56 yo female, EW Presented to outside Ophthalmologist Diagnosed with viral conjunctivitis, but viral testing was negative. Also had pain around the eye and on the right side of her face Interesting, unusual, eclectic cases from 2017 Robert A. Mittra, MD VitreoRetinal Surgery, P.A. Minneapolis, MN Improved after a week or so, but the vision dropped VA 20/70 OD, 20/25 OS IOP 17 OD, 15 OS PMHx External Photo on presentation to outside Ophthalmologist Hyperlipidemia, GERD, Osteoarthritis NO MEDS OCT OD Fundus Exam OD Retinal detachment inferiorly OD, looked exudative. NO breaks seen and marked vitreous debris 1
BScan OD Work Up Patient placed on oral steroids for inflammatory component, medical work up initiated CBC, metabolic profile CT Scan Chest and Abdomen, R/O metastatic tumor Concern for melanoma with possible overlying bleed and adjacent exudative detachment 2 months later OCT OD VA 20/25+ OD, 20/20 OS Off steroids, were tapered slowly Exudative detachment almost completely gone on exam BScan Further work up Full body PET SCAN, MRI of the head 2
64 yo female, LJ Fundus Sent in for macular edema, possible hypertensive retinopathy OS Patient is a nurse, history of Mild BP elevation 162/62 on presentation VA 20/50 OD, 20/60 OS IOP 18 OD, 19 OS SLE 1 2+ NS OU FA OCT Diagnosis? 3 weeks later VA worse 20/80 Atypical Ischemic Optic Neuropathy CRVO Leber s Hereditary Optic Neuropathy Infectious Bartonella Medical Work Up CBC, ESR, CRP VDRL, FTA ABS ANA Toxo IgG, IgM Toxocara Lyme Titer B. Henselae titer TB testing 3
OCT OS VA worse on follow up, edema worse ESR and CRP testing was high, Temporal Artery biopsy donenegative Toxoplasma IgG 81.5, IgM negative Other labs negative Avastin injection given Started on Bactrim DS BID 3 months later, VA 20/600 OS 3 months after presentation, Fundus OS 8 months after presentation VA 20/400 OS 10 months after initial presentation Emergency triage call from patient VA worse OD VA 20/80 OD, 20/300 OS IOP 14, 13 SLE 2+ NS OU 4
Fundus OD FA OCT OD Repeat Labs CBC, ESR, QuantiFERON Gold, Bartonella, Lyme, Toxocara, Toxoplasma Patient started empirically on Azithromycin 19 yo healthy female, A.S. Exam 2 days of vision loss OD, no complaints OS Central vision affected, thought it was a damaged contact lens, ( 1.50 OD, 1.25 OS) Does not take any medications VA 20/80 OD, 20/20 OS IOP 17, 18 SLE: Normal OU 5
Fundus FA OD FA OS OCT OD OCT OD OCT OD 6
OCT OS 7 days after symptoms onset, VA 20/150 OD, 20/20 OS 7 days after symptom onset 2 weeks after symptoms, VA 20/150+ OD, 20/20 OS 2 weeks after symptoms 2 weeks after symptoms 7
6 weeks after presentation 6 weeks after presentation, VA 20/40 Acute Posterior Multifocal Placoid Pigment Epitheliopathy (APMPPE) Acute Posterior Multifocal Placoid Pigment Epitheliopathy (APMPPE) Healthy young patients, average age of 25 Rapid loss of vision of one or both eyes Multiple post equatorial gray white lesions at the level of the RPE 50% have inflammatory cells in the vitreous Can be seen after flu like illness, flu or varicella vaccine, can be associated with systemic and cerebral vasculitis FA block early, stain late ICG dark spots corresponding to acute lesions without late staining OCT classically RPE and adjacent photoreceptors during acute phase and recovery when the lesions heal Rarely unilateral, one eye follows other usually days or weeks after the first Differential Diagnosis Lab Work Up Serpiginous Choroidopathy lesions similar acutely, but resolve more slowly and lesion marked atrophy of the choriocapillaris More chance of CNVM development Persistent Placoid maculopathy Relentless Placoid Choroidopathy QuantiFERON TB Gold negative Treponema Pallidum negative Toxoplasma AB IgG, IgM negative Lyme negative ANA negative CBC/diff negative ESR negative MRI Head/Orbits negative 8
OCT findings Fundus, SG Gass' Atlas RPE and adjacent photoreceptors Occasional SRF over placid lesions Later studies have shown that acute lesions affect the outer retina Which is most likely? A) Age > 65, history of HTN B) Age 40 65, history of HTN C) Less than 40, healthy 9
18 yo female 4 months later, VA 20/25 History of Asthma controlled on Singulair and Loratadine Lab work was extensive FBS, HbA1c, CBC with diff, PT/PTT, ESR, lipid profile, homocysteine, ANA, Hemoglobin electrophoresis, VDRL, Cryoglobulins, antiphospholipid antibodies, Lupus anticoagulant, serum protein electrophoresis, blood viscosity Options discussed: observation vs treatment After 3 Avastin injections 71 yo female, CC Decrease in vision OD VA 20/70 OD, 20/25 OS Diagnosis AMD Neovascular Given Lucentis, after one injection improved to 20/40 Clinical Trial of Implant Device OD Inserted surgically after two treatments, can be refilled in the clinic Trial is still ongoing, results will be available soon and further study is planned 10
10 yo boy presents 3 days after July 4th What is the most likely problem? Direct hit OS from a firecracker 1 week later, VA worse 8/200 VA OD 20/20, OS 3/200 IOP 12 OD, 16 OS SLE OD NL, OS Lid hemorrhage, 2+ cell/flare Fundus VH B Scan VH no RD, no FB OCT shows edema consistent with commotion in the fovea, but also a lamellar macular hole appearance Fundus OS What Now? Surgery? 11
2 months after initial injury OCT OS, observed for 6 months prior to intervention 1 week after PPV/MS, VA 20/200 80 YO female with pseudoexfoliation glaucoma Sudden vision loss 10 years after CE/IOL S/P large functioning superior trab 24 yo Male, TR Sent for emergency Retinal Detachment OS, Macula ON Not a high myope History, VA down for 1 month Diabetes Type 1, on Insulin, Atorvastatin, Lisinopril VA 20/30 OD, 20/100 OS IOP 18 OD, 16 OS SLE NL OU 12
Fundus FA OD FA OS OCT 2 months later, VA 20/20 OD, 20/40 OS Severe PDR OU Need anti VEGF and PRP in the right eye Needs surgery OS 13
Fundus ES Most Likely? A) Age > 65, history of HTN B) Age 40 65, history of HTN C) Less than 40, healthy Over one year later, VA 20/20 Patient is 22 yo Runs track for a big ten school Noticed decrease in vision after an intensive work out Extensive medical work up negative. Initially observed, but vision dropped to 20/400 over several weeks and patient opted for treatment 14
72 yo Male, sent for choroidal nevus OS, LM Fundus VA 20/25 OD, 20/40 OS IOP 15 OD, 16 OS SLE PCIOL OU FA OCT OS B Scan OS, Height 1.69mm, Width 6.83, high internal reflectivity Choroidal Metastasis History of throat cancer biopsy reveal Squamous Cell Carcinoma, primary lung. Initial MRI of the Head showed no CNS involvement Treated with radiation and chemo Currently on chemo infusion every two weeks Discussed external beam radiation if systemic chemo unsuccessful in shrinking the tumor 15
45 yo male, JB Fundus OS Sent by ER for retinal detachment Sudden loss of vision superior visual field OS PMH HTN, but untreated BP 124/90 VA 20/20 OU, IOP 18,19 SLE NL OU OCT OS BRAO OS in a 45 YO patient Medical work up Carotid Doppler, Echo Lipid Panel 25 yo female, KH Fundus Mild central vision loss OU, OD > OS No PMH, no medications Color vision NORMAL VA 20/40 OD, 20/30 OS, IOP 18 OD, 17 OS SLE NORMAL 16
FA 4 years later, VA 20/60 OD, 20/100 OS CONE Dystrophy Genetic Testing 4 years later, the patient now has dramatically decreased color vision OU Differential Diagnosis Can be AD, AR or X linked Associated with many gene defects, genetic testing done, awaiting results 41 yo female, TU Fundus OD Noted to have unusual lesion OD 18 years prior VA 20/400 OD, 20/20 OS IOP 14 OD, 16 OS SLE NORMAL OU 17
FA OD OCT OD B Scan OD Thank You Did not show shadowing 18