EYE PROBLEMS, COUGH, AND PAIN
From the 33rd annual Family Medicine Update, sponsored by the University of Minnesota Medical School, Minneapolis
Educational Objectives
| The goal of this program is to improve the management of eye problems, cough, and pain. After hearing and assimilating
this program, the clinician will be better able to:
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 | 1. Manage corneal abrasions in older patients.
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| 2. Identify common eye conditions in elderly patients, such as conjunctivitis, iritis, and age-related macular degeneration.
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| 3. Discuss causes of chronic cough, such as asthma and reflux disease.
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| 4. Perform appropriate tests for chronic cough, such as laryngoscopy and flexible bronchoscopy.
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| 5. Describe differences between acute pain and chronic pain.
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Faculty Disclosure
In adherence to ACCME Standards for Commercial Support, Audio-Digest requires all faculty and members of the planning
committee to disclose relevant financial relationships within the past 12 months that might create any personal conflicts
of interest. Any identified conflicts were resolved to ensure that this educational activity promotes quality in health
care and not a proprietary business or commercial interest. For this program, the following has been disclosed: Dr.
Kelkar is a consultant and/or is on the Speakers’ Bureaus for Abbott Laboratories, AstraZeneca, GlaxoSmithKline, Greer
Labs, Merck & Co, Pfizer, Sanofi-Aventis, Schering-Plough, UCB, Verus Pharmaceuticals, and Wyeth. Drs. Uttley and
Belgrade and the planning committee reported nothing to disclose.
Acknowledgements
Drs. Uttley, Kelkar, and Belgrade spoke in Minneapolis, MN, at the 33rd annual Family Medicine Update 2007, presented
May 7-11, 2007, by the University of Minnesota Medical School. The Audio-Digest Foundation thanks the
speakers and the University of Minnesota Medical School for their cooperation in the production of this program.
| EYE PROBLEMS IN THE ELDERLY —Scott A. Uttley, MD, Adjunct Assistant Professor, Department of Ophthalmology,
University of Minnesota Medical School, Minneapolis, and Co-Medical Director, St Paul Eye Clinic Laser Vision
Center, St Paul, MN
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| Eye examination: check visual acuity; lookfor Marcus Gunn pupil; check for confrontational visual fields and extraocular
motility; inspect cornea and anterior segment; visualize retina or use direct ophthalmoscopy to detect red reflex
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| Eye trauma in elderly: corneal abrasion—loss of corneal epithelium can be detected with fluorescein staining; evert
eyelid to check for retained foreign body; give prophylactic antibiotic drops to reduce risk for corneal ulceration or bacterial
keratitis; no difference in healing times between patched and unpatched eyes with average epithelial defects (7-8
mm); patching eye of patient with history of contact lens wear increases risk for corneal ulceration; do not prescribe anesthetic
drops (long-term [1 wk] use can result in corneal inflammation, perforation, and scarring); orbital floor fracture—
history of fall and trauma; possibility of ruptured orbital floor and roof of maxillary sinus; periorbital swelling; double
vision; infraorbital hypesthesia from damage of second division of trigeminal nerve; restriction on upgaze in infected eye
classic sign; hyphema—blood in anterior chamber; requires urgent referral to ophthalmologist; in “eight-ball hyphema”
(complete filling of anterior chamber with blood), pressure control can be difficult; ruptured globe—patients usually
present with 360º of subconjunctival hemorrhage and peaked pupil; obvious laceration; ocular emergency; defer examinations;
do not press eye; apply Fox eye shield; surgical emergency (patient must be npo); refer immediately
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Causes of Red Eyes in Geriatric Population
| Conjunctivitis: mucus discharge; inflammation of conjunctiva; bacterial—copious amounts of discharge; viral—most
common; mild discharge; self-limited for 2 wk; prescribe artificial tear drops or cool compresses; chlamydial—usually
mimics viral conjunctivitis, but lasts >4 wk; allergic—itchy; can be due to retained foreign body, toxic reaction to medication,
or long-term medication use
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| Exposure keratopathy: due to postsurgical facial nerve paralysis or Bell’s palsy; usually results in damaged corneal
epithelium, secondary to poor eyelid closure (cornea becomes exposed); use aggressive topical lubrication (eg, Refresh,
Lacri-Lube) to ensure corneal epithelium remains intact
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| Herpes simplex keratitis: presents in cornea as dendrite (tree-branching epithelial defect); can be seen on eyelid (resembles
mild vesicular reaction; also seen in infants); referral to ophthalmologist required; can be recurrent and progress
to chronic inflammatory phase, corneal scarring, and loss of vision
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| Herpes zoster ophthalmicus: patients present with vesicular reaction in ophthalmic nerve (V1); refer to ophthalmologist
to rule out eye involvement; when globe affected, 50% of patients progress to chronic course in eye; chronic inflammation
results in corneal scarring, neurotrophic cornea, and loss of vision; patients do not do well with corneal
transplantation
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| Dry eye: common; burning and stinging in eye; worsens later in day; mild forms treated with topical artificial tear drops;
can be severe (as in, eg, Sjögren’s syndrome; requires referral); avoid eye-whitening agents
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| Corneal infiltrates: focal white opacity on cornea; usually associated with bacterial infection; white blood cells
(WBCs) in cornea; in severe cases, patients develop hypopyon (WBCs in anterior chamber)
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| Iritis: red painful eye; no discharge; can be linked to systemic etiologies, eg, rheumatoid arthritis; WBCs in anterior chamber;
patients require aggressive treatment (topical prednisone); photophobia; sensitivity to light; dull achy pain above
brow
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| Subconjunctival hemorrhage: broken blood vessel; bleeding in subconjunctival space between eyeball and sclera;
benign; resolves over 2 wk; requires no intervention; in patients with multiple subconjunctival hemorrhages, determine
bleeding time or perform cursory coagulopathy work-up
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| Acute angle-closure glaucoma: acute rise in intraocular pressure; pain, blurred vision, nausea, and vomiting; seen in
far-sighted individuals; laser treatment on peripheral iris; ophthalmic emergency (requires immediate referral)
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| Red flags: red eye without discharge may be sign of corneal ulceration, iritis, or angle-closure glaucoma (refer to ophthalmologist);
red eyes in patients with collagen vascular disease or rheumatoid arthritis may indicate iritis; trauma; corneal opacities
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Other Geriatric Eye Conditions
| Primary open-angle glaucoma: chronic; usually inherited; asymptomatic; results in peripheral visual field loss; when
untreated, can result in blindness; check eye pressure every 1 to 2 yr
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| Cataract: nuclear—cloudiness of central nucleus of lens; most common type; posterior subcapsular—grainy opacity on
back edge of lens; more commonly associated with steroid medication; surgery performed as outpatient procedure under
local or topical anesthesia
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| Diabetic retinopathy: leading cause of blindness in Americans <65 yr of age; 99% of patients with type 1 diabetes
have some degree of retinopathy after 20 yr vs 60% incidence in type 2 diabetes; nonproliferative—hemorrhages; microaneurysms;
cotton-wool spots; exudates; treated with observation, control of blood glucose, and control of comorbidities
(eg, hypertension); ischemic process; proliferative—neovascularization; vitreous hemorrhage; can result in retinal
detachment; treated with panretinal photocoagulation (PRP); after laser treatment, new vessels regress; early treatment
can prevent blindness and loss of vision; screening recommendations—in type 1 diabetes, perform initial examination 5
yr after diagnosis; in type 2 diabetes, screen annually, starting at time of diagnosis; planned pregnancy—examine
woman before conception; repeat examination in first trimester
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| Age-related macular degeneration: leading cause of blindness in Americans >65 yr of age; nonexudative (dry)—
gradual loss of central vision; retina becomes atrophied; treatment recommendations include monitoring for progression
with Amsler grid (patient can self-monitor at home and should notify ophthalmologist if any symptoms [ie, metamorphopsia]
noticed) and Age-Related Eye Disease Study vitamin protocol (high amounts of vitamins A, E, and C); drusen
(waste products left behind by retinal pigment epithelium); exudative (wet)—subretinal neovascular membrane; choroidal
blood vessels grow under retina, bleed, leak, and can cause scarring; associated with quicker loss of central vision;
usually irreversible when untreated; new treatments—laser therapy; photodynamic therapy; eye injections of antiangiogenic
factor (eg, bevacizumab [Avastin] or ranibizumab [Lucentis])
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| Giant cell arteritis: sudden painless loss of vision, usually in patients >50 yr of age; symptoms—jaw claudication; temporal
pain; scalp tenderness; aches in joints; weight loss; look for afferent pupillary defect or Marcus Gunn pupil; erythrocyte
sedimentation rate usually markedly elevated; consider checking C-reactive protein and platelets; treatment—
high-dose steroids; start with 1 g intravenous (IV) methylprednisolone sodium succinate (eg, Solu-Medrol) for 3 days,
then switch to prednisone, 60 to 80 mg/day; if untreated, can lead to blindness and involvement of other eye
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| Papilledema: swelling of optic nerve head; usually associated with increased intracranial pressure; mild blurring of vision;
headache; diplopia; perform imaging study to rule out intracranial tumor or bleeding
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| Hypertensive retinopathy: nicking (changes where arteries and veins cross); cotton-wool spots; hemorrhages; edema
of optic nerve head; treatment includes blood pressure control; can be asymptomatic
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| Amaurosis fugax: monocular vision loss, usually due to embolic source, eg, cholesterol deposit; most patients describe
“gray curtain coming over vision for few seconds, then mysteriously lifts”; perform carotid ultrasonography and echocardiography
to rule out embolic source
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| Posterior vitreous detachment: “floaters”; due to normal senile degeneration of vitreous jelly in back of eye; jelly
undergoes syneresis (liquefaction); if patient notices increase in new floaters, new flashing lights, or curtain across vision,
refer for dilated examination to rule out retinal tear or detachment
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| CHRONIC COUGH —Pramod Kelkar, MD, Chair, Cough Committee, American Academy of Allergy, Asthma, and Immunology,
and Co-Chair, Metro Asthma Coalition, Minneapolis, MN
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| Classification: acute—duration <3 wk (<2 wk in children); subacute—3 to 8 wk (2-4 wk in children); chronic—>8 wk
(>4 wk in children); causes of acute cough different from causes of chronic cough; refer patients when uncertain about diagnosis
or management of chronic cough
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| Patient history: triggers—some data suggest that when cough triggered by talking, due to reflux from transient relaxation
of lower esophageal sphincter; laughter-induced cough can be due to uncontrolled asthma or reflux disease; chronic
cough triggered by walking or running typically due to asthma; strong smells and perfumes; timing of cough may be important
(reflux disease symptoms can occur during day); consider relationship to meals; preceding events—viral upper
respiratory infection common cause of cough (postinfectious cough; treat with inhaled or oral steroids or inhaled ipratropium);
recent immigration from or travel to developing country; analysis of cough sound may be useful in children (eg,
honking-type cough suggestive of psychogenic or habitual cough); review of systems important
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| Physical examination: examine throat; thick yellow postnasal drip usually sign of sinusitis (treat with antibiotics);
chronic sinusitis and cough (duration >1 mo) should be treated with 3- or 4-wk continuous course of antibiotics; look in
ears to rule out wax impaction; look at nails for clubbing (sign of cystic fibrosis); check for thyroid masses; look for signs
of atopy (eg, allergic rhinitis)
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| Cough vs airway hyperreactivity: cough reflex different from airway hyperresponsiveness and responds differently
to medications (eg, lidocaine and oral codeine inhibit cough, but not bronchial hyperresponsiveness)
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| Basic management of chronic cough: discontinue angiotensin-converting enzyme (ACE) inhibitor, and wait 1 to 3
mo for cough to resolve (if no resolution after 1 mo, further work-up required); tobacco smoking cessation (may take ≈1
mo for cough to improve); chest x-ray; spirometry
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| Pertussis: study of 75 adults presenting to emergency department (ED) with cough lasting >14 days; ≈20% had evidence
of recent pertussis infection; concluded that pertussis manifesting as chronic cough may be missed; adults do not have
typical whoop as seen in children; guidelines suggest any patient with pertussis and clinical history (eg, positive family
history, history in school or workplace) and patient’s family should be treated for pertussis; be highly suspicious of pertussis
in children who have cough associated with vomiting; only possible to decrease duration of cough if antibiotics
given in first 1 to 2 wk
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| Causes of chronic cough: postnasal drip syndrome—most common; if medications (eg, nasal steroids) ineffective, consider
allergy testing and limited sinus computed tomography (CT); asthma—inflammation, airflow obstruction, airway hyperresponsiveness,
and reversibility; cough-variant asthma common; physical examination, chest x-ray, and spirometry can
be normal; ratio of forced expiratory volume in 1 sec (FEV1 ) to forced vital capacity (FVC) most reliable measurement of
airway caliber; methacholine challenge test to rule out asthma in selected patients (negative predictive value nearly 100%);
chronic cough relieved by prednisone not diagnostic of asthma (consider allergic rhinitis, asthma, or eosinophilic bronchitis);
eosinophilic bronchitis—sputum eosinophilia; no airway hyperresponsiveness (methacholine challenge test negative);
treated with inhaled or oral steroids; natural history unclear; cough can be due to multiple causes (continue previous therapy
and add treatment for other disease); misdiagnosis—failure to consider common extrapulmonary causes (eg, postnasal
drip); insufficient dose of medication or duration of therapy
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| Reflux disease: if patient with chronic cough and suspected reflux disease does not improve with 3-wk course of proton
pump inhibitor (PPI), treatment should be continued aggressively; may need to wait 8 to 12 wk with aggressive treatment
before response seen; nonacid reflux can cause cough; 24-hr pH probe can help diagnose acid reflux disease (some patients
may require esophageal manometry); laryngopharyngeal reflux—diagnosed with laryngoscopy; give double-dose
PPI; determine role of gastrointestinal dysmotility in nonacid reflux; silent reflux—absence of heartburn and regurgitation;
chronic cough; sleep apnea—increased respiratory effort by diaphragm increases chance for reflux disease
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| Flexible bronchoscopy: adds little to diagnosis of chronic cough in context of normal chest x-ray and high-resolution
chest CT; useful when endobronchial lesions (eg, tumors, foreign bodies) suspected; include neck CT when performing
chest CT to detect masses that may impinge on trachea
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| Lung cancer and chronic cough: rare (0%-2% incidence); high negative predictive value of chest x-ray
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| Habit cough: difficult to treat; probably overdiagnosed; patient education, breathing exercises, speech therapy, psychotherapy,
and pimozide may be helpful
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| ACUTE vs CHRONIC PAIN —Miles Belgrade, MD, Adjunct Associate Professor, Department of Neurology, University
of Minnesota Medical Center, and Medical Director, Fairview Pain and Palliative Care Center, Minneapolis
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| Five key points: 1) chronic pain not acute pain; 2) pain can be imaged and measured; 3) opioids have only marginal benefit
in chronic pain; 4) methadone must be initiated and used properly; 5) chronic pain guidelines developed by Institute
for Clinical Systems Improvement
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| Projection sites of pain transmission: 1) somatosensory cortex; sensory discriminative component of pain; identifies
pain as sensation, location of pain, and intensity of pain; 2) limbic system structures (eg, anterior cingulate cortex,
cerebellum); affective and motivational component of pain; all components must be managed, especially in chronic pain
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| Treatment goals: consider average pain scale score (4.5-8.3) of chronic pain patients; for acute pain, maximize comfort
and use strong pharmacologic agents; in chronic pain, lowest average pain score 4.4 (“we will never achieve 0 level of
pain and shouldn’t be trying”); focus on pain improvement and improvement in function and well-being (eg, returning to
work, socializing with family and friends, minimizing utilization of health care products and services)
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| Acute vs chronic pain: acute—pain has beginning, middle, and predictable end; mediated by glutamate that attaches to
“good guy” receptors; chronic—pain persists beyond expectations; existence independent of original cause; not curable;
mediated by substance P and other transmitters that attach to “bad guy” receptors; study—demonstrated that nerve sets
containing chronic pain receptors can be selectively knocked out by attaching toxin (saporin) to substance P; since N-methyl-
D-aspartate (NMDA) receptors and neurokinin-1 (NK-1) receptors not altered by morphine, chronic pain not as responsive
to morphine as acute pain
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| Neuropathic pain mechanisms: nerve damage—can result in spontaneous firing of nerve and pain signals (eg, neuropathic
pain in diabetes); damaged touch nerves (eg, A- β fibers, myelinated fibers) can result in crosstalk when traveling in
same nerve fascicle (even light touch can trigger pain response); loss of nerve input (deafferentation)—automatic firing of
upregulated second-order neuron results in burning spontaneous pain; central sensitization—if stimulus repeated, upregulated
system results in easier pain development (ie, pain with minor stimulus)
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Suggested Reading
Barnes TW et al: The clinical utility of flexible bronchoscopy in the evaluation of chronic cough. Chest 126:268, 2004;
Belgrade MJ et al: The DIRE score: predicting outcomes of opioid prescribing for chronic pain. J Pain 7:671, 2006;
Bloomgarden ZT: Diabetic retinopathy. Diabetes Care 31:1080, 2008; Colquitt JL et al: Ranibizumab and pegaptanib
for the treatment of age-related macular degeneration: a systematic review and economic evaluation. Health Technol Assess
12:1, 2008; Fisher K et al: Goal attainment scaling in evaluating a multidisciplinary pain management programme.
Clin Rehabil 16:871, 2002; Herr J: Chronic cough, sleep apnea, and gastroesophageal reflux disease. Chest 120:1036, 2001;
Irwin RS et al: Managing cough as a defense mechanism and as a symptom. A consensus panel report of the American
College of Chest Physicians. Chest 114:133S, 1998; Johnson MC et al: Giant cell arteritis presenting with cotton wool
spots. Semin Ophthalmol 23:141, 2008; Mahmood AR et al: Diagnosis and management of the acute red eye. Emerg
Med Clin North Am 26:35, 2008; Palombini BC et al: A pathogenic triad in chronic cough: asthma, postnasal drip syndrome,
and gastroesophageal reflux disease. Chest 116:279, 1999; Rainville P et al: Pain affect encoded in human anterior
cingulate but not somatosensory cortex. Science 277:968, 1997; Reeder CE et al: Managed care and the impact of glaucoma.
Am J Manag Care 14:S5, 2008; Toombs JD et al: Methadone treatment for pain states. Am Fam Physician
71:1353, 2005; Wright SW et al: Pertussis infection in adults with persistent cough. JAMA 273:1044, 1995.
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