Transcript Twilight Zone: Strange and Unusual Case Studies


I do not have any affiliations nor am I
paid by any of the companies that are
used in this presentation.
Everyday as eye care professionals we
see strange and unusual cases that we
don’t expect.
 With instrumentation and technology we
can explain some of these interesting
cases.
 Today we will review some cases that I
have seen over the past year that make
you stop and say UMMMMM.

43 y.o. white female presents for her
annual comprehensive eye exam.
 Patient is new to our office and has no
previous records with her today.
 Chief complaint – Glasses don’t feel
strong enough, needs an updated Rx.
 No other complaints noted.

BCVA 20/20 OU
 Slit lamp exam was unremarkable OU
 IOPs normal OU
 Visual Fields unremarkable OU
 Fundus photo appears normal OU

Optic Nerve Head Drusen
 Calcification of protein-like structures in
the optic nerve.
 Can be on the surface or buried deep
within the nerve.
 Frequency about 1% of people.
 75% will have some sort of visual field
defect.

Treatment – majority of cases we
monitor.
 IOP is very important.
 Neuroprotective agents like Alphagan
can be used to protect the nerve as well
as reduce IOP.

24 y.o. wf presents for her annual
contact lens exam
 Chief complaint – out of contacts
 Patient is new to the office
 No other complaints

Entering VAcc = 20/25 OD and 20/25 OS
 Visual Fields were normal
 IOP normal
 Fundus imaging normal
 Refraction BCVA = 20/25 OU
 WHY?


Slit lamp exam
Dense persistent pupillary membranes
OU
 The human iris is closed in early
embryonic development.
 The pupil doesn’t open until later stages
of development.
 In some people, the iris doesn’t
completely open leaving iris strands.

Treatment – None required
 Vision of 20/25 OU would not warrant
surgical intervention.
 Monitor with yearly exams, caution
dilating could cause an iris tear.

54 y.o. wm presents as a walk in to the
office.
 Chief complaint – he thinks there is
something on his contact lens OD. Says
he has rinsed it multiple times but the
spot won’t go away.
 Patient was in a hurry didn’t want to do
any testing just wanted a new contact.

With a lot of convincing I was able to get
the patient to agree to a couple tests.
 Entering VA 20/20 OD
 External slit lamp exam was normal
contact appeared clean and clear of
damages.
 Screening visual fields showed superior
nasal defect
 Patient was dilated (he was very
unhappy)


Optos and 20 D BIO performed
Inferior temporal horseshoe tear of the
retina
 Treatment – refer to retinal specialist for
vitrectomy and scleral buckle.
 Outcome - 20/20 vision OD after
secondary cataract surgery.

42 y.o. wf presents for her annual
comprehensive eye exam
 Chief complaint – needs more contacts
 New patient to our office unremarkable
medical and family history
 No other complaints

Entering visual acuity 20/20 OU c CL
 Visual fields normal OU
 Fundus photos normal OU
 Initial external slit lamp exam reveals
what appears to be a shiny debris on her
contact lens.
 Had pt remove CLs
 Secondary external slit lamp exam
revealed


Upon further inquiry of patient history it
was discovered that she is a dental
assistant who doesn’t wear her contacts
when she works and doesn’t wear safety
glasses when the dentist is drilling out
fillings.
Metallic dental filling material
embedded in cornea
 Treatment – none required material will
sluff off on its own.
 Recommended safety glasses at work.
 Followed up in 3 months – cornea was
almost 100% clear.

40 y.o. wm presents for medical exam
 Chief complaint – doesn’t feel like he is
seeing well OS
 Patient is an airline pilot thinks he may
need glasses
 New patient to the office however I
have know patient for years

Entering visual acuity sc 20/15 OD and
20/30 OS.
 Refraction – no improvement
 AR showed +0.50 OS
 Visual field was normal OU
 External slit lamp was unremarkable
 Fundus photo at first glance
unremarkable.


Without any obvious signs to explain his
symptoms I decide to look at the retinal
photos a little closer.
Upon further inquiry of patient history it
was discovered that he is currently going
through recertification for his pilots
license and has been under a lot of
stress.
 Need to do an OCT!

Central Serous Retinopathy OS
 Often seen is 40 + men with high stress
jobs and type A personalities.
 Treatment – none. Generally resolves on
its own.
 Follow-up 3 months vision returned to
20/15 OS.

34 y.o. wf presents for annual
comprehensive eye exam
 Chief complaint – “Doctor, my husband
thinks I am crazy”
 When we go on vacation I lose the
ability to read?????????????

Entering visual acuity 20/20 OU
 Visual field normal OU
 External slit lamp exam normal OU
 Fundus photos normal OU
 OCT normal OU
 NKDA
 No medications

Doesn’t matter if they drive or fly
 No heart or blood pressure problems
 No history of stroke or TIAs
 No headaches
 No aura
 WAIT…….Flash back to 2001…….

In 2001 I went to an IUPHARM convention
in San Francisco.
 While I was there I went on a wine tour
through Napa Valley.
 About half way through the tour I could
no longer read the wine menus (no I
wasn’t drunk…lol)
 So I did what any one would do in this
situation


Upon further inquiry of patient history it
was discovered that the patient wears
scopolamine patches for motion sickness
when she travels.
Pharmaceutical cycloplegia
 Not crazy, just dilated

Treatment – recommended patient talk
to PCP about switching her to a different
motion sickness medication.
 Follow-up yearly.

12 y.o. Asian Female present for annual
comprehensive eye exam.
 Chief complaint according to mom,
every time she looks at knives she gets
shooting pains in her eyes.
 WHAT?????????????

Entering visual acuity 20/20 OU
 Confrontation fields normal OU
 PERRL –APD
 Fundus photo normal OU
 OCT normal
 External slit lamp exam revealed lower
eye lid turned in OU.

Severe entropion with trichiasis OU
 Treatment – refer to oculoplastic surgeon
for eye lid retraction
 Follow up in 3 months – no more
problems looking at knives.
