Chronic Headache in Your Chair?

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The Eye as a Window to Kidney Function

A recent study in the journal Ophthalmic Research shows that by analyzing the blood flow through the fundus, OCT-A imaging can detect early changes in kidney function.

It is well-accepted within the medical community that early diagnosis and treatment of diabetic kidney disease is essential for improving a patient's quality of life and reducing the risk of developing end-stage kidney disease.

In the study, researchers stated that by examining the blood flow through a fundus, they were able to gain clues to the activity of diabetic kidney disease, and that such OCT-A imaging was able to serve as an alternative to the typical renal biopsy. In the study, the researchers analyzed 157 patients with type 2 diabetes who had prior renal pathology biopsies, OCT-A exams, and other tests. These researchers then graded the diabetic kidney disease findings from stages 1 (early) to 2 through 4 (late). These biopsies were then used to group the fundus flow parameters.

The researchers noted some consistencies, including an increase of the patient’s urinary microalbumin-to-creatinine ratio while the stage of diabetic kidney disease progressed and the glomerular filtration rate decreased. Of interest to the eye doctor is the fact that retinal blood flow in the superficial, deep, and full paracentral rings was also noted to have decreased. The researchers believe that an OCT-A could detect early microvascular disease and predict kidney function by quantifying the retinal capillary network.

According to the study authors, “The entire retina has a good discriminatory ability between the early and late stages of diabetic kidney disease pathology and may be an important reference index to assist or reduce the number of renal pathological biopsies in patients with diabetes mellitus.”

My Two Cents

How many times have we all told our patients, friends, families, and other random people we meet all the fantastic things that a comprehensive eye exam can find? Although many of us won’t be running an OCT-A on all our patients, this study certainly gives us more ammunition when it comes to showing other members of the health care community just how valuable a visit with an eye care provider can be for their patients. It seems like almost monthly a new study is published about something else unique that OCT-A can do!

OUTSIDE THE LANE

Patient Have Frequent Headaches? Look Deeper

A former member of England’s Royal Marine Service, James Greenwood, had been dealing with persistent headaches and eye strain for quite some time, but was dismissed as either being dehydrated or spending too much time in front of digital devices.

The 42-year-old’s symptoms, however, have since been diagnosed as glioblastoma, the most aggressive form of brain cancer, and he has been given 1 year to live. Greenwood’s journey initially brought him to his primary care practitioner (PCP) on two separate visits, and he was told to hydrate better and take more breaks at his desk job at a real estate company. Eventually, his headache symptoms became debilitating, and he wound up in an ER, where doctors discovered a walnut-sized, grade 4 glioblastoma. In June, Greenwood underwent brain surgery to remove the tumor, followed by a 6-week course of chemotherapy and radiotherapy. He is still awaiting results of the treatment.

My Two Cents

In the article, he mentions that his PCP recommended an eye exam as he may “have been overdue.” Unfortunately, no more details were given as to whether an eye exam was even performed, as it would have been interesting to learn if any optic nerve defects were present. Regardless, this is a reminder that persistent and worsening headaches should always be taken seriously in our patients and could warrant more comprehensive imaging than we have in our offices!

CAN YOU RELATE

This past week, I had one of my worst cases of epidemic keratoconjunctivitis in more than a year. The patient, a middle-aged female, was a front desk worker at a primary care office whose “pink eye” had been getting worse for nearly 2 weeks. Her clinic’s main PCP was managing her with broad-spectrum antibiotics, and they were doing little to nothing for her condition. Finally, she was sent our way.

The patient presented with grade 3 injection OD and grade 2 follicles of the palpebral conjunctiva and grade 3-4 injection OS and grade 3 follicles of the palpebral conjunctiva with 2+ subepithelial infiltrates OU. The left eye also had some gnarly pseudomembranes. The video below is of me removing the top lid’s pseudomembrane. It’s not for the faint of heart, but it’s neat if you’re into that kind of stuff like I am.

So, why do I tell you about this? I believe this is patient zero of an upcoming wave of viral conjunctivitis that is about to hit my office. I’m a massive fan of the betadine wash protocol developed by Ron Melton, OD, and Randall Thomas, OD, MPH, FAAO. Their protocol is as follows:

• Anesthetize the affected eye with proparacaine HCl 0.5%.
• Instill a drop or two of a topical nonsteroidal antiiflammatory drug (NSAID) on the eye.
• Instill four to five drops of 5% povidone-iodine (0.5% available iodine) (Betadine 5% sterile ophthalmic prep solution, Alcon).
• Have the patient close their eyes and “roll the eyes around.” (I tell them to paint the inside of their eyelids by moving their eyes around in all directions.)
• While the patient’s eyes are closed, use a cotton swab soaked in betadine to rub along the eyelid margins.
• After about a minute, rinse the ocular surface and eyelid area with sterile saline. Alternatively, you could also use the Rinsada irrigating lid retractor (Rinsada), as I believe this is what it was initially developed for!
• Instill a few more drops of NSAID on the affected eye.
• Prescribe a steroid drop four times daily for 5 to 7 days.
• Follow-up with the patient in 5 to 7 days.

I anticipate using this protocol numerous times in the coming weeks. You might want to keep it handy yourself!

IMAGE OF THE WEEK

Large, full-thickness macular hole.

Paul Hammond, OD, FAAO, @kmkoptometrypro

QUOTE OF THE WEEK

“Only one form of contagion travels faster than a virus. And that’s fear.”

— Dan Brown, American author