Not So Fast! Some Cases Might

Fool You Eric E. Schmidt, O.D., FAAO

Omni Eye Specialists

Wilmington, NC

schmidtyvision@msn.com

As Many Disease As She Pleases

• 77 WF

• Macular hole repair OS 8 yrs prior

• Subsequent SRNVM w/ large macular scar

• VA OD 20/20, OS HM@6’ – stable for 5 yrs

• Recently complained of HA “alot” over OS

• Says her vision OS is worsening, “it will go black at times!”

Exam

• VA OD 20/25- OS – LP • SLE – OD no change, OS – 2+ PCO • DFE –OD - D,M,V,P wnl OS small macular

bleed adjacent to macular scar • ONH - .1/.1 OD pink, .15/.15 OS large area of

PPA • What now? • Did we forget something?

Ancillary Tests

• IVFA – no evidence of new SRNVM • OCT – Plush NFL, no SRNVM • ESR – 20mm/Hr • C-RP – 0.8

• What now? Is she just crazy? • Are you sure we haven’t overlooked anything?

Explain the VF result

• NOW what would you do?

MRI

• Suprasellar mass with impingement on ON

• Probable glioma

• Underwent resection

• Craniopharyngioma!

The Case Of The “Sore Eye”

• 17 y/o WM CC: “Itch and Pain OD”

• 3 weeks duration and it’s getting worse

• Initially very itchy, now it is painful

• FB sensation, photophobia, tearing

• No known trauma, Rx’d Vasocon TID

• Ext – Ptosis RUL, frank injection

• SLE – AC –d & q, 1+ mucus d/c

What is the diagnosis?

• 1. Allergic conjunctivitis

• 2. Corneal abrasion

• 3. Bacterial keratitis

• 4. Dellen

• 5. Vernal keratoconjunctivitis

• 6. Marginal Keratitis

• How Do You Know It’s Not Infectious???

What Is The Best Treatment?

• 1.BCL and Gentamicin QID

• 2. BCL and Bromday QD

• 3. BCL and Zymaxid BID

• 4. Lotemax OD QID

• 5. Besivance OD TID

• 6. Tobradex ST OD QID

• 7. Vigamox and Nevanac TID each

• 8. Some combination of these

Case Of The Sudden Vision Loss

• 17 y/o BM awoke that AM; “couldn’t see” out of OS.

• “somewhat painful”

• Looked in mirror, noticed eye was totally white

• Denies trauma

• No precursors

Exam

• VA s Rx - OD 20/30, OS LP

• Pupils - OD Round, reactive no inverse APD, OS - not visible

• SLE - OD prominent K nerves, no edema, no bulb inj, OS as shown

• IOP 15 OD, 32 OS

Sudden Loss Question 1

What other tests would you perform?

• 1. Gonioscopy • 2. Keratometry/Topography • 3. DFE • 4. Corneal pachometry • 5. VF • 6. Gonio & K Topo • 7. DFE & Gonio • 8. Pachometry & Keratometry

Sudden Loss Question 2

What Is Your Diagnosis?

• 1. Angle Closure Glaucoma

• 2. Corneal Edema

• 3. Corneal Hydrops

• 4. Corneal Perforation

• 5. Pupillary block glaucoma

• 6. Fuch’s dystrophy

Sudden Loss Question 3

How would you treat it?

• 1. Adsorbonac 5% QID, TXE 0.5OS

• 2. Penetrating Keratoplasty

• 3. Timolol 1/2% OS BID, Alrex OS QID

• 4. Pressure patch, Atropine OS

• 5. BCL,Gentamicin OS QID

• 6. BCL, Lotemax OS QID

• 7.Lotemax gel OS QID, Adsorbonac 5% OS QID

Case 4

• A.G. – 60 y/o AAM, struggling with high IOP for years

• IOP ranges from 22-32, disks remain fairly healthy

• C/D .4/.4 OD, .5/.6 OS

• VF as shown

2 years later

• Px presented with unilateral vision loss.

• Describes things as very fuzzy with a dull ache

• VA OD- 20/50-2 OS – 20/20-3

• IOP 32 OD, 33 OS

I TOLD YOU SO!!!

• So what to do now??

The Case of Newfound Eyes

• 70 y/o F referred for chronic sore eyes

• POH: Punctal plugs 3 yrs prior – moderate improvement initially

• Meds: Synthroid, Adalat, Calcium, ASA, Refresh Tears QID

• CC: Eyes burn and sting. Very red worse at times. Mild stringy d/c. Vision seems worse

• “I’m Allergic to everything! Eh!”

Newfound Data

• VA OD 20/25, OS 20/30

• Ext: normal except for “ruddy” complexion

• SLE: Lids – 1+ debris OU

1+ Meib inspissation OU

1+ bulb injection

few papillae OU

K – diffuse SPK OU

Lens – 1+ NS OU

Which test do you want to do

next? 1. Amsler grid

2. Corneal topography

3. Rose-Bengal Stain

4. Schirmer’s strip

5. TBUT

6. Zone Quik

What is your diagnosis?

• 1. Ocular Surface Disease

• 2. Blepharitis

• 3. Ocular rosacea

• 4. VKC

• 5. Allergic conjunctivitis

• 6. Bacterial conjunctivitis

What is the clinical key to making this

diagnosis? • 1. Look under the lids – check for papillae

• 2. Look at the cornea – check for RB staining

• 3. Look at her tears – check Schirmer’s test

• 4. Look at her cheeks – check for telangiectasia

• 5. Look at her daughter – check for a wedding ring

Considering that…

• She has punctal plugs,

• She is using Patanol OU BID

• She is using AT a lot

• Has a Schirmer’s test of 3mm OD, 6mm OS

• She has corneal staining

• She continues to be symptomatic

How are you going to treat Newfound?

• 1. Doxycycline 100mg QD

• 2. Lotemax gel OU QID

• 3. Systane OU Q2H

• 4. Refresh PM ung OU QHS

• 5. Polysporin Ung OU QHS

• 6. Restasis OU Q12H

• 7. Prolensa OU QD

• 8. Some combo of these

What I Did with Newfound

• RX Doxy 100 QAM

• FML OU QID

• AT PRN

• 1mth later she felt much better, lids were much clearer, no NaFl or RB staining

• Now what?

Long term therapy for Newfound?

• 1. Doxy 50 QD and AT

• 2. Optive OU QID

• 3. Restasis OU BID and AT OU QID

• 4. Restasis BID and Doxy 50 QD

• 5. FML OU BID and AT BID

• 6. Lotemax BID and Restasis BID

• 7. Doxy 100 QD and AT TID

• 8. Vitamins and Flax seed oil

48 y/o Asymptomatic Pilot

• VA 20/15 OU

• Anterior Segment: Unremarkable

• Fundus

Diagnosis?

• Choroidal Nevus vs Choroidal Melanoma

Choroidal Nevi

• < 3 mm elevation

• < 3 DD in size ▫ 95% are less than 2 DD

• Slate gray

• Drusen

• SRF associated with drusen

• CNVM

Features Suggesting Nevi

• Drusen

• Overlying neurosensory detachment

• Choroidal neovascular membrane

• Circinate exudate

• Bony pigment spiculing

• Zones of RPE atrophy

Choroidal Melanoma

• >3 mm elevation

• Variable pigment

• Multiple areas of orange pigment (lipofuscin)

• Serous fluid (detachment) in absence of drusen

Unequivocal evidence of growth

Management

• Flat choroidal nevi: follow yearly

• Suspicious nevi:

▫ photo

▫ follow in 6 wks, 3 mo, then 6 mo

▫ evidence of growth -> early melanoma

• Lesions > 3 mm thickness: probably early melanoma

The Case Of The Chubby Disk

• 29 y/o WF cc: blurred vision OS, OS seems to be “pulling” for last 3 wks

▫ HA on L side

▫ Feels like pressure (a suction cup) on OS

▫ Seems like a skim over OS

Meds: none

Past hx of “migraines”

Chubby exam

• VA – OD 20/20, OS 20/20 (blurry)

• PERRL mg (-)

• EOM – no restriction

• SLE – wnl OU

• IOP- 20mm OD, OS

• Fundus – as shown

• What is the diagnosis?

Chubby Diagnosis:

• 1. Central Retinal Vein Occlusion

• 2. Ischemic optic neuropathy

• 3. Optic neuritis

• 4. Papilledema

• 5. Pseudotumor cerebri

What do you want to do with

“Chubby”? • 1. Call 911 • 2. CT scan • 3. Lumbar puncture • 4. IV Methylprednisone • 5. ESR • 6. Send her to Dusty Baker- he is a miracle

worker

Disc edema – differential diagnosis

• Intracranial tumor

• Elevated ICP – Papilledema, PTC

• Vascular/Ischemic – ION

• Inflammatory – Optic neuritis

• Systemic

• Orbital tumors

Papilledema

• Bilateral disk edema

• NFL opacification and hemes

• Hazy retinal vessels

• Paton’s lines

• (-) SVP

• Disk hyperemia, exudates and CWS

• Papilledema is always caused by increased ICP!!

The Hunt For The Cause Of The

Chubby Disk • MRI – Normal

• LP – Opening ICP 402

• Dx: Idiopathic Intracranial Hypertension

How are you going to treat this?

• 1. Diamox 250 2 tabs BID

• 2. Diamox 500 BID

• 3. Patch 1 eye

• 4. Goodies Powder PRN

• 5. Prescribed weight loss

• 6. Intracranial shunt

Idiopathic Intracranial Hypertension

• Bilateral disk edema (papilledema) • Due to increased CSF • Tx: Diamox

▫ Weight loss ▫ Oral steroids ▫ Weight loss ▫ Topamax ▫ Repeat LP ▫ Cerebral shunt ▫ ON sheath fenestration

• WEIGHT LOSS!!, WEIGHT LOSS!!, WEIGHT LOSS! • Lose Weight !*&@*(^^(@!

Chubby’s sequelae

He Said, She Said

• 64 y/o WF treated for pigmentary G x 2 yrs

• Bet S OU BID

• IOP pre-tx 22 – 26mm

• IOP w/tx 16 – 20mm

• Referred for SLT

• G specialist says not pigmentary glaucoma

• NOT GLAUCOMA AT ALL!!

He Said, She Said - 3rd Opinion

• VA - OD 20/20 OS 20/25

• No fam hx, no meds, mild PSC

• Original C/D .3/.3 OU

• My exam OD .5/.4 OS .5/.5

• VF 3/94

• VF 6/97

He Said, She Said – my exam

• Gonio Gr 4 360deg OU, no pigment, no IP

• IOP 22 OD, 24 OS w/ no tx

• SLE – as shown

• Based on hx, IOP, VF,disks and SLE:

What’s your diagnosis?

• 1.Glaucoma suspect • 2.Ocular hypertension • 3. Fuch’s dystrophy • 4. POAG • 5. Pigmentary glaucoma • 6. PDS • 7. Pseudoexfoliative glaucoma

He said, she said – How would you

treat? • 1. VF/IOP Q3mth • 2.VF/IOP Q6mth • 3. Prostaglandin OS QHS • 4. Alphagan OD BID • 5. Betimol ¼% OS BID • 6. Betoptic S OU BID • 7. ALT OU 180deg • 8. Adsorbonac 5% OU QID

I Rx’d Xalatan OS QHS – What’s the

target IOP? • 1.18 -20 mm

• 2. 15 – 17 mm

• 3. 12 -14 mm

• 4. <12mm

• 5. Impossible to know

IOP 19OD, 20OS on Xalatan OS,

What’s your next move? • 1. Xalatan OU QHS

• 2. Xalatan OU QHS, Alphagan OU BID

• 3. Xalatan OU QHS, Betimol ¼ OU QAM

• 4. ALT OS 180deg

• 5. d/c Xalatan, Rx Alphagan OS BID

• 6. d/c Xalatan, Rx Betimol ¼ OS BID

• 7. d/c Xalatan, Rx Cosopt OU BID

• 8. d/c Xalatan, Rx Lumigan OU QD

He Said, She said

• I d/c Xalatan • Rx Betimol ¼ % OS BID • IOP 22OD, 23OS • Now What???

▫ 1. A different prostaglandin ▫ 2. dual meds ▫ 3. ALT/SLT ▫ 4. Combo therapy

He Said, She Said Sequelae

• Lumigan OU QHS and Alphagan OU BID

• Stablized IOP ~14mm Hg OU

• Removed cataract OU