9/21/2015 ANTERIOR SEGMENT GRAND ROUNDS WOULD YOU RATHER DEAL WITH THIS ALL OR DEAL WITH THIS? CASE #1. No financial disclosures DAY?

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1 ANTERIOR SEGMENT GRAND ROUNDS ANTERIOR SEGMENT GRAND ROUNDS No financial disclosures Brad Sutton, OD, FAAO IU School of Optometry Clinical Professor Indianapolis Eye Care Center WOULD YOU RATHER DEAL WITH THIS ALL DAY? OR DEAL WITH THIS? CASE # 1 The African Queen CASE #1 13 year old female recently arriving in US from Zimbabwe Complaint of chronically red, itchy, irritated eyes No significant medical history Taking Benadryl and Opcon-A 1

2 CASE #1 CASE # 1 Entering VA: 20/25 OD, 20/40 OS BCVA of : x / x /25 All entrance / preliminary testing unremarkable IOP 8 OU Patient reported that itching and discomfort were worse in Africa and had gotten better here. Still significantly symptomatic Anterior segment findings: Significant, 360 degree pannus and corneal neovascularization OU with scarring Very feint peripheral KP s OU, but no AC reaction Limbal bumps Iris nodules at pupillary margin OS and fine, refractile iris deposits OU No follicles in lower fornix OU Trace papillary reaction on upper tarsal plate OU Lenses clear OU CASE #1 CASE #1 Posterior segment: Anterior segment appearance. Mild anterior vitreal cells OU Fundus entirely normal Optic nerve normal, CD ratio.2 /.2 OU CASE #1 CASE #1 2

3 CASE #1 CASE #1 CASE # 1 So what do we have here? ANSWER! CASE #1 Limbal vernal keratoconjunctivitis and iris crystals Limbal Vernal Conjunctivitis is a subset of Vernal Conjunctivitis Limbal / Palpebral / Mixed Strikes mostly young females in Africa or other tropical countries Significant limbal findings but little upper plapebral involvement Severe itching, especially seasonally Horner s Trantas dots limbal Eosinophils Outgrown earlier than palpebral vernal Less associated systemic Atopic disease. Same IgE Need substantial antiinflammatory treatment 3

4 CASE #1 REGULAR VERNAL (VERNAL=SPRING) CASE #1 Iris crystals are very rare, with limited reports in the literature Most reports associated with chronic uveitis, mostly Fuch s heterochromic (90% unilateral) Believed to be Russel bodies : immunoglobulin in plasma cells?hypergammaglobulin Not a known component of limbal vernal This patient, however, experienced severe, chronic limbal inflammation First literature report of iris crystals in 1969, and only a few more since CASE #1 WHAT ABOUT A SYSTEMIC SYNDROME? Standard combination mast cell stabilizer / antihistamine drops provided no relief at all for this patient Generic Pred Forte QID during peak seasons and QD or BID the rest of the year works well Can t afford Lotemax Monitored for side effects, of course Should a uveitis work up be conducted? No other systemic symptoms Family has no health insurance so reluctant to pursue What about Fuch s heterochromic iridocyclitis? Hyperimmunoglobulin emia E, or Job syndrome First described in 1966 and expanded in 1972 Primary immunodeficiency disease Elevated serum IGE levels Recurrent skin abscesses, recurrent pneumonia, broad and course facial features, dermatitis Cases have been reported with associated limbal vernal conjunctivitis Iris crystals linked to increased immunoglobulin E? JOB SYNDROME JOB SYNDROME Pt was tested, and IgE levels were not consistent with Job syndrome Pt eventually underwent lab testing: only abnormal finding was a very high ESR What are the main causes of granulomatous uveitis in the US? Any problems with testing in the young? 4

5 Are you sure this picture is not upside down? 43 year old white male complaining of poor vision, pain, itching and watering OD History of RD OD due to trauma and subsequent repair 10 years prior Taking Naphcon-A and Hydrocodone BCVA of LP OD, 20 / 30 + OS IOP 50 OD, 15 OS EOM s normal VF normal OS Pupil unreactive OD, but reverse APD OS White appearance to upper half of iris with the naked eye Anterior segment evaluation. Eyelid edema OD Aphakic OD Solid, clear bubble in central AC OD with top half of chamber filled with a white substance 2+ Conj. injection OU reverse pseudohypopyon Anterior segment OS unremarkable Posterior segment OS unremarkable. No view of fundus OD Anterior segment appearance.. : LOOKS LIKE STYROFOAM! 5

6 ANSWER! So what have we here? Silicone oil emulsification Silicone oil tamponade is routinely used in complicated retinal detachment repair It must be removed later to avoid potential complications One complication is emulsification Emulsifcation basically means turning to soap Silicone oil turns in to smaller droplets of soap like material when surface tension decreases significantly This occurs when the oil contacts various biological products Proteins, lipids, and phospholipids Particularly HDL Occurs up to 50% of the time if oil is not removed Happens in the vitreal cavity, then droplets travel to the AC, especially in an aphakic patient inverse pseudohypopyon Leads to corneal endothelial toxicity and edema, band keratopathy, and increased IOP / glaucoma In a seeing eye, prompt removal is indicated 6

7 This patient was given cycloplega for ciliary spasm Also offered pressure lowering agents for comfort, but deferred Sent for consideration of surgical removal of emulsified oil Lost to follow up ANOTHER EXAMPLE OF EMULSIFICATION MORE AC OIL WITH AC IOL MORE AC OIL WITH AC IOL CASE #3 CASE #3 Should those things be there? 43 year old Caucasian male Complaining of distance blur OU HIV + (AIDS), Non- Hodgkins Lymphoma Truvada, Reyataz, Norvir cocktail for HIV History of CMV ocular infection 13 years prior Treated at that time with surgery Entrance testing normal OU BCVA 20 / 20 in each eye IOP 20 OD, 20 OS Anterior segment entirely normal OU 7

8 CASE #3 Posterior segment examination revealed epiretinal membranes OU, severe peripheral CR scarring OU Also revealed large, gelatinous, spherical mass in the bottom of each vitreal cavity Mildly mobile CASE #3 CASE #3 CASE #3 So what have we here..? ANSWER! Retained Vitrasert Gancyclovir Implants CASE #3 Vitraserts are implanted in the vitreal cavity of patients with CMV retinitis (mostly AIDS patients) Anchored to inferior sclera with sutures Far less common today than years ago due to better HIV medications 4.5 MG of gancyclovir Also contains magnesium sterate Coated in a capsule of polyvinyl alcohol and ethylene Releases gancyclovir at a rate of 1 microgram per hour for 6-8 months Then removed (usually!) 8

9 CASE #3 CASE #3 Drawback to use is that CMV is a systemic infection Need IV or oral treatment to control infection outside of the eye Potential complications include RD or endophthalmitis Complication of retention could also be a cataract This patient chose not to have the retained capsules removed. They had been present for 13 years with no complications After the original surgery, the patient was doing better so did not continue to seek care CASE #3 ANOTHER CMV EXAMPLE ATOPIC DISEASE ATOPIC DISEASE ASSOCIATIONS Atopic Dermatitis (Eczyma) : Chronic skin condition associated with allergic responses Family history common Hay fever, asthma, allergic rhinitis frequently seen Eczymatous skin changes with pruritis Eyelids commonly affected High incidence of Staph Aureus infection (40-90% vs 5-10% of normals). May play a role in ocular disease through elevated exotoxin levels High rate of HSV infections, both ocular and nonocular. Often bilateral ocular involvement (40% of such cases) 9

10 OCULAR COMPLICATIONS AKC Keratoconjunctivitis Severe PEK ASC cataracts Keratoconus (eye rubbing vs. collagen) Retinal detachment AKC ATOPIC KERATITIS TYPICAL CLINICAL PROFILE Red, scaly, itchy skin on eyelids and around eyes that does not respond well to topical steroid preperations Have a racoon look Significant keratocunjunctivitis / PEK that is refractory to topical treatment CLINICAL PROFILE Proper differential diagnosis is critical! Very frustrating for doctor and patient because nothing seems to bring relief.steroids, tears, punctal occlusion, anti-allergy drops all provide limited relief There is hope! 10

11 EFFECTIVE TREATMENTS.03% or.1% Tacrolimus ointment (Protopic) or Pimecrolimus 1% cream (Elidel) applied to skin of lids / periorbital area are very effective in managing both skin and ocular complications Elidel highly advertised as a treatment for eczyma TACROLIMUS.1% or.03% ointment 30 gm, 60 gm, 100gm PIMECROLIMUS 1% cream 30 gm, 60 gm, 100 gm TACROLIMUS / PIMECROLIMUS Non-steroidal immune modulators Blocks t-lymphocyte activation : atopic disease is caused by abnormal t-cell numbers and functions Inhibits formation of proinflammatory cytokines Treatment of skin leads to resolution of ocular complications by decreasing inflammatory mediators TACROLIMUS / PIMECROLIMUS Treatment regimen is to apply to skin / lids BID NOT to be used in the eye.03% Tacrolimus eye drops, however, are used as a veterinary treatment for KCS in dogs After several weeks, if treatment has been effective can reduce to two applications per week then discontinue Does not cause skin atrophy or discoloration like topical steroids can but.. SIDE EFFECTS Not for long term chronic use due to questionable cancer risk (lymphoma, skin) Not for use in children under two Avoid excessive sun exposure on areas of use May interact with steroids, macrolide antibiotics, calcium channel blockers, and antifungals 11

12 ATOPY PRE TREATMENT POST TIMECROLIMUS TREATMENT ATOPIC DISEASE TREATMENT Restasis can be used in refractory cases to help relieve ocular complications by mediating T-cell function May be a long term treatment option HYPHEMA HYPHEMA / MICROHYPHEMA Blunt trauma leads to hemorrhaging from iris or limbal vessels resulting in blood in the anterior chamber Microhyphema = dispersed, suspended RBC s while hyphema = layered or clotted RBC s Complete filling of anterior chamber with blood is referred to as eight ball hyphema 12

13 HYPHEMA Decreased VA, increased IOP, pain Often associated with angle recession or iridodialysis Synechiae, corneal blood staining are late sequelae Often other ocular trauma as well Incidence about 20 / 100,000 / year in US HYPHEMA MANAGEMENT Examine as completely as possible B-scan if necessary Management depends upon the extent of the hyphema and the reliability of the patient Microhyphema and mild hyphema patients who are reliable can be treated with cycloplegics and steroids HYPHEMA MANAGEMENT IOP lowering agents if needed: avoid prostaglandins and miotics Restricted activity, bed rest with head elevated 30 degrees Analgesics but no aspirin or NSAID s Follow daily watching for re-bleeds which spontaneously occur in about 25% of cases Restrict heavy activity for 1-2 weeks after clear SEVERE HYPHEMA MANAGEMENT Cycloplegia and bed rest full time with head elevation IOP lowering agents Eye shield and analgesics Examine daily HYPHEMA EIGHT BALL HYPHEMA AND GLOBE RUPTURE 13

14 HYPHEMA HYPHEMA HYPHEMA HYPHEMA HYPHEMA IN SICKLE CELL Unique! Question sickle cell history in AA Aqueous Humor causes sickling Applies to all genotypic variants and trait carriers (SS, SC, SThal, AC, SA) Mild elevation in IOP results in severe optic atrophy and risk of CRAO. So..surprise! 24 for -24 rule (IOP can not exceed 24 for more than 24 hours) No Diamox (Neptazane OK) ANGLE RECESSION Blunt trauma leads to recession of the angle structures away from the iris root Gonioscopy reveals a wide ciliary body in the affected area May cause increased IOP and secondary glaucoma years after the incident so patient education and follow up are key Iridodialysis : complete tear of iris root 14

15 IRIDODIALYSIS CHEMICAL BURNS CHEMICAL BURNS Conjunctival injection and chemosis Necrotic tissue Burns to eyelid skin Mild to severe anterior chamber reaction Often elevated IOP Perilimbal blanching indicates severe ischemia and is a bad sign CHEMICAL BURNS Late sequelae include symblepharon, cicatricial scarring, corneal opacification and glaucoma Rinse until neutral Ph then remove necrotic tissue. Swab fornices with a cotton tip applicator or a glass rod to remove all residual particles Cycloplege aggressively CHEMICAL BURN TREATMENT CHEMICAL BURN Utilize a bandage contact lens. Healing is often very slow and it usually takes several days to fully assess the extent of permanent damage Oral pain meds and IOP control as needed Antibiotic coverage Utilize steroids and lubricants heavily and follow closely Topical (10% sodium ascorbate) or oral vitamin C ( mg) to decrease scarring 15

16 CHEMICAL BURN S/P CHEMICAL BURN S/P CHEMICAL BURN MILD SYMBLEPHERON ANTERIOR SEGMENT OCT IMAGES PLATEAU IRIS Very helpful with angle morphology and iris changes Can be used for cornea and anterior chamber as well Extremely valuable with scleral lens fits New cap for the Cirrus 4000 and 5000 models = Visante 16

17 WOUND LEAK WITH CHOROIDALS WOUND LEAK POST REPAIR SCLERAL LENS VAULT AND LANDING ZONE TWO FOR THE PRICE OF ONE! AHMED VALVE 17

18 CELLS IN A/C LASIK FLAP: OPTOVUE TEAR PRISM: OPTOVUE PKP: OPTOVUE THE END! Any Questions? 18