Case : The glaucoma consult Case: The Glaucoma Consult Case: The Glaucoma Consult Case : The Glaucoma Consult Case : The weekend call you don t want

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Hugh Day
5 years ago
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1 Case : The glaucoma consult CC: second opinion on glaucoma HPI: OU/ 1 mos/optometrist thinks I have glaucoma/ no Rx yet / no POAG family hx 62 BM, VA OD = 20/40, VA OS = 20/30 NS +1 IOP: 20 11:00 am OU Pach: 574u VF OD: reliable / abn PD / hemifield zone defect VF OS: reliable / abn PD / hemifield depression OCT: CDR 0.8 OD / 0.70 OS Abn quadrant defects, abn RNFL OU, Abn cup volume OD Case: The Glaucoma Consult IMP: POAG OU Plan: Start latanoprost 0.005% qhs OU, RTO 3 weeks Next visit IOP is 19/19..and tolerated RTO 4 months LOOK AGAIN Case: The Glaucoma Consult IMP: VF are suggestive of a chiasmal compressive lesion, most likely pituitary adenoma ROS: negative HA: negative Call PCP and arrange for MRI of brain Results massive supracellar pituitary adenoma with extension and bone erosion Plan - neurosurgery Case : The Glaucoma Consult Pearls Optic nerve cupping can be glaucomatous or non-glaucomatous Tumors involving the visual pathways will cause VFDs Most glaucoma VFDs are nasal Too much information can be misleading Case : The weekend call you don t want CC: lost vision since yesterday HPI: OS/1 day/constant/decreased vision Cat-IOL/OS post op day 3, Cipro qid & prednisolone qid, no pain Offered to bring to office; pt declined; follow up appointment moved up to Monday (4 days after surg) 67 F, VA OD = 20/40, VA OS = LP, was 20/80 dilated at same day post-op visit PCIOL OS IOP: 10 OU Hypopion inferiorly in anterior chamber

2 Case : The weekend call IMP: exogenous endophthalmitis OS PLAN: Retina consult STAT, NPO, schedule for same day pars plana vitrectomy, Early Vitrectomy Study (EVS) LP = PPV, better than LP = AC tap, Vit tap and injection AC tap/culture, vitreous tap/culture, intravitreal antibiotic (vancomycin & ceftazidime), intravitreal steroid (dexamethasone) Switch to different topical antibiotic (moxifloxacin) Tests results Bacterial culture low growth of staphylococcus Sensitivity resistant to ciprofloxacin, sensitive to others Post-operative course was resolution of infection and corneal edema, followed by another retina procedure to wash-out vitreous for heavy floaters/opacities Uncorrected VA of 20/30 Case: The Weekend Call Pearls Presents on day 3 to week 3 after eye surgery Common complaints are decreased vision after initial improvement, and pain Incidence is 0.01% of all cataract surgeries Start topical antibiotics 1-3 days prior to surgery Then betadine lavage at surgery (antiseptic) Prognosis often poor if delay in diagnosis VA = 20/40 in 75% if identified early and aggressively treated with antibiotics that work We are running out of antibiotics!!! Case : The Blurry after LASIK CC: Blurry HPI: OU/4y/mod/LASIK OU 14 yrs ago 33 F, Meds: none MR OD: x65 = 20/30 MR OS: x105 = 20/25 IOP: 14OU AC: D&Q Color: OD 13/15, OS 9/15 Retina: white lesions punched out, foveal atrophy OCT: OD 381u, OS 375u +CME, +SRF IVFA: cap drop out, multiple vascular staining and leakage, petalloid macular leakage IMP Retinal vasculitis OU, etiology unknown PLAN PE with PCP Labs CBC w differential, C-reactive protein, Anti-nuclear antibody,

3 Angiotensin converting enzyme, Rapid plasma reagin, erythrocyte sedimentation rate, metabolic panel Consult retina order Brain MRI IMP Retinal vasculitis OU, etiology unknown PLAN Subtenon s depo-medrol OS CBC w differential - nl C-reactive protein - nl Anti-nuclear antibody - nl Angiotensin converting enzyme - nl Rapid plasma reagin - nl Erythrocyte sedimentation rate nl Metabolic panel - nl Brain MRI posterior basilar vasculitits (MS?) OCT pearls IVFA and OCT both reach same conclusion Both tests are abnormal No surprises CC: Had cataract surgery and cant see HPI: OS/1m/Cat-IOL/OD gave 2 new glasses, likes one better than other 80 F, VA OD = 20/30, VA OS = 20/40+ at one week post ops, admits to one drop per day? PCIOL OU IMP Pseudophakic OU PLAN Predforte tid OU, release to optometrist for continued care, emphasis on correct drug dosing CC: Had cataract surgery and cant see HPI: OS/1m/Cat-IOL/OD gave 2 new glasses, likes one better than other Now after one month VA OD = 20/200 OS Hands me the steroid prescription (never filled) PCIOL OU IMP Pseudophakic CME OS? OCT: OD 311u, OS 510u Plan: Retina for IVK (failure with drop compliance) OCT Pearls OCT demonstrates abnormal thickness OS IVFA not needed to confirm diagnosis Pseudophakic CME in this case related to inflammation from noncompliance with steroidal eyedrops

4 Treatment with topicals may be beneficial but with questionable ability to comply, intraocular depot drug is the best choice Case: The Big Black Spot CC: Black spot HPI: OS/2 days/constant/decreased vision Cat- IOL/OU ROS: recent diagnosis Hairy cell leukemia, chemotherapy and spleenectomy, now anemic 76 F, VA OD = 20/40, VA OS = 20/400, was 20/25 two months prior PCIOL OU IOP: 10 OU Fundus: peripheral small retinal hemorrhages OU, thick macular hemorrhage OS, schisis cavity inf OS OCT: 286u/333u Case: The Big Black Spot IMP: Leukemic Retinopathy PLAN: Retina consult TPA & gas to displace macular hemorrhage Continue oncologic care Follow-up visit one month RE 20/25 LE 20/30 No retinopathy noted! Case: The Leukemic Retina Pearls OCT demonstrates abnormal thickness OS OCT clearly shows pre-retinal and intra-retinal nature of hemorrhages Prognosis often very good Case: Upper part missing 65yowm referred for AION CC: wavy things HPI: OD / 5 wks wavy / 2 wks upper part of vision missing / no pain / no flashes Meds: MV, OM3, ASA NKDA BVA: HM OD, 20/25 OS PERRL No APD EOM: Full EXT: W&Q SLE: NS 2 OU IOP: 15 OU Fundus: as pictured What is the likely diagnosis? 1. Retinal tear/detachment 2. Lattice degeneration 3. Vitreous hemorrhage 5. Benign choroidal nevus 6. Malignant melanoma What is the best course now? 1. Retina consult, surgery

5 Ocular Oncology 3. PCP Case: Fell & Hit head 89yowm MD referred for RD CC: retina problem HPI: OS / 1 wk / no pain / no flashes / no vision loss Meds: levothyroxine, OM3, garlic NKDA BVA: 20/50, 20/60 OS PERRL No APD EOM: Full EXT: W&Q SLE: PCIOL OU IOP: 15 OU Fundus: as pictured What is the likely diagnosis? 1. Retinal detachment 2. Choroidal detachment 3. Vitreous hemorrhage 5. Macular degeneration 6. Malignant melanoma What is the best course now? 1. Retina detachment surgery 2. Ocular Oncology 3. IVFA and anti- VEGF 4. No Rx; observation Case: 10 days of bad vision 49yowm OD referred for VO CC: Can t see for 10 days HPI: OD / 10 days / no pain / no flashes Meds: amlodipine, OM3, ASA NKDA BVA: CF, 20/20 OS PERRL No APD EOM: Full EXT: W&Q SLE: NL OU IOP: 13 OU Fundus: as pictured BP 190/105 What Options Are Available Now? PCP for immediate assessment of HTN (or ER) Intravitreal steroids Intravitreal Anti-VEGF Focal grid photocoagulation RIDE/RESOLVE studies Lucentis for ME Ozurdex implant

DISCLOSURE: What to do? 2/22/2016

DISCLOSURE: What to do? 2/22/2016 DISCLOSURE: Dr. Joseph Sowka is a member of the Speakers Bureau for Alcon Laboratories, and Carl Zeiss Meditec. He is on the advisory boards for Alcon, Zeiss, and Allergan. He is a consultant for Alcon.