Grand Rounds Clinical Cases from Alex D. Gibberman, O.D. Harpers Point Eye Associates

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Kory Miller
6 years ago
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1 Grand Rounds Clinical Cases from 2016 Alex D. Gibberman, O.D. Harpers Point Eye Associates

2 Relevant Financial Interests -none

8 Case 1: 54 year old African American Female CC: Noticed a green line in her central vision in her right eye since last week. says it hasn t gotten better or worse but is constant Went to urgent care last week. Mild pain when looking up OD, worsening (-)discharge (-)photophobia (-)noticeable vision loss (-)redness (-)tearing/itch/burn (- )floaters Entering VA: OD 20/25-2 OS 20/20

9 Systemic History Hypertension, controlled with Lisinopril Hernia surgery: 1.5 months ago, finished all meds related to this (-)pertinent family history Otherwise feels healthy, no other meds

10 Last Years 30 degree Field

11 This Years 30 Degree Field

12 To Recap 54 years old Mild pain OD Inferior altitudinal defect OD mainly Green flashes OD 20/25- OS 20/20 No pertinent health history

13 Differentials Retinal tear/detachment Ocular migraine Vascular events BRAO/BRVO Neurological Optic neuritis NAION

14 Pertinent Clinical Findings VA: OD 20/25-2 OS 20/20 Pupils: trace APD OD? EOM: smooth and full, moderate pain on upgaze OD Chamber: quiet OU Lens: clear OU Vitreous: (-) Shafer s sign Intact and quiet Macula: flat OU (-)sub retinal fluid (-)macular edema (-)pigment change Vessels: intact OU (-)hemorrhages 2/3 AV ratio

15 Fundus OU

16 Optic neuritis (retrobulbar) NAION AION/GCA Pain YES NO YES Disc edema NO YES YES Disc hemorrhage NO YES YES Vision loss Over 1-10 days acute acute Acuity at onset 20/25-no light perception 50% are better than 20/60 No light perception Field defect Enlarged blind spot altitudinal Complete loss

17 Updated Differential Atypical Ocular Migraine Retrobulbar optic neuritis

18 MRI Results: (+)optic neuritis OD (+)white matter lesions in brain

19 Diagnosis:Optic Neuritis In this case was the presenting sign of Multiple Sclerosis Usually PAINFUL decrease in vision, anywhere from 1 line to light perception over hours to 10 days. Retrobulbar means that initially nerve likely will NOT be swollen or pale. Eventually will become pale, usually temporally

20 Treatment In this case, none. Follow up with neuro/pcp to manage MS Steroids? Optic neuritis treatment trial (ONTT) IV steroids followed by oral steroid, OR Nothing at all

21 Prognosis VA should improve steadily over weeks May reoccur at any time, depends on underlying cause, if one exists in either eye APD, partial pallor, color defect, field defect all may remain Educate patient! May be able to initiate tx if caught early enough

22 Case 2 58 year old Caucasian Male CC: floaters OS x 3 months, larger floater x 1 month OD Flashes OU but > OS Denies pain, discharge, photophobia Entering VA OD: 20/20 OS 20/25+

23 Oh yah, and this

24 So floater pellets Physostigmine Same stig mechanism used to treat myasthenia Parasympathomimetic, aka increases acetylcholine activity Same mechanism of action as. Pilocarpine Causes miosis Potential side effect of

26 B scan OD

27 B scan OS

28 30 degree threshold fields

29 Diagnosis: Bilateral Retinal Detachment What happened? Presence of traction (floater) + constant pharmaco induced miosis (constant ciliary muscle contraction) = not a good outcome Edge of detachment affected macula but starting vision was still around 20/20. - relatively emergent

30 Treatment Turns out there was one giant tear OD and multiple tears OS related to the RD Pars plana vitrectomy OU Silicon oil used OD due to giant tear. Phaco to be performed at time of oil removal OD(oil left in place for 3 months)

31 Prognosis According to the surgeon, the repairs went well and retina was reattached OU NO guarantee that retina will stay attached once oil removed Refraction following phaco hasn t occurred yet but expect decent vision assuming well attached. Likely not perfect considering macular involvement.

33 Case 3: 80 yr old Afr.American male CC: woke up in middle of the night and vision was gone in the left eye Denies any pain, photophobia, redness, flashes or floaters Entering Best corrected VA OD 20/30 OS Count 2 feet

34 Systemic History/meds (+)Leukemia (+)multiple myeloma (+)Hypertension Past Hx of prostate cancer (+)Hx of radiation and chemo past year Current Meds: dexamethasone, multivitamin, carfilzomib, losartan

35 Differentials: Unilateral Sudden Vision Loss Neuro AION/Giant cell NAION Optic neuritis Vascular CRVO/CRAO/BRAO/BRVO Retina Detachment maculopathy

36 OCT Macula OD

37 OCT Macula OS

38 30 Degree Threshold Field

39 Fundus OS

40 But if this is a CRVO, where is all the blood and thunder? And why is the vision so poor?

41 Fundus OS

42 Diagnosis:CRVO + cilioretinal artery occlusion! NON ischemic CRVO (better vision) Would normally expect improving vision Cilioretinal artery occlusion (not good vision) Macula involved Prognosis depends on extent of parafoveal capillary net involved

43 Hypercoaguable State Central retinal artery and vein share common sheath Virchow triad Vessel damage Stasis Hypercoaguability/thrombosis This patient had leukemia and multiple myeloma

44 Treatment Avastin injections For edema Alphagan TID Neuroprotection Lower IOP = better perfusion Carotid embolic workup Doppler/echo Lifetime control of vascular risk factors Neovascularization risk = LOW

45 Case 4 45 yr old AA female. New patient. CC: vision in left eye became poor around 6 months ago. Was never seen. Decided to get it checked today. Ocular history: High myope (-24.00D OU) Strab Sx OD in childhood. Longstanding alternating Esotrope

46 History/Vision No medications Denies HTN, DM, Cholesterol Entering best corrected VA OD 20/40-2 OS CF

47 Pertinent Anterior Segment Cover Test: Constant Alternating ET, large angle Ductions OD smooth and full OS complete abduction deficit, stops at midline

48 Differentials Was vision loss sudden or gradual Patient has no idea but thinks was pretty quick High myopia Detachment Photoreceptor atrophy/retinal atrophy Break in bruch s membrane 6 th nerve palsy does NOT relate to high myopia

49 Fundus OS

50 Online example

52 Lacquer Crack High myope Tilted disc/ppa Thin, stretched retina cracks Can lead to CNVM, as in this case TREATMENT Focal laser or anti VEGF if CNVM Otherwise no treatment

53 6 th nerve palsy? Physical to rule out vascular Rule out thyroid Expect resolution in 90 days if vascular MRI if not resolved

54 Scleral s

55 Who benefits? Just about anyone and everyone Keratoconus/other ectasia Post surgical (LASIK, RK) Post transplant High refractive error scarring Dry eye patients Still recommend restasis/xiidra/doxy Old people just kidding

56 Appointments Visit 1: consult, topography, pachymetry 15 minutes Visit 2: The fit 1 hour Visit3: Dispense, Insertion/removal training 1 hour

57 Setup a Work Station

65 Scleral Case 1 36 year old female, keratoconus OS>OD Previously wore soft lenses Best spec Rx: OD 20/30- OS 20/100 Corneal Striae OU, scarring OS Pachs: OD 470um OS 403um

66 OD OCT with lens

67 OS OCT with lens

68 With Sclerals OD 20/30+ OS 20/30 (improved from 20/100) Happy patient

69 Scleral case 2 63 year old keratoconus Had transplant in OS only Transplant zone clear but not smooth OD very mild Best corrected spec Rx OD 20/20 OS 20/100 Fit with Maxim 16.4 diam lens MF OS only. Inverse design

70 OS OCT with lens

71 With Multifocal Sclerals OD 20/20 OS 20/20 OU 20/20 distance and near Happy Patient Happy Cornea specialist Happy me

72 Final examples

74 THANKS!

Neuro-Ocular Grand Rounds Anthony B. Litwak,OD, FAAO VA Medical Center Baltimore, Maryland

Neuro-Ocular Grand Rounds Anthony B. Litwak,OD, FAAO VA Medical Center Baltimore, Maryland Dr. Litwak is on the speaker and advisory boards for Alcon and Zeiss Meditek COMMON OPTIC NEUROPATHIES THAT CAN