Physicians share reports of insomnia-inducing complex cases.

Size: px

Start display at page:

Download "Physicians share reports of insomnia-inducing complex cases."

Magdalene Wilcox
5 years ago
Views:

Unfortunately, o i loing. There are many patient whoe peronal cenario, take of urgery, and potoperative coure linger indelibly in my memory.

1 Phyician hare report of inomnia-inducing complex cae. BY ANAND MANTRAVADI, MD; LINDA HUANG, MD; TA CHEN PETER CHANG, MD; AND SAHAR BEDROOD, MD, PHD WINNING AND LOSING By Anand Mantravadi, MD V ince Lombardi once aid, Winning i habit. Unfortunately, o i loing. There are many patient whoe peronal cenario, take of urgery, and potoperative coure linger indelibly in my memory. Sometime, econd-gueing deciion and wihing for factor beyond my control to be within my control have led to leeple night for me. A VISUAL PROFESSIONAL Several year ago, I encountered a patient who wa a former curator of an art mueum and an avid artit himelf. He had retired from hi role at the mueum and moved hour away from the city when he began to oberve difficulty in hi viion. Upon preentation, hi viual acuity wa 38 GLAUCOMA TODAY JULY/AUGUST /30 in each eye and, unfortunately, he had far advanced glaucomatou dic damage in both eye with evere field lo. What happened next i a cenario we all ee far too often. Whether due to peronal circumtance, ditance, inability to get ride to the office, or other factor, the patient topped following up regularly. He returned 1 year later with no light perception in hi left eye and with 20/50 viual acuity and uncontrolled IOP in hi right eye. I urged him to proceed with urgery, and he underwent trabeculectomy with mitomycin C in hi only ighted right eye. Hi immediate potoperative coure wa unremarkable, and by a few month after urgery he wa off topical medication and eemed table. However, follow-up wa again an iue, and, nearly a year later, the patient returned, aying, Doctor, I m jut not eeing well. The viion in hi better-eeing eye had declined to light perception, and he had a grade 3 flat anterior chamber, a white cataract, a large bleb, and an IOP of 7 mm Hg. B-can ultraonography did not demontrate any choroidal effuion. The deciionmaking at thi point wa clear, and I recommended that we proceed immediately with cataract extraction and bleb reviion, which we did (ee Watch It Now). GREAT STAKES The patient peronal tory, what he had at take, and the immene trut he placed in me definitely had an impact on me. He had lived alone, wa fiercely independent, and, a an artit, wa a viual profeional and thi wa all gone, and fairly rapidly at that. Thi certainly elevated the urgical take. The urgery proceeded according to plan, but the viual outcome wa indeed uncertain. The patient eventually improved to 20/40 viual acuity, with IOP ettling in the low teen off medication. He regained independence and the ability to cook for himelf, and he reumed painting. Another artit, the patient friend, ent me picture of my patient art becaue he wa too humble to hare. What he could create depite hi impairment wa incredible.

WATCH IT NOW Complex Cataract Extraction With Tranconjunctival Bleb Reviion DESPITE THE EVIDENCE THAT SHE IS LOSING HER SIGHT, SHE CONTINUES TO DOUBT THAT THE NEXT PROCEDURE WILL SOMEHOW WORK WHEN

LY/UPATNIGHT0818 SHIFTING PERSPECTIVES Trying to focu on what I can control rather than worrying about what I can t ha helped me to reduce my leeple night over the pat decade.

2 WATCH IT NOW Complex Cataract Extraction With Tranconjunctival Bleb Reviion DESPITE THE EVIDENCE THAT SHE IS LOSING HER SIGHT, SHE CONTINUES TO DOUBT THAT THE NEXT PROCEDURE WILL SOMEHOW WORK WHEN ALL OTHERS HAVE FAILED. BIT.LY/UPATNIGHT0818 SHIFTING PERSPECTIVES Trying to focu on what I can control rather than worrying about what I can t ha helped me to reduce my leeple night over the pat decade. It an exciting time to be a glaucoma pecialit, and the future of glaucoma care promie to bring afer modalitie and approache. However, our empathy and peronal invetment in our patient outcome are certain to till produce ome more leeple night ahead. UP AGAINST HELPLESSNESS By Linda Huang, MD We glaucoma pecialit have all pent countle hour thinking about our patient. Whether we are mulling over the bet coure of action or reflecting on what previouly went wrong, we all know that glaucoma management i hardly a traightforward endeavor. Many time, patient pat experience will guide our choice for their treatment coure, a wa the cae for thi patient. A LONG HISTORY An 85-year-old white woman preented with a long hitory of urgerie on her left eye. She had been diagnoed with peudoexfoliative glaucoma and underwent trabeculectomy in the left eye. The trabeculectomy unfortunately failed quickly, and a Baerveldt glaucoma implant (Johnon & Johnon Viion) wa inerted. The patient then developed late hypotony that did not repond to ligation of the tube hunt, and the drainage device wa explanted. Her IOP ubequently increaed, and an Ahmed Glaucoma Valve (New World Medical) wa placed. Depite injection of an OVD at the end of the urgery, on potoperative day 1 the patient had a hallow anterior chamber and hemorrhagic choroidal. Viual acuity in the eye wa light perception. The Ahmed device wa ligated, and the choroidal were drained. NEXT COURSE OF ACTION The patient wa ubequently referred to our clinic for management of her right eye, in which the IOP wa in the 50 mm Hg. She had undergone only cataract urgery in thi eye. I performed a trabeculectomy in the right eye, and laer uture lyi wa done potoperatively to titrate the IOP. Three week after the trabeculectomy, the patient IOP in thi eye wa in the midteen. It remained well controlled for approximately 3 year, when the urgical ite began to car and the IOP increaed into the mid-20 mm Hg. Topical medication were retarted, but the patient IOP increaed into the 40 mm Hg depite medical therapy. With the long urgical hitory and poor viion in her left eye, he wa reluctant to undergo inciional glaucoma urgery on her right eye. After many long dicuion, the patient agreed to proceed with cyclophotocoagulation. One week after the laer procedure, her IOP wa in the low 20 mm Hg. At 1 month, her IOP decreaed to 3 mm Hg, and he had a hallow anterior chamber and ignificant choroidal. With increaed teroid and atropine treatment, her IOP eventually increaed, along with reolution of the choroidal. At 5 month, however, her IOP increaed into the 30 mm Hg. Medication were retarted, and her preure fluctuated in the mid-20 mm Hg. It wa clear that the patient IOP wa not ufficiently controlled, a viual field teting howed progreion to a central iland. Surgical intervention wa readdreed. Given the hitory of hypotony in her left eye, I dicued implanting a valved drainage device, uch a an Ahmed Glaucoma Valve, in the right eye. To prevent early hypotony, the tube could be ligated and laer uture lyi performed at a later time. To date, however, at each viit, the patient continue to be fearful of urgery, a he previouly experienced immediate lo of viion with devatating complication in her left eye. Depite the evidence that he i loing her ight, he continue to doubt that the next procedure will omehow work when all other have failed. I ene that he ha already given up. JULY/AUGUST 2018 GLAUCOMA TODAY 39

Courtey of Ta Chen Peter Chang, MD CURRENT OBJECTIVES Currently, at each viit, I m not only checking the patient preure and dicuing her urgical option, I am alo trying to revere her ene of helplene.

ADDING INSULT TO INJURY By Ta Chen Peter Chang, MD An 8-day-old infant preented with a left-ide port wine birthmark and aociated buphthalmo and corneal opacity (Figure 1).

IOP meaured 35 mm Hg in the left eye, and B-can ultraound revealed moderate to marked cupping and a thickened choroid.

By 6 week later, the cornea had cleared (Figure 2), but the eye axial length had increaed out of bound of normal ocular growth curve, and the IOP remained elevated at 27 mm Hg Figure 1.

3 Courtey of Ta Chen Peter Chang, MD CURRENT OBJECTIVES Currently, at each viit, I m not only checking the patient preure and dicuing her urgical option, I am alo trying to revere her ene of helplene. If I am able to convince her to proceed with urgery, perhap it will be the lat opportunity to ave her eye. That will certainly keep me up at night. ADDING INSULT TO INJURY By Ta Chen Peter Chang, MD An 8-day-old infant preented with a left-ide port wine birthmark and aociated buphthalmo and corneal opacity (Figure 1). Glaucoma econdary to the port wine birthmark wa upected, and an examination under anetheia (EUA) wa performed. IOP meaured 35 mm Hg in the left eye, and B-can ultraound revealed moderate to marked cupping and a thickened choroid. During the ame EUA eion, I performed the firt tage of a Baerveldt device implantation and a circumferential ab externo trabeculotomy uing an illuminated microcatheter. By 6 week later, the cornea had cleared (Figure 2), but the eye axial length had increaed out of bound of normal ocular growth curve, and the IOP remained elevated at 27 mm Hg Figure 1. Color external photograph demontrate a large left-ide port wine birthmark and aociated buphthalmo. The left cornea wa enlarged and hazy. depite treatment. The econd tage of the Baerveldt implantation wa performed with the tip of the tube in the anterior chamber, and two cleral window were created in anticipation of choroidal effuion. Eight week later, on repeat EUA, the patient IOP wa 15 mm Hg, and I noted a large bullou exudative retinal detachment without concurrent choroidal effuion (Figure 3). Following conultation with the pediatric vitreoretinal ervice, the parent declined external beam radiation treatment and opted intead for intravitreal anti- VEGF injection. Over the next 15 month, multiple injection were required a the retinal detachment waxed and waned but never completely reolved. Then, approximately 6 week after the lat intravitreal injection, the child developed redne of the eye, lid welling, and decreaed oral intake. EUA revealed intact conjunctiva and hypopyon in the anterior chamber. The patient wa diagnoed with evere endophthalmiti (Figure 4). Vitreou biopy wa performed and intravitreal antibiotic injection were given, and the culture wa negative. Over the following 2 month, the retina became totally detached, and the eye wa chronically inflamed and painful. The eye wa enucleated hortly thereafter. Six month later, the child developed photophobia and a granulomatou anterior chamber reaction in her other eye. Dilated fundu examination revealed Dalen-Fuch nodule upiciou for ympathetic ophthalmia (Figure 5). MY THOUGHTS Thi cae wa particularly challenging for everal reaon. Firt, the patient i an infant. Second, the glaucomatou eye wa buphthalmic and had a large choroidal hemangioma, which make any type of glaucoma urgery hazardou. Third, Figure 2. Color anterior egment and fundu photograph demontrate bilaterally clear cornea and nonglaucomatou optic dic. Figure 3. Color fundu photo of the left eye. A large, bullou exudative retinal detachment can be noted. the abnormal choroidal anatomy wa uch that, even with a modet decreae in IOP and concurrent creation of cleral window (the child wa never hypotonou), recalcitrant exudative retinal detachment developed. Fourth, adding inult to injury, the remaining eye became the unwitting victim of thi aga and developed preumed ympathetic ophthalmia. Lat, and perhap the mot harrowing part of all, I do not know what I hould, would, or could have done differently. Some anecdotal literature upport the ue of ytemic propranolol in Sturge-Weber yndrome patient to decreae the rik of choroidal vaculature related complication, which I believe would have been worth a try. Courtey of Ta Chen Peter Chang, MD Courtey of Ta Chen Peter Chang, MD 40 GLAUCOMA TODAY JULY/AUGUST 2018

Courtey of Ta Chen Peter Chang, MD Figure 4. Color anterior egment photograph and echographic image demontrate turbid aqueou and hypopyon in the anterior chamber.

Color anterior egment photograph demontrate granulomatou anterior chamber reaction, and fundu photograph how Dalen-Fuch nodule.

and hypertenion, preented with decreaed viion in both eye and a bulging right eye for 2 month. He wa diagnoed with glaucoma 4 year earlier but had been noncompliant with hi eye drop.

Anterior egment examination wa notable for ignificant proptoi of the right eye with conjunctival chemoi, poor ocular urface, lid edema, and eyelid flare conitent with thyroid eye dieae.

4 Courtey of Ta Chen Peter Chang, MD Figure 4. Color anterior egment photograph and echographic image demontrate turbid aqueou and hypopyon in the anterior chamber. The vitreou wa filled with debri with extenive membrane formation. Figure 5. Color anterior egment photograph demontrate granulomatou anterior chamber reaction, and fundu photograph how Dalen-Fuch nodule. COMPLICATED BY THYROID EYE DISEASE By Sahar Bedrood, MD, PhD A 40-year-old man with a new diagnoi of hyperthyroidim with recent acute thyroid crii, and with previouly exiting diabete mellitu type 2 and hypertenion, preented with decreaed viion in both eye and a bulging right eye for 2 month. He wa diagnoed with glaucoma 4 year earlier but had been noncompliant with hi eye drop. He wa recently retarted on maximal medical therapy and wa referred to our center for IOP control. On examination, hi viual acuity wa 20/50 OD and 20/30 OS, and IOP wa 43 mm Hg OD and 22 mm Hg OS. Anterior egment examination wa notable for ignificant proptoi of the right eye with conjunctival chemoi, poor ocular urface, lid edema, and eyelid flare conitent with thyroid eye dieae. Poterior egment examination of the right eye howed a 0.85 cup-todic ratio with a pale remaining rim; the macula had an epiretinal membrane with multiple cotton wool pot near the arcade, attenuated veel, and normal periphery. Poterior egment examination of the left eye howed a 0.99 cup-to-dic ratio, a flat macula, and attenuated veel but wa otherwie normal (Figure 6 and 7). Figure 8 how Humphrey viual field (Carl Zei Meditec) of the right and left eye. The right eye howed nonpecific uperior defect, and the left eye had a central iland of viion remaining. CLINICAL COURSE AND TREATMENT The patient underwent trabeculectomy of the right eye due to high IOP on maximal medical therapy. In the immediate potoperative period, he had a diffue bleb, IOP in the low teen, and preervation of baeline viual acuity. However, around potoperative week 2, the right eye developed ignificant chemoi and proptoi from reactivation of hi thyroid eye dieae and orbital congetion that required immediate pule therapy with intravenou methylpredniolone odium, followed by weekly intravenou methylpredniolone odium. The orbital congetion and preure were puhing hi globe forward and encouraging outflow through the trabeculectomy ite, cauing a hallow anterior chamber. At potoperative week 4, viual acuity wa reduced to hand motion, and radiation of the orbit wa performed to reduce the orbital congetion (Figure 9 and 10). At potoperative week 8, orbital decompreion wa performed endocopically, which improved the proptoi and chemoi. At 5 month after initial preentation to our center, the proptoi in the right eye wa improved, the IOP wa 14 mm Hg, the chamber continued to be moderately hallow with peripheral choroidal, and viual acuity wa hand motion with a dene poterior ubcapular cataract. After cataract extraction, the patient viual acuity remained table at 20/800. Courtey of Sahar Bedrood, MD, PhD MULLING IT OVER Thi cae truly kept me up at night becaue I quetioned the timing and neceity of glaucoma urgery in a patient with advanced glaucoma and evere thyroid eye dieae. Thi cae had me mulling over the following quetion: Should one perform glaucoma urgery in a patient with active thyroid eye dieae and advanced glaucoma with high IOP? Would conjunctival urgery incite inflammation of hi thyroid eye dieae? Would a minimally invaive approach reduce the rik of hypotony, or would it fail given the tage of glaucoma and level of inflammation? Should I operate on the other eye that ha only a central iland of viion remaining and rik aggravating the thyroid dieae in that eye? Should I have operated on that eye firt? Now that the proptoi ha improved, hould I remove the cataract? What eye meaurement would I ue for the IOL? Should I conider draining the Figure 6. Photograph of the optic nerve OS at preentation; OD looked imilar. JULY/AUGUST 2018 GLAUCOMA TODAY 41

Courtey of Sahar Bedrood, MD, PhD Figure 9. CT can of the patient orbit prior to radiation and decompreion. Figure 7.

B-can of the orbit at potoperative week 4 after trabeculectomy, howing choroidal and tenting of the clera econdary to orbital congetion. Figure 8.

TAKEAWAYS Overall, I took away a few pearl from thi cae. Firt, avoid filtering urgery in a patient with active thyroid eye dieae.

Additionally, if a patient ha active thyroid eye dieae and glaucoma urgery i required, conider pretreatment with intravenou methylpredniolone odium pule doing prior to glaucoma urgery, and

n SAHAR BEDROOD, MD, PHD n Glaucoma and Cataract Surgeon, Acuity Eye Group, Lo Angele, California n Clinical Aitant Profeor, USC Roki Eye Intitute, Lo Angele, California n aharbedrood@gmail.

5 Courtey of Sahar Bedrood, MD, PhD Figure 9. CT can of the patient orbit prior to radiation and decompreion. Figure 7. OCT (Spectrali, Heidelberg Engineering) of the retinal nerve fiber layer in the right and left eye. A B Figure 10. B-can of the orbit at potoperative week 4 after trabeculectomy, howing choroidal and tenting of the clera econdary to orbital congetion. Figure 8. Humphrey viual field (Carl Zei Meditec) of the right (A) and left (B) eye. choroidal in a patient with poterior preure, a hallow chamber, and aggreive thyroid eye dieae? TAKEAWAYS Overall, I took away a few pearl from thi cae. Firt, avoid filtering urgery in a patient with active thyroid eye dieae. If the inflammation i not controlled, there are rik of choroidal effuion, hallow anterior chamber, hypotony, and failure of the trabeculectomy due to inflammation. Additionally, if a patient ha active thyroid eye dieae and glaucoma urgery i required, conider pretreatment with intravenou methylpredniolone odium pule doing prior to glaucoma urgery, and follow with weekly doing of methylpredniolone odium during the potoperative period. n SAHAR BEDROOD, MD, PHD n Glaucoma and Cataract Surgeon, Acuity Eye Group, Lo Angele, California n Clinical Aitant Profeor, USC Roki Eye Intitute, Lo Angele, California n aharbedrood@gmail.com n Financial dicloure: None TA CHEN PETER CHANG, MD n Aociate Profeor of Clinical Ophthalmology and Pediatric at Bacom Palmer Eye Intitute in Miami, Florida n t.chang@med.miami.edu n Financial dicloure: None relevant LINDA HUANG, MD n Private practice, The Glaucoma Intitute of Northern New Jerey in Rochelle Park n lindayhuangmd@gmail.com n Financial dicloure: None relevant ANAND MANTRAVADI, MD n Glaucoma Phyician and Surgeon, Philadelphia, Pennylvania n Glaucoma Specialit, Will Eye Hopital, Philadelphia, Pennylvania n Financial dicloure: Conultant (Allergan, Glauko); Speaker (Glauko) 42 GLAUCOMA TODAY JULY/AUGUST 2018

PREVIOUS EIGHT-INCISION RADIAL KERATOTOMY

PREVIOUS EIGHT-INCISION RADIAL KERATOTOMY Trying to fix a refractive urprie after cataract urgery. BY KARL G. STONECIPHER, MD; JACK T. HOLLADAY, MD, MSEE, FACS; DAVID COOKE, MD; BRET L. FISHER, MD; AND