My Favourite Cases Anthony B. Litwak, OD, FAAO VA Medical Center Baltimore, MD
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1 My Favourite Cases Anthony B. Litwak, OD, FAAO VA Medical Center Baltimore, MD Dr. Litwak is a speaker and on advisory boards for Alcon and Zeiss Meditek CASE CR! 35 YOHF! Neg PMH! +FOH mother and grandmother with glaucoma! VA 20/20 OD, 20/20 OS! SL unremarkable! TA OD, OS! CCT 554/561! Gonio: 4+ open OU, s PAS or angle recess How Strongly Do You Feel That This Patient Has Glaucoma? % % % % % How Strongly Do You Feel This Patient is at Risk for Becoming Visually Impaired from Glaucoma? 1. No risk 2. Very little risk 3. Low risk 4. Moderate risk 5. High risk Should We Treat or Observe? 1. Does the patient have nerve damage?! If yes then in most cases TREAT! If no, then access risk factors to determine the benefits of treatment vs. observation o Level of IOP o CCT o Age o FOH o Race o POAG Endpoints by Central Corneal Thickness and Baseline IOP (mmhg) in Observation Group*
2 o Decided to treat o Based on elevated IOP o Strong family history o Hispanic race o Young age o Follow up o Pt started on Timolol.5% bid ou o IOP range OD OS o What should you do? How Strongly Now Do You Feel This Patient is at Risk for Becoming Visually Impaired from Glaucoma? 1. No risk 2. Very little risk 3. Low risk 4. Moderate risk 5. High risk Glaucoma as the Disease Progresses Visual Field changes occur late in the disease What Should You Do Now?! Reset TP < 15 OU! Add Travatan qhs ou! Change Timolol to Cosopt bid ou! IOP 12, 15, 17 OD 13, 14, 17 OS What Should We Do?! Add Alphagan?! ALT/SLT?! Would you filter?! 30-2 vs 10-2 Testing Points CASE RR! 65 YOBM transferring care to VA! C/O reduced VA in OS! Glaucoma suspect, OU on med! IOP s meds: OD 16-22, OS 16-23! CCT: 570/560! CD ratio.3/.3! Started Latanoprost QHS OU, set tentative TP < 18 OU (4/2013) Past Medical History! Closed fracture of clavicle! Panic disorder! Male erectile disorder
3 ! H/O Nasopharyngeal Carcinoma VA & Current Specs! BVA cc! OD 20/25! OS 20/40-2! MR! OD x113! OS x85! ADD Neuro-ocular exam! EOM: full and smooth, OU! CVF: FTFC, OU! PERRL ( )APD, OU! Amsler Grid Test! OD cl! OS Pt reports fog superior temporal to fixation Slip Lamp! Cornea: cl OU! Conjunctiva: white and quiet OU! AC: D + Q OU! Iris: No NVI OU! Tonometry! IOP! OD 18! OS 18! Time 1:30pm Gonioscopy: 3+ open OU with 1+ pigment in TM OU DFE VF Review (5/2013) Did you expect to see this? Diagnosis? Plan? Oct: ONH (6/2013) OCT: onh, GCC (6/2013) Oct: Macula OD (6/2013) Oct: macula OS (6/2013) Diagnosis? Is this glaucoma? Is this a retina problem? Is this a neurological problem? Is this a pituitary tumor? Is this something else?
4 CASE RB! 76 YOBM! +PMH HTN, DM, s/p R CVA! -POH! VA 20/20 OU! EOM full! PERRLA APD! CF left superior quad! SL unremarkable OU! TA 24 OD 22 OS Does this patient have glaucoma? CASE TC! 69 YOWM! PMH HTN, Arthritis Ocular Problem List: 1. H/O Allergic Conjunctivitis OU a. Prior history of severe allergies and eczema 2. H/O Chronic Recurrent Anterior Uveitis OD>OS a. Lab test Review b. (-) Lyme, TB, RPR, ACE c. (+), ANA, elevated ESR (arthritis) d. AC deep and quiet OU 02/05/15 e. (+)photophobia; longstanding 3. Dry Eye Syndrome OU 4. Pseudophakia OU 3/2015 CC:! Bilateral blurred vision and pain and redness in both eyes x 3 days! VA 20/60 OD 20/200 OS! EOM full! CF FTFC! PERRLA APD! SL! Conj 2+ hyperemia OU! Cornea cl OU! AC 2+ cell/flare OU! Iris No NVI OU! TA 14/ Diagnosis
5 Management Treatment CME Topical NSAID Treatment Uveitis Cycloplegia Topical Steroids CASE VT 65 YOWM Problem List: 1. Stage 4 macular hole OD a. S/P unsuccessful repair (PPV, FGE, ILM peel, 10% C3F8 OD (9/10)) 2. Stage 1b macular hole OS a. VA 6ft OD 20/30 OS Management??? Patient s vision dropped from 20/30 to 20/60 in left eye over last 6 months Treatment options??? Patient given option Jetra injection. Performed 6/11/14 1 week F/U Pt reports improvement of vision in left eye VA 20/40 OS VA 20/30 OS JETREA (Ocriplasmin)! Intravitreal Injection, 2.5 mg/ml, is a proteolytic enzyme indicated for the treatment of symptomatic vitreomacular adhesion! VMA resolution occurred in 26.5% of Jetra patients vs. 10.1% in vehicle injection patients! A decrease of 3 lines of best-corrected visual acuity (BCVA) was experienced by 5.6% of patients treated with JETREA and 3.2% of patients treated with vehicle in the controlled trials! Intraocular inflammation occurred in 7.1% of patients injected with JETREA vs. 3.7% of patients injected with vehicle
How Strongly Do You Feel That This Patient Has Glaucoma? % % % % %
My Favorite Cases Anthony B. Litwak, OD, FAAO VA Medical Center Baltimore, Maryland Dr. Litwak is a speaker and on advisory boards for Alcon and Zeiss Meditek CASE CR 35 yohf Neg PMH +FOH mother and grandmother
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