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Grand Rounds

Grand Rounds. Joseph Reck VAMC Wilkes-Barre, PA November 3, 2006. Clinical Presentation. Seen in Texas six weeks ago; GAT- 54 Current Medications: Diamox 500mg b.id.; ran out 5d ago Cosopt b.id. Atropine b.id. Brimonidine b. id. Ocular history:

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Grand Rounds

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  1. Grand Rounds Joseph Reck VAMC Wilkes-Barre, PA November 3, 2006

  2. Clinical Presentation • Seen in Texas six weeks ago; GAT- 54 • Current Medications: • Diamox 500mg b.id.; ran out 5d ago • Cosopt b.id. • Atropine b.id. • Brimonidine b. id. • Ocular history: • Cataract extraction without implantation, 1983. • Anterior chamber IOL implantation, 1987.

  3. Acuity and Externals • VA cc: O.D. 20/60, PH 20/40 O.S. 20/20 • Pupils: O.D. pharm fixed; O.S. RRL –APD • EOM: Full and smooth, O.U. • Confrontation fields; Full, O.U.

  4. Clinical Findings • Slit Lamp Exam: • 1+ injection. • Diffuse microcysts and SPK. • 1+ AC Reaction. • Iris atrophy with exposed iris vessels near ACIOL haptic foot.

  5. O.D. - 52 O.S.- 13 Tonometry

  6. Uveitic Glaucoma • Unilateral, red eye. • Pain and photosensitivity. • Corneal edema. • AC reaction. • Increased IOP.

  7. Inflammatory Cells • Decrease aqueous outflow • Physically obstruct trabecular meshwork.

  8. Synechiae

  9. Topical steroid. Pred Forte q15min; then taper. Strong cycloplegia. Atropine 1% b.id. Break synechiae. Phenylephrine 10%. Beta-blocker Alpha-agonist CAI Avoid Prostaglandins. Inflammation, then Pressure

  10. Assessment/Plan: • Lotemax q2h • Atropine t.id. • Cosopt b.id. • Diamox 500mg, b.id. • Follow-up in 1 week.

  11. One Week Follow-Up • VA cc: O.D. 20/100, PH 20/40 O.S. 20/20 • GAT: O.D. 52, O.S. 12 • 1+ AC Reaction

  12. Updated Treatment Plan • Continue meds as scheduled. • Add Alphagan t.id. • Run full uveitis work-up. • Follow-up next day.

  13. Return Visit • Patient experiencing some pain. • VA cc: O.D. 20/80, ph 20/30 O.S. 20/20 • GAT: O.D. 55, O.S. 11. • 1+ AC reaction.

  14. Differential • Unilateral increase in IOP • Steroid response • PAS • Endopthalmitis • Chronic inflammation • Retained lens material

  15. Gonioscopy • Lens position in iris; not angle • Small areas of synechiae. • Small areas of bleeding. • Peripheral rubeosis, superiorly. • Dilated iris tissue rolled into angle. • ACIOL haptics appear to have pushed peripheral iris directly into angle • Discontinue Atropine.

  16. UVEITIS • GLAUCOMA • HYPHEMA

  17. UGH Syndrome • Inflammation after anterior chamber IOL implantation, caused by the haptics of the IOL. • Misplaced or misdirected haptics from the anterior chamber IOL erode the tissues of the angle, causing bleeding and inflammation.

  18. UGH Syndrome • Excessive lens movement • Small size • Decentration or dislocation • Poorly manufactured edges • Iris-clipped IOL • Rigid, closed loop haptics

  19. Open Loop IOL -good finish/polish -easy to size -less area of contact Closed Loop IOL -difficult to fit -erosion chaffing -large contact zone -poorly finished/ sharp edges Open v. Closed Loop

  20. UGH with PCIOL’s • Unstable sulcus fixation • PCIOL decentration • zonular weakness • trauma

  21. UGH Etiology; Uveitis • Activation of innate immunity. • Theories • Cytokine and eicosanoid synthesis triggered by mechanical excoriation of the angle or iris by the haptics or optic • Plasma-derived enzymes (especially complement or fibrin) activated by the surface of the IOLs • Adherence of bacteria and leukocytes to the IOL surface • Toxicity caused by contaminants on the IOL surface during manufacturing or implantation

  22. Post-Operative Timing • UGH Development • Usually weeks to months. • Literature suggests 1-8 yrs. • This patient; 1987 to 2006 – 19 years.

  23. Clinical Spectrum • Iris pigment epithelial defects • Pigment dispersion • Microhypema • Macrohyphema I • Increase in IOP

  24. Presenting Symptoms • Intermittant blurring • ‘Redness’ to vision • Eye pain • Red eye • Photophobia

  25. UGH Complications • Pseudophakic bullous keratopathy • Corneal staining; recurrent hyphema • Chronic inflammation • Cystoid macular edema • Glaucoma

  26. UGH Management • Bed rest with elevated head position to encourage hyphema settling • Topical steroid • Reduce increased IOP • Ultimately, the lens may have to be repositioned or removed.

  27. UGH Treatment Options • Observe, treat episodes individually. • Pharmacologically reposition IOL • IOL rotation • IOL explanation +/- replacement.

  28. Patient Returns • VA cc: O.D. 20/50, ph 20/30 O.S. 20/20 • GAT: 22, O.D.; 13 O.S. • 2+ AC reaction. • Patient scheduled for IOL removal.

  29. STUDY:Indications for IOL Explanation (FL) • The majority of the removed IOLs were anterior chamber styles (53.9%), followed by iris-fixated lenses (33.7%) • The most common indications for surgery included: • Pseudophakic bullous keratopathy, 69% • UGH syndrome, 9% • IOL instability, 7%.

  30. Surgical Timing with ACIOL • Time between implantation and explanation with ACIOL complications: • 1 to 8 years.

  31. Surgical Outcome • The poorest visual outcome was seen in patients with the UGH syndrome. • 83% had a final acuity of 20/200 or worse. • Resolution of pain and inflammation • Better control of their IOP as a result of the surgery.

  32. 1- Day Post-Operative • Surgery without incident • VA- 20/400, PH 20/100 • Some corneal edema; 3+ AC reaction. • GAT- 13. • Continue with meds: • Cosopt b.id. - Tobradex ung q.id. • Alphagan P b.id. - Atropine b.id. • Diamox 500mg b.id.

  33. Follow-Ups • Seen on Day 2, 4, then 1 week, 2 week. • VA improves to 20/100 with pinhole and +15D lens. • Cornea improves; AC reaction diminishes to grade 1. • IOP in mid to low teens. • Continuing all meds.

  34. 3 Week Follow-Up • VA- 20/80 • Refracts to 20/30. • Trace AC reaction. • GAT- 13. • SLOW taper off all meds.

  35. Review: Key Points • Be suspicious of misplaced IOL • ACIOL with Uveitis • Gonioscopy

  36. THE END

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