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Challenging Cases From Clinical Practice

Challenging Cases From Clinical Practice. Eric E. Schmidt, O.D., FAAO Omni Eye Specialists Wilmington, NC schmidtyvision@msn.com. A Diagnostic Quandary. 76 y/o WM cc: OD hurts, “like a toothache” Pain is worse at night, lasts for 3-6 hrs. 3 occurrences over past 2 weeks

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Challenging Cases From Clinical Practice

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  1. Challenging Cases From Clinical Practice Eric E. Schmidt, O.D., FAAO Omni Eye Specialists Wilmington, NC schmidtyvision@msn.com

  2. A Diagnostic Quandary • 76 y/o WM cc: OD hurts, “like a toothache” • Pain is worse at night, lasts for 3-6 hrs. • 3 occurrences over past 2 weeks • VA has decreased since 1st episode • Type I DM – BS 130 today, sliding scale • MD says BP is “way hi recently” • BP med

  3. Quandary Exam • VA – OD 20/100 ph 20/80-2 OS 20/40 ph NI • EOM – no rest. • PERRL mg (-) • SLE – K – cl OU • Conj – cl OU • Lens – 2+/2+/1+ OD, 2+NS, 1+PSC OS • AC – quiet OU, Gr 2 VH OU • IOP – 18 OD, 18 OS

  4. Quandary cont • Gonio – OD 3,2,2,1 OS 2,2,2,2 • DFE – Should you dilate these eyes?

  5. Quandary Retina • NPDR OU (OS > OD) • No CSME • No NVD, NVE • C/D - .3/.3 OU • Anything else?

  6. What is your differential diagnosis? • How you treat this depends upon your diagnosis!!!>>>@@@@****

  7. Quandary options • Cataract extraction • PI OU • Glaucoma drops • Blood work • Refer to Internist • Refer to Retina • SLT OU • Retinal/ONH Imaging

  8. I Rx’d Lumigan OU QHS • Ordered labs • CBC – low RBC • ESR – 80mm/Hr • A1c – 5.3 • C-RP – normal • 2 wk f/up

  9. 2 week exam • Pain had returned even w/ Lumigan • VA worsening • AC- mild cell OD, d & q OS • Angles – unchanged OU • IOP – 17mm OU • Retina – scattered h/MA OU, disk heme OS • Does this change your mind?

  10. TA biopsy vs PI • Pros and cons for each • How did our man end up?

  11. A Strange Cup Of Tea • 68 y/o African –American • Treated for NTG x 12 yrs • Seidel’s scotomas OU • Notch at 2:00 OS • NTG well controlled w/ Lumigan OU QHS • (IOP ~ 11mm Hg) • VF and rims now stable • VA stable at 20/20 OU

  12. Routine Follow-Up? • No subjective complaints • VA OD 20/30, OS 20/20 • NI w/ refraction • When asked again – OD did feel “kind of funny.” • PERRL mg (-), EOM- no restrictions • SLE – OS normal - OD as shown

  13. Oh Yeah... • IOP 42mm Hg OD, 14mm Hg OS • What’s your next step? • What is your differential diagnosis?

  14. Glaucomatocyclitic Crisis • Unilateral increased IOP w/ accompanying iritis • No predispositioning, no precursors • Absence of all other findings • Mildly symptomatic • Diagnosis of exclusion • R/O ACG, NVG, Inflammatory G, PDS

  15. Treatment • Gonio is the key to the diagnosis • Lower IOP • Aqueous suppressors • Quiet the anterior chamber reaction • PF QID • Taper quickly • IOP sequelae?

  16. Case Of The Sudden Vision Loss • 17 y/o BM awoke that AM; “couldn’t see” out of OS. • “somewhat painful” • Looked in mirror, noticed eye was totally white • Denies trauma • No precursors

  17. Exam • VA s Rx - OD 20/30, OS LP • Pupils - OD Round, reactive no inverse APD, OS - not visible • SLE - OD prominent K nerves, no edema, no bulb inj, OS as shown • IOP 15 OD, 32 OS

  18. Sudden Loss Question 1What other tests would you perform? • 1. Gonioscopy • 2. Keratometry/Topography • 3. DFE • 4. Corneal pachometry • 5. VF • 6. Gonio & K Topo • 7. DFE & Gonio • 8. Pachometry & Keratometry

  19. Sudden Loss Question 2What Is Your Diagnosis? • 1. Angle Closure Glaucoma • 2. Corneal Edema • 3. Corneal Hydrops • 4. Corneal Perforation • 5. Pupillary block glaucoma • 6. Fuch’s dystrophy

  20. Sudden Loss Question 3How would you treat it? • 1. Adsorbonac 5% QID, TXE 0.5OS • 2. Penetrating Keratoplasty • 3. Betimol 1/2% OS BID, Eflone QID • 4. Pressure patch, Atropine OS • 5. BCL, Quixin OS QID • 6. BCL, Lotemax OS QID • 7. Eflone OS QID, Adsorbonac 5% OS QID

  21. The Case Of The Low IOP • The history : • 72 y/o BF w/ long-standing POAG • Trusopt BID, Xalatan QHS, Betimol ½ BID • IOP - hi teensOU • C/D - .8/.8 OD, 85/.85OS lamina visible OU • VF- OD mild double arcuate OS- Seidel’s scotoma sup VA – OD 20/70 OS 20/25 SLE – cataracts OD > OS

  22. Low IOP cont • Px underwent combined procedure OD • 6 wks S/P surgery VA OD 20/20 • IOP 3 OD, 21 OS • G meds OS Only • 2 ½ years later: • Pain OD, VA 20/50 OD • 3+ bulb inj, 2+ AC cell • IOP – 3mm OD, 17mm OS • Fundus- hazy view

  23. What is your management plan? • 1. EP QID OD • 2. EP Q2H OD • 3. Atropine ½% OD, PF OD QID • 4. Retinal referral • 5. Glaucoma referral • 6. Vigamox OD QID

  24. I Rx’d EP OD QID, HA5% OD BID • 2 days later- • VA 20/50-2 • Eye feels better • AC rxn 1+ cell • DFE- as shown

  25. What is your diagnosis? • 1. Choroidal detachment • 2. Posterior Uveitis • 3. Retinal detachment • 4. Retinoschisis • 5. Retinal tear

  26. What are you going to do with this? • 1. Retinal referral • 2. Glaucoma referral • 3. Pred Forte OD Q2H • 4. Close observation • 5. Run out of the door screaming! • 6. Calling DrMcGreal!

  27. Why has this occurred? • Prolonged hypotension? • Bleb problems? • Ciliary body shutdown? • Prolonged uveitis? • **** Check The Bleb****

  28. 2 holes in surface of bleb • Now what? • 1. BCL • 2. Vigamox OD QID • 3. PF QID • 4. BCL, TXE ½ QAM • 5. BCL, Vigamox TID • 6. Vigamox TID, TXE ½ QAM • 7. Vigamox TID, TXE ½ QAM, BCL

  29. Trabeculectomy post-op • Don’t want IOP too low for too long • Bleb management is the key • IOP hi, bleb hi • IOP hi, bleb flat • IOP low, bleb low • IOP low, bleb high • Know what to look for, know how to treat

  30. Causes of Ocular Hypotony • 1. Wound Leak • 2. Ciliary Body Shutdown • 3. Choroidal detachment • 4. Retinal Detachment • 5. Uveitis

  31. Choroidal Effusion • Accumulation of Fluid in suprachoroidal space • Caused by trauma, hypotony or inflammation • Clinical Features: • Anterior displacement of choroid in annular, lobular or flat arrangement • Must differentiate from RD • Can occur days, weeks or months post-op

  32. Choroidal detachment • CONSERVATIVE TREATMENT!!! • PANIC NOT!!!! • Patch if wound leak • Monitor closely if no wound leak • Try to elevate the IOP • Steroids???

  33. The Case Of The “Sore Eye” • 17 y/o WM CC: “Itch and Pain OD” • 3 weeks duration and it’s getting worse • Initially very itchy, now it is painful • FB sensation, photophobia, tearing • No known trauma, Rx’d Vasocon TID • Ext – Ptosis RUL, frank injection • SLE – AC –d & q, 1+ mucus d/c

  34. What is the diagnosis? • 1. Allergic conjunctivitis • 2. Corneal abrasion • 3. Bacterial keratitis • 4. Dellen • 5. Vernal keratoconjunctivitis

  35. How Do You Know It’s Not Infectious???

  36. What Is The Best Treatment? • 1.BCL and Gentamicin QID • 2. BCL and Xibrom BID • 3. BCL and Zymar QID • 4. Lotemax OD QID • 5. Vigamox OD TID • 6. Tobradex OD QID • 7. Vigamox and Nevanac TID each • 8. Some combination of these

  37. Does She Or Doesn’t She? • A Glaucoma Conundrum • 51 y/o WF • No family hx of G • BCVA 20/20 OD, OS • SLE – normal • C/D - .65/.75 OD, .65/.70 OS • IOP – 23 OD, 23 OS @ 8:40 AM • 22/22 @10:20AM, 25/26@3:30PM • Does she have glaucoma?

  38. Based on this info would you... • Start therapy? • Get more data? • Follow with routine care?

  39. Additional Information • Gonioscopy – Gr 4 360 degrees OU • PMH: Htn, hypercholesterolemia • Meds: Vasotec, Lipitor • Pachs – OD 652, OS 668 • Now would you treat?

  40. Now what would you do? • What is her “actual “ IOP? • What is your target IOP for her? • What type of glaucoma does she have? • Which drop would you prescribe?

  41. One last piece of the puzzle • In our office IOP readings were... • 23/21 gat, 18.0/16.3 Pascal • 23/21 GAT, 18.3/17.3 Pascal • Does this change anything?

  42. As Many Disease As She Pleases • 77 WF • Macular hole repair OS 8 yrs prior • Subsequent SRNVM w/ large macular scar • VA OD 20/20, OS HM@6’ – stable for 5 yrs • Recently complained of HA “alot” over OS • Says her vision OS is worsening, “it will go black at times!”

  43. Exam • VA OD 20/25- OS – LP • SLE – OD no change, OS – 2+ PCO • DFE –OD - D,M,V,P wnl OS small macular bleed adjacent to macular scar • ONH - .1/.1 OD pink, .15/.15 OS large area of PPA • What now? • Did we forget something?

  44. Ancillary Tests • IVFA – no evidence of new SRNVM • OCT – Plush NFL, no SRNVM • ESR – 20mm/Hr • C-RP – 0.8 • What now? Is she just crazy? • Are you sure we haven’t overlooked anything?

  45. Explain the VF result • NOW what would you do?

  46. MRI • Suprasellar mass with impingement on ON • Probable glioma • Underwent resection • Craniopharyngioma!

  47. The Case of Newfound Eyes • 70 y/o F referred for chronic sore eyes • POH: Punctal plugs 3 yrs prior – moderate improvement initially • Meds: Synthroid, Adalat, Calcium, ASA, Refresh Tears QID • CC: Eyes burn and sting. Very red worse at times. Mild stringy d/c. Vision seems worse • “I’m Allergic to everything!”

  48. Newfound Data • VA OD 20/25, OS 20/30 • Ext: normal except for “ruddy” complexion • SLE: Lids – 1+ debris OU 1+ Meib inspissation OU 1+ bulb injection few papillae OU K – diffuse SPK OU Lens – 1+ NS OU

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