Grand Rounds: Interesting and Exemplary Cases From Guanajuato and Djibouti
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1 Learning Community: January 25, 2015 Grand Rounds: Interesting and Exemplary Cases From Guanajuato and Djibouti JORGE CUADROS, OD, PHD
2 EyePACS In Guanajuato Program started in 2007 Cameras go from clinic to clinic on a rotating basis. About 1000 patients screened per year. View over the historic town of Guanajuato, Province of Guanajuato, Mexico, UNESCO World Heritage Site.
3 Case 1: yr. old female from Victoria, Guanajuato, a small farming community Photographed by Dr. Emma Puente Pinon on Sept. 6, yrs. DM II, uses insulin, metformin, and glibenclamide. HbA1c = 13.0 No prior eye exam Images read by Dr. Aline Manriquez Beginning proliferative retinopathy and macular edema
4 Case 1: yr. old female from Victoria, Guanajuato, a small farming community Photographed by Dr. Emma Puente Pinon on Sept. 6, yrs. DM II, uses insulin, metformin, and glibenclamide. HbA1c = 13.0 No prior eye exam Images read by Dr. Aline Manriquez Beginning proliferative retinopathy and macular edema
5 89 km (53 miles) Case 1: 2014 Patient was treated through the Guanajuato Vision For All Public-Private Partnership in San Miguel de Allende early 2014
6 Case 1: 2014 Patient was treated through the Guanajuato Vision For All Public- Private Partnership in San Miguel de Allende early 2014 Focal and panretinal scars are visible Neovascular net involution Macular edema has receded An example of when things go right!
7 Case 1: 2014 Patient was treated through the Guanajuato Vision For All Public- Private Partnership in San Miguel de Allende early 2014 Focal and panretinal scars are visible Neovascular net involution Macular edema has receded An example of when things go right!
8 Case 2: March, year old male from San Luis de la Paz, Guanajuato Photographed by Dr. Jezabel del Refugio Benitez Rodriguez DM II X 7 yrs Glibenclamide only Microaneurysms Cotton wool spots One small hard exudate Advised to return for re-examination in one year
9 Case 2: March, year old male from San Luis de la Paz, Guanajuato Photographed by Dr. Jezabel del Refugio Benitez Rodriguez DM II X 7 yrs Glibenclamide only Cotton wool spots Microaneurysms One small hard exudate Advised to return for re-examination in one year
10 Case 2: March, year old male from San Luis de la Paz, Guanajuato Photographed by Dr. Jorge Aburto Ramos DM II X 12 yrs Glibenclamide and metformin Intraretinal hemorrhage Cotton wool spots Edema marked by hard exudates Dr. Rajeev Ramchandran advised control of glycemia, blood pressure, and lipids. Patient was referred to retina service
11 Case 2: March, year old male from San Luis de la Paz, Guanajuato Photographed by Dr. Jorge Aburto Ramos DM II X 12 yrs Glibenclamide and metformin Intraretinal hemorrhage Cotton wool spots Edema marked by hard exudates Dr. Rajeev Ramchandran advised control of glycemia, blood pressure, and lipids. Patient was referred to retina service
12 Case 2: September, year old male from San Luis de la Paz, Guanajuato Photographed by Dr. Victor Manuel Torres Flores DM II X 14 yrs S/P focal laser : Focal laser scars Edema and hard exudates have receded Dense cotton wool spots and superficial hemorrhages, suggesting uncontrolled hypertension Blurred images from cataract
13 Case 2: September, year old male from San Luis de la Paz, Guanajuato Photographed by Dr. Victor Manuel Torres Flores DM II X 14 yrs New blood vessels formed on optic nerve, consistent with widespread retinal ischemia Although macular edema was successfully treated, continued surveillance is important!
14 Case 2: September, year old male from San Luis de la Paz, Guanajuato Photographed by Dr. Victor Manuel Torres Flores DM II X 14 yrs New blood vessels formed on optic nerve, consistent with widespread retinal ischemia Although macular edema was successfully treated, continued surveillance is important!
15 EyePACS in the Republic of Djibouti Population: 810,000 Estimated 10% with diabetes No formal epidemiological data on prevalence of diabetic retinopathy
16 Case 3: January 23, yr. old Djiboutian male DM II since 1989 Treated successfully for tuberculosis in ophthalmic findings: Few microaneurysms and hard exudates DX: diabetic retinopathy, no treatment recommended Retinal detachment in right eye in fasting glucose = 352 Year HbA1c
17 Case 3: January 23, 2015 Right eye: Cannot detect retina due to opacification of ocular media, likely not a cataract. Left eye: Extensive neovascularization Fibrous proliferation Preretinal hemorrhage at optic nerve and below macula Past the stage where laser will help Vitrectomy may preserve some vision
18 Case 3: January 23, 2015 Right eye: Cannot detect retina due to opacification of ocular media, likely not a cataract. Left eye: Extensive neovascularization Fibrous proliferation Preretinal hemorrhage at optic nerve and below macula Past the stage where laser will help Vitrectomy may preserve some vision
19 59 yr. old Djiboutian male
20 Case 4: January 15, yr. old Djiboutian female, mother of 3 children Not diabetic Chronic bilateral panuveitis (painful internal ocular inflammation) first episode in 1996 Diagnosed as idiopathic uveitis, treated with corticosteroid eye drops Presented to ophthalmology clinic in 2008 with recurring uveitis in right eye Persistent moderate anterior chamber cells Fixed pupil Posterior synechiae (iris was attached to the lens) Right eye vision: 20/25 Left eye had cataract extraction, but vision was very poor. Example of posterior synechiae
21 Case 4: January 15, 2015 (continued) 30 yr. old Djiboutian female, mother of 3 children Not diabetic Patient returned to ophthalmology clinic om 2014 with no improvement in left eye; vision decreased to 20/50 in the right eye: Right cataract and opacities on cornea noted. Ultrasound showed no obvious retinal abnormalities. Patient presented to Dr. Ayoub in primary care clinic with: Rapidly decreased vision in right eye Chronic headache Earache Alopecia (hair loss) Arthritis
22 Case 4: January 15, 2015 (continued) 30 yr. old Djiboutian female, mother of 3 children Not diabetic Consider Behcet s disease given North African setting, expecially if there are any signs of apthous ulcers in the mucosa Vogt-Kayanagi-Harada syndrome was considered due to the symptoms and appearance Both are autoimmune diseases that have no known cure Treat agressively with corticosteroids Needs specialist to evaluate treatment for cataract and retinal status of right eye. Desires travel to the US to seek specialist intervention.
23 EyePACS Djibouti Results 90 Cases screened Comparable to results from Guanajuato and the US for diabetic retinopathy Greater incidence of glaucoma Goal is 120 for the first month Not bad for a new program!
24 Thank You!
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