:II) vision SLE with with stromal examination Aggressive treatment with topical substantial impro
Tuberculosis Discharge fluorescein infiltrate (A:II) Culture and fortified antibiotics and/or antifungal High risk for corn
Cryptococcus Timing of DOE (C:III) Tend to be more gram stain agents (A:II) perforation (A:II)
symptom severe and bilateral (A:II)
onset in HIV+ patients
(B:III) (A:II)
Microsporidial keratitis < 100 Reduced VA Punctate epithelial Scraping or Immune reconstitution (A:II) Serial examinatio
cells/l vision SLE with keratopathy (A:II) biopsy of Directed treatment options include: resolution
(A:II) Ocular fluorescein Mild papillary suspicious topical propamidine isethionate, topical
symptoms conjunctivitis (A:II) corneal and fumagillin, oral albendazole, oral
FBS, Mild AC conjunctival itraconazole (A:II)
irritation, inflammation (A:II) lesions (A:II) Consider debulking (B:III)
photophobi Giemsa stain
a (A:II)
Vortex keratopathy Any FBS VA Characteristic History and Reduce or discontinue offending Lesions resolve sl
(Phospholipidosis) (B:II) Medication SLE whorl-like pattern clinical medication, if possible (A:II)
history (eg. of gray-white examination
amiodaron subepithelial
e, corneal deposits
chloroquin (A:II)
e,
chlorproma
zine,
ganciclovir,
acyclovir)
(A:II)

Page 52
Drug-associated uveitis Any Reduced VA AC inflammation History and Topical corticosteroids with or without Serial every 1 to 2
Cidofovir (A:II) vision SLE (A:II) clinical dose reduction of offending medication examinations unt
Rifabutin Medication IOP (B:III) Rifabutin- examination (A:II) resolution
Terbinafine history, DOE (B:III) associated Usually unnecessary to discontinue
including hypopyon (A:II) offending medication (B:III)
daily doses Mydriatic agent
(A:II)
Immune
status
(B:III)
Duration
on HAART
(B:III)
History of
CMV
retinitis
(A:II)
HIV = human immunodeficiency virus, VA = visual acuity, SLE = slit lamp examination, TBUT = tear film breakup time, VZV = varicella zoster virus, HSV = herpes zoster virus, IOP = intraocular pressure
dilated ophthalmoscopic examination, DFA = direct fluorescent antibody, PCR = polymerase chain reaction, PO = per os (by mouth), IV = intravenous, AIDS = acquired immunodeficiency syndrome, FBS =
foreign body sensation, AC = anterior chamber, HAART = highly active antiretroviral therapy, CMV = cytomegalovirus
Table 3. Posterior Manifestations of HIV/AIDS (A:III unless otherwise indicated)
Entity CD4 count History Examination Key Findings Diagnostic workup Management Follow-up
HIV < 50 Visual and VA Conjunctival Clinical diagnosis Improve immune status with Lesions spontaneously re
retinopathy cells/l ocular SLE (B:III) microvascular changes HAART (A:II) over weeks to months (A
(A:II) symptoms DOE (A:II) (B:II) Screen for other infections/illnesses DOE every 3 months for
(typically CWS (A:II) Consider corticosteroids (B:III) or counts persistently < 50 c
asymptomatic) IRH (A:II) focal laser (A:II) for macular edema (A:II)
(B:III) MAs (A:II)
Retinal ischemia (A:II)
CME (A:II)

Page 53
CMV < 50 Duration of VA (A:II) Geographic thickening Primarily a clinical Improve immune status, although CMV cannot be eliminate
retinitis cells/l AIDS (A:II) SLE (B:II) and opacification of the diagnosis consider delay of HAART in the eye (A:II); patient edu
(A:II) History of DOE (A:II) retina (A:II) CD4 count (A:II) HAART-nave patients until for recurrences is crucial
systemic CMV Mild anterior chamber Rule out syphilis and retinitis is improved to reduce the Reevaluate patients mon
infection (A:II) and vitreous other causes of risk of IRU (A:II) while treating with anti-C
Ocular inflammation (B:II) retinitis (A:II) Immediate treatment if persistent medications (A:II)
symptoms Characteristic linear or Consider vitreous immune suppression is expected Extend visit intervals wh
including stellate KP (B:II) biopsy in challenging (A:II) counts are elevated, anti-
blurred vision, 3 main types: granular cases Induction followed by maintenance medications are discontin
gradual visual retinitis with satellite (A:II) and the disease remains i
field loss, lesions, hemorrhagic Ganciclovir: IV (5 mg/kg every 12 in the setting of immune
photopsia, and retinitis with prominent hours for 3 weeks, then 5 (A:II)
floaters (A:II) edema, or perivascular mg/kg/day) (A:I); IO (2- Consider serial fundus
retinitis (A:II) 2.5mg/0.1ml twice weekly until photography (B:II)
inactive) (A:I); intraocular implant Treat recurrences with re
(A:I), combine with oral anti-CMV induction of same therap
medications for systemic coverage contraindicated due to si
(A:II) or resistance (A:II)
Foscarnet: IV (60 mg/kg every 8 May discontinue mainten
hours or 90 mg/kg every 12 hours therapy in patients witho
for 14 days, then 90 to 120 CMV retinitis and at leas
mg/kg/day) (A:I); IO (1.2 mg/0.05 months of CD4 cell coun
ml) (A:I) 150 cells/l (A:II)
Valganciclovir: PO (900 mg bid for
2 weeks, then 900 mg daily).
Monitor for leukopenia (A:II)
HIV = human immunodeficiency virus, VA = visual acuity, SLE = slit lamp examination, DOE = dilated ophthalmoscopic examination, CWS = cotton wool spots, IRH = intraretinal hemorrhages, MA =
microaneurysms, CME = cystoid macular edema, HAART = highly active antiretroviral therapy, CMV = cytomegalovirus, AIDS = acquired immunodeficiency syndrome, KP = keratic precipitates, IRU = Im
recovery uveitis, IV = intravenous, IO = intraocular, PO = per os (by mouth), IOP = intraocular pressure, AC = anterior chamber, PCR = polymerase chain reaction, IOP = intraocular pressure, PPD = purif
protein derivative, CXR = chest X-ray, IGRA = Interferon-gamma release assay, FA = fluorescein angiography, ICG = indocyanine green angiography, OCT = optical coherence tomography, RPR = rapid pl
reagin, VDRL = venereal disease research laboratory, FTA-ABS = fluorescent treponemal antibody absorption, MHA-TP = microhemagluttination-Treponema pallidum, CSF = cerebrospinal fluid, PORN =
progressive outer retinal necrosis, ARN = acute retinal necrosis, HZO = herpes zoster ophthalmicus, TTP/HUS = thrombotic thrombocytopenic purpura/hemolytic uremic syndrome, TRD = tractional retin
detachment, RNV = retinal neovascularization, ERM = epiretinal membrane, CME = cystoid macular edema, FA = fluoroscein angiography, PPV = pars plana vitrectomy, VMTS = vitreomacular traction sy
PVR = proliferative vitreoretinopathy, OU = oculus uterque (both eyes), CXR = chest X-ray, ABG = arterial blood gas, CT = computed tomography, TMP-SMX = trimethoprim sulfamethoxazole, EOM = ex
motility, CNS = central nervous system, MRI = magnetic resonance imaging, N/A = not applicable

Page 54
Table 3. (continued) Posterior Manifestations of HIV/AIDS (A:III unless otherwise indicated)
CD4
Entity History Examination Key Findings Diagnostic workup Management Follow-up
count
Toxoplasmosis < 200 Visual VA (A:II) Moderate-to-severe AC Clinical diagnosis Trimethoprim/sulfamethoxazole Initially every 3 to 5 days
cells/l symptoms (A:II) IOP (B:II) and vitreous Anti-Toxoplasma (800/160) 500 mg PO bid for 4 to 6 indicated by examination
(A:II) Exposure to SLE (C:II) inflammation (B:II) IgM/IgG (A:II) weeks (A:II) Maintenance therapy wit
undercooked DOE (A:II) Retinochoroiditis with a PCR of aqueous in Pyrimethamine and one medication is recomm
meat or cats relative lack of retinal unclear cases (B:II) sulfamethoxazole for 4 to 6 weeks for all patients with persi
(A:II) hemorrhage (A:II) (option of combination with severe immune deficienc
Smooth leading edge azithromycin) (B:II)
without satellite lesions Clindamycin (300 mg PO every 6
(B:II) hours) for 3 or more weeks (B:II)
A rare cause of isolated Atovaquone (750 mg PO qid) for 3
anterior uveitis(C:II) months (B:II)
Tuberculosis < 200 Visual VA Vitritis (A:II) Presumptive Systemic treatment with rifampin Monitor all patients for d
cells/l symptoms (A:II) External Choroidal tubercles and diagnosis combined (500 mg/day for weight > 50 kg toxicity (A:II)
(A:II) History of M. examination tuberculomas (A:II) with PPD skin testing and 600 mg/day for weight < 50 Examine patients monthl
Tuberculosis (B:III) Overlying exudative and CXR (A:II) kg), isoniazid (5 mg/kg/day), significant improvement
infection, SLE (B:III) retinal detachment (B:II) Consider IGRAs (eg. pyrimethamine (25 to 30
systemic IOP (B:III) Retinal periphlebitis QuantiFERON-TB mg/kg/day, and ethambutol (15
complications, DOE (A:II) (A:II) Gold; T.SPOT-TB) mg/kg/day) for 2 months then
or exposure (B:II) rifampin and isoniazid for another 4
(A:II) FA, ICG, and OCT to 7 months (A:II)
when indicated (see PO prednisone (1 mg/kg/day),
text) (B:III) taper as directed by clinical
response (A:II)
Immune reconstitution (A:II)
Involve an infectious disease
specialist

Page 55
Syphilis Often < 200 Visual VA (A:II) Iridocyclitis or diffuse RPR or VDRL (A:II) Treat as neurosyphilis (A:II) Serial serum and CSF ant
cells/l, but symptoms (A:II) IOP (B:II) inflammation (A:II) FTA-ABS or MH- Involve an infectious disease levels every month for 3
can vary Sexual history SLE (B:II) Necrotizing retinitis ATP (A:II) specialist then every 6 months unti
(A:II) (B:II) DOE (A:II) (A:II) Consider IV penicillin G, 18 to 24 million count normalizes and CS
Subretinal plaque (B:II) seronegative syphilis units for 14 days (A:II) becomes non-reactive (A:
Papillitis, optic neuritis, (B:II) Maintenance therapy not
or neuroretinitis (A:II) CSF examination recommended (B:II)
(A:II) Monitor patients for a Jar
Herxheimer reaction (A:I
Non-CMV PORN: < 50 History of HZO VA (A:II) Retinal whitening with Clinical diagnosis Induction with high-dose Can progress rapidly (A:I
necrotizing cells/l or dermatitis IOP (B:III) occasional hemorrhages Aqueous or vitreous intravenous acyclovir (15 mg/kg q Daily until significant
herpetic (A:II) (A:II) SLE (B:III) (A:II) biopsy for PCR-based 8 hours) (A:II) improvement, then week
retinitis ARN: > History of DOE (A:II) Multiple large confluent analysis can aid in Intraocular ganciclovir (2 to
50cells/l herpes areas of retinitis (A:II) diagnosis (B:II) 2.5mg/0.1ml twice weekly) or
(A:II) encephalitis Rapid progression (A:II) Note location and foscarnet (1.2 mg/0.05ml) as
(B:II) Prominent (ARN) or extent of involved indicated (A:II)
Visual minimal (PORN) vitreal retina Maintenance with long term oral
symptoms inflammation (B:II) valacyclovir or valganciclovir may
(pain, vision be considered (B:II)
loss, new Patients receiving high doses of
floaters or valacyclovir should be monitored
scotomata) for TTP/HUS (A:II)
(A:II) Patients receiving valganciclovir
should be monitored for leukopenia
(A:II)
microaneurysms, CME = cystoid macular edema, HAART = highly active antiretroviral therapy, CMV = cytomegalovirus, AIDS = acquired immunodeficiency syndrome, KP = keratic precipitates, IRU
recovery uveitis, IV = intravenous, IO = intraocular, PO = per os (by mouth), IOP = intraocular pressure, AC = anterior chamber, PCR = polymerase chain reaction, IOP = intraocular pressure, PPD = pu
protein derivative, CXR = chest X-ray, IGRA = Interferon-gamma release assay, FA = fluorescein angiography, ICG = indocyanine green angiography, OCT = optical coherence tomography, RPR = rapid
reagin, VDRL = venereal disease research laboratory, FTA-ABS = fluorescent treponemal antibody absorption, MHA-TP = microhemagluttination-Treponema pallidum, CSF = cerebrospinal fluid, PORN
progressive outer retinal necrosis, ARN = acute retinal necrosis, HZO = herpes zoster ophthalmicus, TTP/HUS = thrombotic thrombocytopenic purpura/hemolytic uremic syndrome, TRD = tractional r
detachment, RNV = retinal neovascularization, ERM = epiretinal membrane, CME = cystoid macular edema, FA = fluoroscein angiography, PPV = pars plana vitrectomy, VMTS = vitreomacular traction
syndrome, PVR = proliferative vitreoretinopathy, OU = oculus uterque (both eyes), CXR = chest X-ray, ABG = arterial blood gas, CT = computed tomography, TMP-SMX = trimethoprim sulfamethoxaz
= extraocular motility, CNS = central nervous system, MRI = magnetic resonance imaging, N/A = not applicable

Page 56
Page 57
Immune >100 History/extent VA (A:II) Panuveitis with vitreous Diagnosis based on Topical, periocular, or intraocular Weekly until resolution
recovery cells/l or of CMV retinitis IOP (B:II) predominance (A:II) history and clinical corticosteroids (A:II)
uveitis 50 cell/l (A:II) SLE (A:II) May be complicated by examination PPV for VMTS, ERM, cataract, PVR
increase History of DOE (A:II) TRD, RNV, ERM Consider FA to rule (A:II)
(A:II) cidofovir use formation, or CME (A:II) out CME (B:III)
(B:II)
Pneumocystis < 200 History of VA (A:II) Multiple well- Clinical diagnosis TMP-SMX or pentamidine Monthly until resolutio
choroiditis cells/l aerosolized SLE (C:III) demarcated yellowish Consider workup for (4 mg/kg/day) (A:II) 1 to 3 months
(A:II) pentamidine use DOE OU choroidal lesions in the systemic disease, Following a 3 week IV i
(A:II) (A:II) posterior pole (A:II) including CXR, ABG regimen, maintain on or
Lack of iritis, vitritis, or analysis, abdominal prophylactic treatment
vasculitis (A:II) CT, and liver immune system recover
function testing count above 200 cells/
Cryptococcus < 50 Visual VA Signs and symptoms of Clinical diagnosis Isolated choroiditis: Weekly until resolution
cells/l symptoms SLE (B:II) central nervous system CNS symptoms IV fluconazole, 400 mg/day and IV
(A:II) including vision EOM (A:II) infection (A:II) think of cryptococcal flucytosine, 100 to 150 mg/kg/day
loss, diplopia, DOE (A:II) Papilledema (A:II) meningitis (A:II) for 10 weeks (A:II)
and new Retrobulbar optic Skin lesions biopsy Associated with meningitis:
scotomata (A:II) neuritis (B:II) (B:II) IV amphotericin B, 0.7 to 1
Headache/ Multifocal choroiditis mg/kg/day and IV flucytosine 100
meningismus (A:II) mg/kg/day for 2 weeks followed
(A:II) Other findings may by IV fluconazole for at least 10
include iritis, iris mass, weeks (A:II)
vitritis, necrotizing
retinitis, and eyelid or
conjunctival mass (B:II)

Page 58
HIV- > 120 Visual VA Peripheral multifocal Clinical diagnosis Antiretroviral therapy should lead Weekly until resolution
associated cells/l symptoms (A:II) IOP (C:II) retinitis (A:II) Rule out other to regression (A:II)
retinitis (A:II) SLE (C:III) Retinal vasculitis (A:II) entities, particularly
DOE (A:II) Mild vitreous syphilis (A:II)
inflammation (B:II)
Lack of retinal
hemorrhage (B:II)
Slow progression (B:II)
Intraocular < 500
lymphoma cells/l
Floaters (A:II) VA (A:II) Necrotizing retinitis
(A:II)
Workup and
treatment for
Radiation and chemotherapy (A:II) Monthly DOE
DOE (A:II) Involve Oncology Poor prognosis (A:II)
(A:II) Vision loss Retinal vasculitis (B:II) infectious processes Immune reconstitution (B:II)
(A:II) Subretinal mass (A:II) (A:II)
Vitritis (A:II) AC tap for IL-10
Multifocal choroiditis (B:II)
(A:II) Vitreous biopsy with
Poor response to cytologic
treatment (A:II) examination (A:II)
CNS symptoms (A:II) Consider retinal
biopsy
MRI for CNS
lymphoma (A:II)
Retinal N/A
detachment
History/extent VA (A:II) Rhegmatogenous retinal
detachment (A:II)
Clinical diagnosis PPV with long-term silicone oil
tamponade and scleral buckling
Routine post-operative fo
of necrotizing SLE (B:II) B-scan ultrasound if As directed by other diso
DOE (A:II) Holes or microholes in visualization is poor (A:II)
retinitis (A:II)
areas of areas of atrophic
History of retina or chronic retinitis
trauma (B:II) (A:II)
History of Note extent of
myopia (B:II) detachment, number,
size, and location of
retinal holes, and
involvement of the
macula (A:II)

Page 59

Page 60
Posterior Vitreous Detachment, Retinal Breaks
and Lattice Degeneration

Symptoms of PVD (A:I)
Family history (A:II)
Prior eye trauma (A:III)
Myopia (A:II)
History of ocular surgery including refractive lens exchange and cataract
surgery (A:II)

Examination of the vitreous for hemorrhage detachment and pigmented
cells (A:III)
Examination of the peripheral fundus with scleral depression (A:III) The
preferred method of evaluating peripheral vitreoretinal pathology is with
indirect ophthalmoscopy combined with scleral depression (A:III)
Ancillary Tests
Perform B-scan ultrasonography if peripheral retina cannot be evaluated.
(A:II) If no abnormalities are found, frequent follow-up examinations are
recommended. (A:III)
Surgical and Postoperative Care if Patient Receives Treatment:

Inform patient about the relative risks, benefits and alternatives to surgery
(A:III)
Formulate a postoperative care plan and inform patient of these
arrangements (A:III)
Advise patient to contact ophthalmologist promptly if they have a substantial
change in symptoms such as new floaters or visual field loss (A:II)

Page 61
Care Management
Management Options
Type of Lesion Treatment
Acute symptomatic horseshoe tears Treat promptly (A:II)
Acute symptomatic operculated tears Treatment may not be necessary
(A:III)
Traumatic retinal breaks Usually treated (A:III)
Asymptomatic horseshoe tears Usually can be followed without
treatment (A:III)
Asymptomatic operculated tears Treatment is rarely recommended
(A:III)
Asymptomatic atrophic round holes Treatment is rarely recommended
(A:III)
Asymptomatic lattice degeneration Not treated unless PVD causes a
without holes horseshoe tear (A:III)
Asymptomatic lattice degeneration with Usually does not require treatment
holes (A:III)
Asymptomatic dialyses No consensus on treatment and
insufficient evidence to guide
management
Fellow eyes atrophic holes, lattice No consensus on treatment and
degeneration, or asymptomatic insufficient evidence to guide
horseshoe tears management
PVD = Posterior vitreous detachment
Follow-up History
Visual symptoms (A:I)
Interval history of eye trauma or intraocular surgery (A:II)

Evaluation of the status of the vitreous, with attention to the presence of
pigment, hemorrhage, or syneresis (A:II)
Examination of the peripheral fundus with scleral depression (A:II)
B-scan ultrasonography if the media are opaque (A:II)
Patients who present with vitreous hemorrhage sufficient to obscure retinal
details and a negative B-scan should be followed periodically. For eyes in
which a retinal tear is suspected, a repeat B-scan should be performed
within approximately 4 weeks of the initial examination (A:III)

Page 62
Patient Education
Educate patients at high risk of developing retinal detachment about the
symptoms of PVD and retinal detachment and the value of periodic follow-
up exams. (A:II)
Instruct all patients at increased risk of retinal detachment to notify their
ophthalmologist promptly if they have a substantial change in symptoms
such as an increase in floaters, loss of visual field, or decrease in visual
acuity. (A:III)
*Adapted from the American Academy of Ophthalmology Summary Benchmarks,


Page 63
Primary Open-Angle Glaucoma (Initial Evaluation)


Family history (A:II)
Review of pertinent records (A:III)
Assessment of impact of visual function on daily living and activities (A:III)

Pupils (B:II)
Slit-lamp biomicroscopy of anterior segment (A:III)
Measurement of IOP (A:I)
Central corneal thickness (A:II)
Gonioscopy (A:III)
Evaluation of optic nerve head and retinal nerve fiber layer with magnified
stereoscopic visualization (A:III)
Documentation of optic nerve head appearance by color stereophotography
or computer-based image analysis (A:II)
Evaluation of the fundus (through a dilated pupil whenever feasible) (A:III)
Visual field evaluation, preferably by automated static threshold perimetry
(A:III)
Management Plan for Patients in Whom Therapy is Indicated

Set an initial target pressure of at least 25% lower than pretreatment IOP,
assuming that the measured pretreatment pressure range contributed to
optic nerve damage. (A:I)
Target pressure is an estimate; all treatment decisions must be
individualized according to the needs of the patient. (A:III)
Medical therapy is presently the most common initial intervention to lower
IOP; consider balance between side effects and effectiveness in choosing a
regimen of maximal effectiveness and tolerance to achieve the desired IOP
reduction for each patient. (A:III)
Assess the patient who is being treated with glaucoma medication for local
ocular and systemic side effects and toxicity. (A:III)
Laser trabeculoplasty can be considered as initial therapy in selected
patients (A:I)
Filtering surgery can be considered in selected cases as initial therapy. (A:I)

Page 64
Surgery and Postoperative Care for Laser Trabeculoplasty Patients
The ophthalmologist who performs surgery has the following
responsibilities:
o Obtain informed consent. (A:III)
o Ensure that the preoperative evaluation confirms the need for
surgery. (A:III)
o At least one IOP check within 30 minutes to 2 hours of surgery. (A:I)
o Follow-up examination within 6 weeks of surgery or sooner if concern
about IOP-related optic nerve damage. (A:III)
Surgery and Postoperative Care for Incisional Glaucoma Patients

responsibilities:
o Obtain informed consent. (A:III)
o Ensure that the preoperative evaluation accurately documents
findings and indications for surgery. (A:III)
o Prescribe topical corticosteroids in the postoperative period. (A:II)
o Follow-up evaluation on the first postoperative day (12 to 36 hours
after surgery) and at least once during the first 1 to 2 weeks. (A:II)
o In the absence of complications, perform additional postoperative
visits during a 6-week period. (A:III)
o Schedule more frequent visits, as necessary, for patients with
postoperative complications. (A:III)
o Additional treatments as necessary to maximize chances for a
successful long-term result. (A:III)
Patient Education for Patients with Medical Therapy

Discuss diagnosis, severity of the disease, prognosis and management
plan, and likelihood of lifelong therapy. (A:III)
Educate about eyelid closure or nasolacrimal occlusion when applying
topical medications to reduce systemic absorption. (B:II)
Encourage patients to alert their ophthalmologist to physical or emotional
changes that occur when taking glaucoma medications. (A:III)


Page 65
Primary Open-Angle Glaucoma
(Follow-up Evaluation)
Exam History
Interval ocular history (A:III)
Interval systemic medical history (B:III)
Side effects of ocular medication (A:III)
Frequency and time of last IOP-lowering medications, and review of use of
medications (B:III)
Physical Exam
Evaluation of optic nerve head and visual fields (see table below) (A:III)
Measurement of central corneal thickness should be repeated after any
event that may alter it (A:II)
Management Plan for Patients on Medical Therapy:

At each exam, record dosage and frequency of use, discuss adherence to
the therapeutic regimen and patient's response to recommendations for
therapeutic alternatives or diagnostic procedures. (A:III)
Perform gonioscopy if there is a suspicion of angle closure, anterior-
chamber shallowing or anterior-chamber angle abnormalities or if there is
an unexplained change in IOP. (A:III) Perform gonioscopy periodically (e.g.,
1-5 years). (A:III)
Reassess treatment regimen if target IOP is not achieved and benefits of a
change in therapy outweighs risks. (A:III)
Adjust target pressure downward if optic disc or visual field change is
progressive. (A:III) Within each of the recommended intervals, factors that
determine frequency of evaluation include the severity of damage, the rate
of progression, the extent to which the IOP exceeds the target pressure and
the number and significance of other risk factors for damage to the optic
nerve. (A:III)

Page 66
Follow-Up:
Recommended Guidelines for Followup:
Recommended Guidelines for Follow-up Glaucoma Status Evaluations with
Optic Nerve and Visual Field Assessment (B:III) *
Target IOP Progression of Duration of Approximate
Achieved Damage Control (months) Follow-up Interval
(months)**
Yes No 6 6
Yes No >6 12
Yes Yes NA 12
No Yes NA 12
No No NA 36
IOP = intraocular pressure; NA = not applicable
* Evaluations consist of clinical examination of the patient, including optic nerve head
assessment (with periodic color stereophotography or computerized imaging of the optic
nerve and retinal nerve fiber layer structure) and visual field assessment.
** Patients with more advanced damage or greater lifetime risk from POAG may require
more frequent evaluations. These intervals are the maximum recommended time
between evaluations.
Patient Education:
Educate about the disease process, rationale and goals of intervention,
status of their condition, and relative benefits and risks of alternative
interventions so that patients can participate meaningfully in developing an
appropriate plan of action. (A:III)
Refer for or encourage patients with significant visual impairment or
blindness to use appropriate vision rehabilitation and social services. (A:III)


Page 67
Primary Open-Angle Glaucoma Suspect


Family history (A:III)
Review of pertinent records (A:III)
Assessment of impact of visual function on daily living and activities (A:III)

Pupils (B:II)
Slit-lamp biomicroscopy of anterior segment (A:III)
Central corneal thickness (A:II)
Gonioscopy (A:III)
Evaluation of optic nerve head and retinal nerve fiber layer, with magnified
stereoscopic visualization (A:III)
Documentation of optic nerve head appearance color stereophotography or
computer-based image analysis(A:II)
Evaluation of the fundus (through a dilated pupil whenever feasible) (A:III)
Visual field evaluation, preferably by automated static threshold perimetry
(A:III)
Management Plan for Patients in Whom Therapy is Indicated:

A reasonable initial goal is to set target pressure 20% less than mean of
several baseline IOP measurements. (A:I)
Choose regimen of maximal effectiveness and tolerance to achieve desired
therapeutic response. (A:III)
Follow-Up Exam History

Interval ocular history (A:III)
Interval systemic medical history and any change of systemic medications
(B:III)
Side effects of ocular medications if patient is being treated (A:III)
Frequency and time of last glaucoma medications, and review of use, if
patient is being treated (B:III)

Page 68
Follow-Up Physical Exam
IOP (A:III)
Gonioscopy is indicated when there is a suspicion of an angle-closure
component, anterior chamber shallowing or unexplained change in IOP
(A:III)
Follow-up Intervals
Visit intervals depend on the interaction between patient and disease, which
is unique for every patient. (A:III)
Frequency of periodic optic nerve head and visual field evaluation is based
on risk assessment. Patients with thinner corneas, higher IOPs, disc
hemorrhage, larger cup-to-disc, larger mean pattern standard deviation, or
family history of glaucoma may warrant closer follow-up.
Patient Education for Patients with Medical Therapy:

Discuss diagnosis, number and severity of risk factors, prognosis,
management plan and likelihood that therapy, once started, will be long
term. (A:III)
Educate about disease process, rationale and goals of intervention, status
of their condition, and relative benefits and risks of alternative interventions.
(A:III)
Educate about eyelid closure and nasolacrimal occlusion when applying
topical medications to reduce systemic absorption. (B:II)
Encourage patients to alert their ophthalmologist to physical or emotional
changes that occur when taking glaucoma medications. (A:III)


Page 69
Primary Angle Closure
(Initial Evaluation and Therapy)

Ocular history (symptoms suggestive of intermittent angle-closure attacks)
(A:III)
Family history of acute angle-closure glaucoma (B:II)
Systemic history (e.g., use of topical or systemic medications) (A:III)

Refractive status (A:III)
Pupils (A:III)
o Conjunctival hyperemia (in acute cases)
o Central and peripheral anterior chamber depth narrowing
o Anterior chamber inflammation suggestive of a recent or current
attack
o Corneal swelling with or without microcystic edema (in acute cases)
o Iris abnormalities, including diffuse or focal atrophy, posterior
synechiae, abnormal pupillary function, irregular pupil shape, and a
mid-dilated pupil (suggestive of a recent or current attack)
o Lens changes, including cataract and glaukomflecken
o Corneal endothelial cell loss
Gonioscopy of both eyes (A:III)
Evaluation of fundus and optic nerve head using direct ophthalmoscope or
biomicroscope (A:III)
Management Plan for Patients in Whom Iridotomy is Indicated

Laser iridotomy is the preferred surgical treatment for acute angle-closure
crisis. (A:II)
In acute angle-closure crisis, usually use medical therapy first to lower the
IOP, to reduce pain and clear corneal edema in preparation for iridotomy.
(A:III)
Perform prophylactic iridotomy in fellow eye if chamber angle is
anatomically narrow. (A:II)

Page 70
Surgery and Postoperative Care for Iridotomy Patients
responsibilities:
o Obtain informed consent (A:III)
o Ensure that preoperative evaluation confirms the need for surgery
(A:III)
o Perform at least one IOP check within 30 minutes to 2 hours of
surgery (A:III)
o Prescribe topical corticosteroids in the postoperative period (A:III)
o Ensure that the patient receives adequate postoperative care (A:III)
Follow-up evaluations include:
o Evaluation of patency of iridotomy (A:III)
o Measurement of IOP (A:III)
o Gonioscopy, if not performed immediately after iridotomy (A:III)
o Pupil dilation to reduce risk of posterior synechiae formation (A:III)
o Fundus examination as clinically indicated (A:III)
Use medications perioperatively to avert sudden IOP elevation, particularly
in patients with severe disease. (A:III)
Follow-up of Patients with Iridotomy:

After iridotomy, follow patients with glaucomatous optic neuropathy as
specified in the Primary Open-Angle Glaucoma PPP. (A:III)
After iridotomy, patients with a residual open angle or a combination of open
angle and some PAS with or without glaucomatous optic neuropathy should
be followed at least annually, with special attention to repeat gonioscopy.
(A:III)
Education for Patients if Iridotomy is Not Performed:

Inform patients at risk for acute angle closure about symptoms of acute
angle-closure crisis and instruct them to notify immediately if symptoms
occur. (A:III)
Warn patients of medications that could cause pupil dilation and induce an
acute angle-closure crisis. (A:III)


Page 71
Trachoma

Living in a trachoma-endemic region (A:I)
Duration of red eye (an acute follicular conjunctivitis may be due to other
organisms) (C:III)
Any previous similar episodes (active trachoma is often recurrent) (C:III)
Household contacts with history of trachoma or chronic conjunctivitis (B:I)
Purulent discharge (although active trachoma is often sub-clinical or
asymptomatic) (C:III)
Duration of trichiasis (C:III)
History of previous lid surgery (A:III)

Using 2.5x magnification loupes and adequate lighting (daylight or
torchlight) or using a slit lamp, assess signs of trachoma using the WHO
simplified grading scale:
www.who.int/ncd/vision2020_actionplan/documents/Simplifiedgradingoftrac
homa.PDF (A:III)
Briefly, note any trichiasis or corneal opacity. Evert the upper palpebral
conjunctivae and note follicles over the tarsal plate (5 follicles greater than
0.5 mm in the central tarsus constitutes the WHO grade of TF), intense
inflammatory thickening obscuring 50% of the normal, underlying
conjunctival vasculature (TI), and easily visible scarring (TS).
Diagnostic (Laboratory) Tests

PCR testing for chlamydial DNAthis is the gold standard for identifying
infection but not for diagnosing trachoma (B:I)
Direct Chlamydial Immunofluorescence test +/- chlamydial culture of
conjunctival epithelial cells (C:II)
Chlamydial culture (difficult to perform) (C:II)
Giemsa stain of conjunctival scrape to look for:
o Basophilic intracytoplasmic inclusion bodies in epithelial cells (C:III)
o Polymorphonuclear leucocytes (C:III)

Page 72
Management
Management of trachoma should be community based. The WHO
recommends the integrated SAFE Strategy, surgery for trichiasis,
community wide antibiotic treatment, facial cleanliness education and
environmental improvements (B:III)
Surgical: Trichiasis surgery (bilamellar tarsal rotation or the related Trabut
procedure) should be considered if any of the following are present:
o one or more in-turned eyelashes are abrading the cornea when the
patient is looking straight ahead (A:II)
o pre-existing evidence of corneal damage from trichiasis (B:II)
o severe discomfort from trichiasis (C:III)
o Contra-indications to trichiasis surgery include defective lid closure,
children with trichiasis (may need general anesthetic), and poor
general health. (C:III)
o Epilation is considered an alternative for refusal to have surgery
(B:III)
Community-wide antibiotic treatment is recommended if there is >10%
active trachoma in children aged 1-9 years of age in the community.
Targeted treatment of clinically active cases is recommended for a lower
prevalence. Household contacts, and in particular, siblings, may also be
treated, even if they have no active signs of infection (B:II)
The following antibiotic treatment is recommended by the WHO:
o Single dose azithromycin: in children aged <16 years dosage is
20mg/kg (maximum dose 1g); in adults dosage is 1g (A:I)
o Or, use topical 1% tetracycline eye ointment in pregnant women,
children aged below 6 months and those allergic to macrolides, used
twice daily in both eyes for 6 weeks (A:I)
o It is acceptable to treat follicular conjunctivitis in a trachoma-endemic
area with antibiotics even without laboratory documentation of active
chlamydial infection (A:I)
Facial Cleanliness: promote regular face-washing with clean water. Clean
faces have been associated with clinically active trachoma, but it should be
noted that face-washing interventions have not been shown to reduce
ocular chlamydial infection (B:II)
Environmental Improvements: (improving water supply, latrine provision and
fly control). The face fly Musca sorbens has been implicated as a possible
vector for trachoma and breeds preferentially on human feces. These flies
cannot breed in latrines, so latrine construction is thought to reduce fly
populations and trachoma transmission (B:II)

Page 73
WHO recommends annual, community based treatment with
reassessment at three years. (B:II)
Note that follicles can take months to clear even after infection has been
eliminated, and that re-treatment may not be warranted if follicles are slowly
improving depending on the time that has elapsed since the last treatment
was given. (B:II)
For treatment of individual more frequent examinations can be
undertaken. Follow-up 1 month after treatment, with retreatment as
necessary is reasonable.
Re-infection frequently occurs in endemic areas, so patient education
regarding methods that may reduce transmission is useful. (C:III)
After trichiasis surgery, patients should be seen within 2 weeks for suture
removal, and annually to ensure that trichiasis has not returned. (A:III)


Page 74

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ICO International Clinical Guidelines: List of Guidelines Available

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November 2010

ICO International Clinical Guidelines

The Guidelines are designed to be translated and adapted by ophthalmologic

List of Guidelines Available

Preface to the Guidelines

ICO International Clinical Guidelines, 2010

(Ratings: A: Most important, B: Moderately important, C: Relevant but not critical

Initial Exam History (Key elements)

Initial Physical Exam (Key elements)

ICO International Clinical Guidelines, 2010

Follow-up Physical Exam

Follow-up Treatment after Neovascular AMD

ICO International Clinical Guidelines, 2010

* Adapted from the American Academy of Ophthalmology Summary Benchmarks,

ICO International Clinical Guidelines, 2010

Treatment Recommendations and Follow-up Plans for

Diagnoses Eligible for

Early AMD (AREDS Return exam at 6 to 24 months if asymptomatic or

Antioxidant vitamin and Intermediate AMD Monitoring of monocular near vision

Fundus photography as appropriate

Fluorescein angiography if there is evidence of

Return exam approximately 4 weeks after

Monitoring of monocular near vision

ICO International Clinical Guidelines, 2010

Bevacizumab intravitreal Subfoveal CNV Patients should be instructed to report any

Monitoring of monocular near vision

Occult CNV may be

ICO International Clinical Guidelines, 2010

Monitoring of monocular near vision

* Adapted from the American Academy of Ophthalmology Summary Benchmarks,

ICO International Clinical Guidelines, 2010

(Ratings: A: Most important, B: Moderately important, C: Relevant but not critical

Initial Exam History (Key elements)

Initial Physical Exam (Key elements)

ICO International Clinical Guidelines, 2010

* Adapted from the American Academy of Ophthalmology Summary Benchmarks,

ICO International Clinical Guidelines, 2010

(Ratings: A: Most important, B: Moderately important, C: Relevant but not critical

Initial Exam History

Initial Physical Exam

ICO International Clinical Guidelines, 2010

* Adapted from the American Academy of Ophthalmology Summary Benchmarks,

ICO International Clinical Guidelines, 2010

(Ratings: A: Most important, B: Moderately important, C: Relevant but not critical

ICO International Clinical Guidelines, 2010

Gram-positive Cocci Cefazolin 50 mg/ml 100 mg in 0.5 ml

Gram-negative rods Tobramycin or 9-14 mg/ml 20 mg in 0.5 ml

Gram-negative Ceftriaxone 50 mg/ml 100 mg in 0.5 ml

* Adapted from the American Academy of Ophthalmology Summary Benchmarks,

ICO International Clinical Guidelines, 2010

Initial Exam History

ICO International Clinical Guidelines, 2010

* Adapted from the American Academy of Ophthalmology Summary Benchmarks,

ICO International Clinical Guidelines, 2010

Initial Exam History

Initial Physical Exam

ICO International Clinical Guidelines, 2010

Nd:YAG Laser Capsulotomy

* Adapted from the American Academy of Ophthalmology Summary Benchmarks,

ICO International Clinical Guidelines, 2010

(Ratings: A: Most important, B: Moderately important, C: Relevant but not critical

Initial Exam History

Initial Physical Exam