Transcript Challenging Cases From Clinical Practice

Challenging Cases From Clinical
Practice
Eric E. Schmidt, O.D., FAAO
Omni Eye Specialists
Wilmington, NC
[email protected]
A Diagnostic Quandary
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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
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
Quandary cont
• Gonio – OD 3,2,2,1 OS 2,2,2,2
• DFE – Should you dilate these eyes?
Quandary Retina
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NPDR OU (OS > OD)
No CSME
No NVD, NVE
C/D - .3/.3 OU
• Anything else?
What is your differential diagnosis?
• How you treat this depends upon your
diagnosis!!!>>>@@@@****
Quandary options
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Cataract extraction
PI OU
Glaucoma drops
Blood work
Refer to Internist
Refer to Retina
SLT OU
Retinal/ONH Imaging
I Rx’d Lumigan OU QHS
• Ordered labs
– CBC – low RBC
– ESR – 80mm/Hr
– A1c – 5.3
– C-RP – normal
• 2 wk f/up
2 week exam
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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?
TA biopsy vs PI
• Pros and cons for each
• How did our man end up?
A Strange Cup Of Tea
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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
Routine Follow-Up?
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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
Oh Yeah...
• IOP 42mm Hg OD, 14mm Hg OS
• What’s your next step?
• What is your differential diagnosis?
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
Treatment
• Gonio is the key to the diagnosis
• Lower IOP
– Aqueous suppressors
• Quiet the anterior chamber reaction
– PF QID
– Taper quickly
• IOP sequelae?
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
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
Sudden Loss Question 1
What other tests would you perform?
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1. Gonioscopy
2. Keratometry/Topography
3. DFE
4. Corneal pachometry
5. VF
6. Gonio & K Topo
7. DFE & Gonio
8. Pachometry & Keratometry
Sudden Loss Question 2
What Is Your Diagnosis?
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1. Angle Closure Glaucoma
2. Corneal Edema
3. Corneal Hydrops
4. Corneal Perforation
5. Pupillary block glaucoma
6. Fuch’s dystrophy
Sudden Loss Question 3
How would you treat it?
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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
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
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
What is your management plan?
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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
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
What is your diagnosis?
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1. Choroidal detachment
2. Posterior Uveitis
3. Retinal detachment
4. Retinoschisis
5. Retinal tear
What are you going to do with this?
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1. Retinal referral
2. Glaucoma referral
3. Pred Forte OD Q2H
4. Close observation
5. Run out of the door screaming!
6. Calling Dr McGreal!
Why has this occurred?
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Prolonged hypotension?
Bleb problems?
Ciliary body shutdown?
Prolonged uveitis?
• **** Check The Bleb****
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
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
Causes of Ocular Hypotony
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1. Wound Leak
2. Ciliary Body Shutdown
3. Choroidal detachment
4. Retinal Detachment
5. Uveitis
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
Choroidal detachment
• CONSERVATIVE TREATMENT!!!
• PANIC NOT!!!!
– Patch if wound leak
– Monitor closely if no wound leak
– Try to elevate the IOP
– Steroids???
The Case Of The “Sore Eye”
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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
What is the diagnosis?
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1. Allergic conjunctivitis
2. Corneal abrasion
3. Bacterial keratitis
4. Dellen
5. Vernal keratoconjunctivitis
• How Do You Know It’s Not Infectious???
What Is The Best Treatment?
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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
Does She Or Doesn’t She?
• A Glaucoma Conundrum
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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?
Based on this info would you...
• Start therapy?
• Get more data?
• Follow with routine care?
Additional Information
• Gonioscopy – Gr 4 360 degrees OU
• PMH: Htn, hypercholesterolemia
• Meds: Vasotec, Lipitor
• Pachs – OD 652, OS 668
• Now would you treat?
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?
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?
As Many Disease As She Pleases
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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!”
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?
Ancillary Tests
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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?
Explain the VF result
• NOW what would you do?
MRI
• Suprasellar mass with impingement on ON
• Probable glioma
• Underwent resection
• Craniopharyngioma!
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!”
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
Which test do you want to do next?
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Amsler grid
Corneal topography
Rose-Bengal Stain
Schirmer’s strip
TBUT
Zone Quik
What is your diagnosis?
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1. Ocular Surface Disease
2. Blepharitis
3. Ocular rosacea
4. VKC
5. Allergic conjunctivitis
6. Bacterial conjunctivitis
What is the clinical key to making this
diagnosis?
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1. Look under the lids – check for papillae
2. Look at the cornea – check for RB staining
3. Look at her tears – check Schirmer’s test
4. Look at her cheeks – check for
telangiectasia
• 5. Look at her daughter – check for a wedding
ring
Considering that…
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She has punctal plugs,
She is using Patanol OU BID
She is using AT a lot
Has a Schirmer’s test of 3mm OD, 6mm OS
She has corneal staining
She continues to be symptomatic
How are you going to treat Newfound?
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1. Doxycycline 100mg QD
2. Lotemax OU QID
3. Systane OU Q2H
4. Refresh PM ung OU QHS
5. Polysporin Ung OU QHS
6. Restasis OU Q12H
7. Acular LS OU TID
8. Some combo of these
What I Did with Newfound
• RX Doxy 100 QAM
• FML OU QID
• AT PRN
• 1mth later she felt much better, lids were
much clearer, no NaFl or RB staining
• Now what?
Long term therapy for Newfound?
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1. Doxy 50 QD and AT
2. Optive OU QID
3. Restasis OU BID and AT OU QID
4. Restasis BID and Doxy 50 QD
5. FML OU BID and AT BID
6. Lotemax BID and Restasis BID
7. Doxy 100 QD and AT TID
8. Vitamins and Flax seed oil