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“Three Cases”

“Three Cases”. Thomas Landgraf, O.D., F.A.A.O. UMSL College of Optometry Fall 2008. Case #1. My Worst? Case Ever Of Herpes Zoster Ophthalmicus S: 36 yo AA male Augmentin, neurontin, “pain med with codeine”, acyclovir

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“Three Cases”

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  1. “Three Cases” Thomas Landgraf, O.D., F.A.A.O. UMSL College of Optometry Fall 2008

  2. Case #1 • My Worst? Case Ever Of Herpes Zoster Ophthalmicus • S: • 36 yo AA male • Augmentin, neurontin, “pain med with codeine”, acyclovir • Blur, dryness, discharge, redness, grittiness, itching, burning, tearing, light sensitivity, pain, tiredness, fever

  3. Neurontin

  4. Case #1 • My Worst? Case Ever • S: • 2-11-04 • H/O HZO , OD red with “matting” and burning • Right facial skin lesions involving nose • Onset 6 days ago • Began Acyclovir 800 mg 5x/day 1 day ago

  5. Case #1 • My Worst? Case Ever • O: • VA: 20/200 (ph 20/30), 20/20 • SLE: diffuse SPK with pseudodendrites, endothelial KP’s, at least 3+ cells, 3+ conjunctival injection OD • IOP: 15 OU

  6. Case #1 • My Worst? Case Ever • A/P • HZO with severe uveitis and pseudodendrites OD • Prednisolone Acetate 1% q2h OD, Homatropine 5% bid OD, Tobramycin qid OD, Bacitracin ung bid to lesions • CPM per PCP

  7. Case #1 • My Worst? Case Ever • 2-13-04 (2 days later) • Improvement in signs symptoms? • “tested for HIV…no results yet” • VA 20/400 (ph 20/200) • Diffuse SPK with pseudodendrites, ALL 3+ KP’s, corneal edema and striae, conjunctival chemosis and injection, GD 2-3 cells

  8. Case #1 • My Worst? Case Ever • 2-13-04 • Unable to assess retina • IOP: 16 • A/P: HZO with slight improvement in AC reaction, decreased VA secondary to corneal edema, CPM

  9. Case #1 • My Worst? Case Ever • 2/16/04 (3 days later) • “skin lesions better” • “vision not good and eye discomfort” • VA 20/400 (phni) • SLE the same but corneal edema worse and ptosis present

  10. Case #1 • My Worst? Case Ever • 2/16/04 (3 days later) • IOP: 19 • A/P: same assessment except worse overall • change Pred Acetate 1% to QID, Add Viroptic 9x/day x 1 week, otherwise CPM

  11. Dendrites or pseudo dendrites?

  12. Dendrites or Pseudodendrites? • Pseudodendrites stain lightly with NaFl but vividly with RB • No NaFl staining of terminal bulbs • Pseudodendrites are more linear…I.E. not like a “branched-tree root system”

  13. Case #1 • My Worst? Case Ever • 2/16/04 • A/P: HELP…refer to corneal specialist for second opinion • Colleague worried about the patient…

  14. Case #1 • My Worst? Case Ever • 1st visit prior to consult • 3+ eye pain, decreased VA • Bullae and increased IOP (29) • Decreased pseudodendrites • Added Medrol dose pack, NaCl drops, Pred 6x/day, D/C Tobramycin • Lots of patient education

  15. Case #1 • My Worst? Case Ever • 2nd visit prior to consult • Finally, some definite improvement • Decreased eye pain • Pinhole 20/80, no microbullae, IOP normal • CPM

  16. Case #1 • My Worst? Case Ever • Consult • Agreed with management • Gave taper schedule

  17. Case #1 • My Worst? Case Ever • Make a long story short • 4/6/04 • No eye pain, mild photophobia, tearing, mattering in AM • Still on Pred 6x/day • Skin lesions resolved • Ptosis, trace cells, mild SPK and injection, tonometry 19, retina fine • VA 20/25

  18. Case #1 • What did I learn • HZO oral meds may include more than Acyclovir • Prednisone • Narcotic • Neurontin • Analgesic to treat the pain associated with PHN

  19. Case #1 • Keep in Mind with HZO: Zovirax (Acyclovir) • 800 mg 5x/day for 7 days • Within 72 hours • Generic available • Remarkably safe • Alternatives • Valtex (valacyclovir) 1 gram tid x 7d • Famvir (famciclovir) 500 mg tid x 7d

  20. Case #1 • Keep in Mind with HZO: Zovirax (Acyclovir) • For HSK • 400 mg 5x/day for 7d as alternative to topicals • Benefits • concurrent topically treated uveitis • Suppresses recurrence of epithelial and stromal disease (400 mg 5x/day for 12 months) • Thyeson’s SPK?

  21. Case #2: OIS Diagnosis Made Even More Difficult • OIS: Ocular Ischemic Syndrome • History • 79 yo African-American female • Painful and severe vision loss OD • 4 days duration • Pertinent negatives: • Jaw claudication, weight loss, temporal artery associated pain, amaurosis fugax or other TIA

  22. Case #2: OIS DX Even More Difficult • History: • Current medically treated conditions • Hypertension • Congestive heart failure • Possible stroke 3 years prior • POAG, taking Alphagan-P bid OU

  23. Case #2: OIS DX Even More Difficult • Exam • BVA: FC @ 8’ OD, 20/20 OS • Normal CF’s and EOM’s • Pupil OD: 5mm, non-reactive • OS peaked and reactive to light

  24. Case #2: OIS DX Even More Difficult • Exam • SLX: • Iris neovascularization OD • Mild conjunctival hyperemia • PCIOL’s OU • IOP’s: 26 mm Hg OD, 18 OS at 1:25 pm

  25. Case #2: OIS DX Even More Difficult • Exam • DFE • Mild attenuated vessels and macular mottling OU • C/D’s: .7/.6 OD and .5/.5 OS • Normal ONH color and margins OU

  26. Case #2: OIS DX Even More Difficult • Assessment • Acute vison loss OD • Fixed dilated pupil • Increased IOP • Iris neovascularization

  27. Case #2: OIS DX Even More Difficult • Plan: • Referred immediately to ophthalmic co-management center • Second opinion • Continue Alphagan-P

  28. Case #2: OIS DX Even More Difficult • Consultation: • OIS versus retinal occlusive disease • Carotid bruit right side • Referred for carotid ultrasound • Bilateral plaque formation • 60-70% right carotid stenosis • 40-50% left carotid stenosis • Lumen narrowing of right common carotid, normal vertebral blood flow bilaterally

  29. Co-Management

  30. Case #2: OIS DX Even More Difficult • Eventually: • Fluorescein Angiography of the iris and retina • 19 months post-onset: • Shunt disc vessels, retinal capillary non-perfusion, neovascularization • PRA (Pan-Retinal Ablation) performed to prevent pain

  31. Photos Pre-PRA

  32. Photos Post-PRA

  33. Case #2: OIS DX Even More Difficult • Eventually: • Assessments: POAG and Neovascular Glaucoma • Plan: monitor for increased IOP

  34. Case #2: OIS DX Even More Difficult • Most recent optometric follow-up • 29 months post-onset • No eye pain • Travatan qhs and Azopt tid OU • NLP OD, 20/30 OS • Pupillary, iris, posterior pole findings stable OD • IOP’s: 32 OD and 21 OS • Review of recent GDx, OCT, and VF results

  35. Most recent GDx

  36. Most recent OCT RNFL

  37. Most recent VF OS

  38. Case #2: OIS DX Even More Difficult • Most recent optometric follow-up • 29 months post-onset • Additionally Rx Alphagan-P bid OU • Refer to retinal specialist • Additional IOP lowering management regimens OD • She reports follow-up with PCP regarding carotid ultrasound • We have kept the PCP appraised

  39. Case #2: OIS • Background • Rare and blinding condition • Associated with serious systemic morbidity • Unilateral • Average age of onset: 64 years • Associated systemic conditions: HTN, DM, ischemic heart disease, CVA, peripheral vascular disease

  40. CASE #2: OIS • Background • Cause: decreased blood flow to the eye • Results: anterior and posterior segment ischemia • Most patients: severe carotid artery disease

  41. CASE #2: OIS • Symptoms • Decreased vision • Eye pain • Amaurosis fugax

  42. Case #2: OIS • Signs • NVI, NVG, uveitis, cataract, red eye • Pupil rarely involved • Hypoperfusion retinopathy • Narrowed retinal arterioles, hemorrhages, dilated veins, microaneurysms, NVD, NVE, collateral vessels, cherry red spot

  43. Case #2: OIS • Differential Diagnosis • Retinal vascular occlusive disease • Diabetic retinopathy • Hypertensive retinopathy • Ischemic optic neuropathy

  44. Case #2: OIS • Management: difficult and controversial • PRA if retinal ischemia • Carotid endarterectomy? • Reduction of IOP, including cyclocryotherapy

  45. CASE #2: OIS • Bottom Lines for the Primary Care O.D. • Diverse and subtle presentation • Vision and life-threatening • Referral, angiography, carotid artery imaging

  46. CASE #2: OIS • Ocular management: long-term IOP reduction and prevention of eye pain • Systemic management: stresses prevention of ischemic heart disease and stroke

  47. Case #3 • The Post-Op Beyond 90 Days • S: 11/21/02 • 58 yo African-American female • Cataract surgery: • OD on 8/30/02 • OS on 6/21/02

  48. Case #3 • The Post-Op Beyond 90 Days • S: • Significant cardiovascular disease • Type II DM • “eyes feel good” • H/O PRA OU

  49. Case #3 • The Post-Op Beyond 90 Days • O: • BVA 20/30 OD and OS • 2+ AC cells OU • Posterior pole hemes OU • Macula clear OU

  50. Case #3 • The Post-Op Beyond 90 Days • A: • Persistent uveitis after cataract surgery OU • NPDR OU

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