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1 Slide 1 Slide 4 Demographics El Paso Eye Care Border Healthcare-Based Grand Rounds Derek N. Cunningham, O.D % Mexican-Americans Diabetes Hypertension Hyperlipidemia Obesity 70% uninsured High poverty levels Division of Ophthalmology Texas Tech School of Medicine Director of Inpatient Ophthalmology Services Thomason County Hospital Slide 2 Texas Tech Division of Ophthalmology at El Paso Slide 5 Residency Supervisor Derek N. Cunningham, O.D. Surgical Faculty Daniel G. Blumenfeld, M.D., Marc Ellman, M.D., Paul S. Gulbas, M.D. Slide 3 Average patient Slide 6 Pterygium excision Patient presents with complaints of eye irritation. Post excision, patient claims to have lost vision in both eyes.

2 Slide 7 Humphrey 120 Slide 10 Slide 8 Slide 11 Slide 9 Slide 12

Slide 13 Slide 16 Typical Inpatient Consults Concerns

pseudotumor cerebri, etc Anterior segment inflammation

Blood born infections candidemia, bacteremia Slide 14

3 Slide 13 Slide 16 Typical Inpatient Consults Concerns of optic neuritis or papilledema MS, meningitis, pseudotumor cerebri, etc Anterior segment inflammation scleritis, episcleritis, uveitis. Blood born infections candidemia, bacteremia Slide 14 Slide 17 Optic Neuritis Slide 15 Slide 18 Papilledema Anaplastic oligoastrocytoma

4 Slide 19 Papilledema Slide 22 Diagnosis? Risk Factors? Slide 20 Slide 23 Slide 21 Pseudotumor cerebri Slide 24 Multiple Sclerosis

5 Slide 25 MS Slide 28 Candida Endophthalmitis Educate patient on Uhthoff s symptom 70% recover 20/20 No Oral Steroids Alone! (ONTT) Likely long term reduction of color vision and contrast sensitivity Systemic Amphotericin B Depending on severity Paracentesis Ampho/Dex Pars plana vitrectomy Topical steroid and cyclo Slide 26 Uveitis Slide 29 Charo 25 Y/O LAF with HX of HTN and asthma Referred to ER by OD for papilledema Reported to have Bilateral ONH swelling Poor vision Nausea Light headedness Slide 27 Candidemia Slide 30 Charo 25 Y/O LAF with HX of HTN and asthma Repeat admissions to county hospital for atypical MS based on bilateral disc edema with symptoms of headaches and dizziness Repeat MRI was negative

6 Slide 31 Slide 34 Key Findings No eye consult Labs - wbc, sed rate, all others normal rbc and lymph% in csf Bilateral pan-uveitis Granulomatous kp, vitritis Bilateral serous retinal detachments Bilateral disc edema Loss of vision Headaches Nausea CSF Pleocytosis, ESR, all other labs normal Slide 32 IM Doc doing rounds notices bilateral red eyes Orders eye consult Slide 35 Differential Diagnosis Sympathetic Ophthalmia Uveal effusion syndrome Posterior Scleritis Sarcoidosis Acute posterior multifocal placoid pigment epitheliopathy (APMPPE) Primary intraocular B-cell lymphoma Vogt-Koyanagi-Harada disease Slide 33 November 14 Slide 36 UVEOMENINGOENCEPHALITIDES American Academy of Optometry

7 Slide 37 VKH Chronic bilateral granulomatous panuveitis involving the central nervous, auditory, and integumentary systems. More prevalent in pigmented races (except blacks) Key Bilateral involvement Bilateral serous retinal detachments Bilateral pan-uveitis Slide 40 Key Points An eye consult should be ordered on every atypical optic neuritis diagnosis in the ER Treatments must be aggressive and tapered slowly to decrease risk of re-inflammation Slide 38 Treatments Steroids have been the standard treatment HIGH dose LONG duration SLOW taper Nonsteroidal Immunomodulatry Therapy (IMT) Slide 41 Clinical Pearl Bring a retina doc into the loop for any posterior pole inflammation Bilateral intraocular inflammation requires a consultation and likely a medical work up Slide 39 ADHERENCE Slide 42 JL Paramount Importance Patient and entire health care team must understand 28 year old Hispanic female presents to OD for reduced vision in OD (20/30ish) OD refracts patient and tells her that refraction is unstable and come back in 3 month for another refraction OD does not dilate

Slide 43 JL Slide 46 Differential DX 28 year old Hispanic female presents to the ER for sudden vision loss over the last couple months ER doc diagnosis RD calls for eye consult Choroidal metastases

8 Slide 43 JL Slide 46 Differential DX 28 year old Hispanic female presents to the ER for sudden vision loss over the last couple months ER doc diagnosis RD calls for eye consult Choroidal metastases Amelanotic choroidal melanoma Amelanotic chroidal nevus Choroidal hemangioma Choroidal osteoma Intraocular lymphoma Posterior sclerotis Slide 44 B-scan Slide 47 What do we do? Shows small heavily reflective spots in mass Slide 45 Slide 48 Clinical Pearls Always dilate unexplained VA decreases

9 Slide 49 Emergency room trauma Slide 50 Triage

Misdiagnosed Vogt-Koyanagi-Harada (VKH) disease and atypical central serous chorioretinopathy (CSC)

HPTER 12 Misdiagnosed Vogt-Koyanagi-Harada (VKH) disease and atypical central serous chorioretinopathy (S) linical Features VKH disease is a bilateral granulomatous panuveitis often associated with exudative