Transcript Grand Rounds in Eye Care

Grand Rounds in
Eye Care
FROM THE LIDS TO
THE MESHWORK
Lee W. Carr, O.D.
Jeff D. Miller, O.D.
28 y.o. White female
 C/O: “I had a big stye on my lid, and now
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it’s really swollen up, and it hurts really
bad.”
No known health problems
No medications, currently
Allergic to penicillin
No other known allergies
Relevant History
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First noted “sty” one week ago
Initially: small, non-tender “lump”
“Looked ugly. Made me look ugly.”
Patient squeezed it, “Like a zit.”
Patient tried to “pop it” using a sewing needle.
DID sterilize the needle in a flame
Did not disinfect skin first
Did manage to draw blood from the site
Worked on lesion “…for about 20 minutes.”
Worked on lesion “…till it started to swell pretty
good and it really started to hurt.”
Currently…
 “Swelling is spreading”
 Lesion is becoming increasingly painful
 “It really hurts now.”
 “I’m afraid I’ve got an infection in my eye.”
The Exam
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VA’s (sc): OD: 20/20 OS: 20/20
Pupils: PERRLA, brisk OU
Motilities: full, unrestricted OD + OS
Conf Fields: full, OD + OS
SLE: quiet and clear cornea and anterior
chamber
 EXTERNAL: OD: quiet, WNL
OS: extensive lid swelling
Assessment: Preseptal vs
Postseptal Cellulitis
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Re-checked EOM’s. Full, unrestricted
Took patient’s temperature: 97.5 degrees
Pulse & BP: 74 bpm; 122/78
Questioned patient regarding current or recent
sinusitis
Evaluated nasal passages with transilluminator
light
Attempted sinus transillumination
Attempted combined scan ultrasound
Discussed monitor/empiric therapy or CT
evaluation options with patient
Management
 Rx: azithromycin (z-pack x 2)
Take 2 (250mg) tablets twice per day for two
days;
Then reduce to 1 tablet per day until all tablets
are gone
 Rx: tramadol
Take 1 (50mg) tablet qid x 2 days
 Requested tetanus booster via Adult Med
 RTC: 24 hours to re evaluate motilities,
other findings
DILATED FUNDUS EXAM
 All findings considered benign and WNL
for OD and for OS
54 year old male
 Yearly eye exam
 C/O OD blurry for the last 3-4 weeks
 Has happened before but intermittent
 Refr. Hx: hyperopic/astigmat/presbyope
 Medical Hx: Type II DM, HTN, elevated
cholesterol
 Meds:Metformin,HCTZ,Toprol-XL,
Zetia,Vitamins
The Exam
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VA’s sc OD 20/40 OS 20/30
Pupils, motility, CVF all normal
BVA OD:+1.25-0.25x100 20/30
OS:+1.25-1.00x097 20/20
Ant Seg: trace SPK OD > OS
Quick TBUT OU
NS 1+ OU
IOP: 21/23 @3:25pm
Retina and ONH appear normal OU
.3 c/d OU
No BDR noted
Additional Testing
 Lissamine Green
 Cirrus OCT of Macula OU
 Topography
 Pachymetry OD 530 OS 509
 Additional History: always sleeps with
ceiling fan on high
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Cirrus SD OCT
Topography OU
Working Diagnosis
 Irregular topography OD secondary
to Dry Eye
 Suspect corneal thickness OS > OD
(Ocular HTN/Glaucoma suspect?)
 REC: D/C ceiling fan if possible, AT’s upon
waking and throughout day, various samples
given, consider “gel” HS
 RTC 3-4 weeks progress evaluation
F/U Exam
 Patient states mild improvement some days better than
others
 Using Soothe XP with some success
 C/O of Mild itching
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VA cc OD 20/25- OS 20/20
Cornea eval trace SPK OD, clear OS
Everted Lids: clear however, lids very “flaccid”
Lids everted w/o any particular effort or technique
Additional History
 At this point the spouse offered some
information through a question
 “We’ve stopped the ceiling fan however,
he has just recently started using a CPAP
for sleep apnea. Will that dry his eyes out
more?”
 Working Diagnosis Changed
FES, Sleep Apnea, and Glaucoma
 Several ocular disorders have been found in association with Obstructive
Sleep Apnea or OSA: FES, optic neuropathy, glaucoma, NAION, and
papilledema.
 5-15% of OSA pts. have FES
 96% of FES pts. have OSA (collagen in esophagus / pharynx similar to
tarsal plate – results in esophageal collapse)
 57% of NTG pts. Have sleep apnea symptoms
 Glaucoma – 2% of general population, 7+% of OSA patients
 Multiple studies have shown over 70% of NAION pts. have OSA
Trigger: failure of AUTOREGULATION
(all NAION pts. Should be advised to be evaluated for OSA)
 www.slideshare.net/rhodopsin/sleep-apnea-and-the-eye
 Rick Trevino, O.D.
GDX
Evidence of Ischemia’s Role
in Glaucoma
 Overwhelming evidence indicates high IOP
contributes to the development of glaucoma
 As many as 80% of Ocular HTN’s don’t develop
glaucoma
 What about NTG? – about 30% of glaucoma
patients appear to have normal IOP yet go on to
have their nerves collapse and deteriorate
 The Key? – AUTOREGULATION
Management
 Continue to treat Ocular surface disease
 Continue to monitor for Glaucoma
 Encourage patient to have continued f/u
care with PCP discussed OSA and
potential neurovascular, cardiovascular
sequela as well as glaucoma and ION
66 y.o. White female
 Referred in from Low Vision Service and
Rural Eye Program clinic for evaluation for
ectropion repair—right lower lid
 History of longstanding Bell’s Palsy, right
side (“at least 14 years ago”)
 Hx:
Type 2 diabetes, on insulin
Hypertension
Ocular History
 General Ophthalmologist
 Pan retinal photocoagulation OU (2002)
 Retinal Specialist
 PRP and grid (2002)
 Vitrectomy, OD, (2003)
 Low Vision Service (2003)
 VA: OD: 10/400
OS: 20/150
Hx (continued):
 Corneal Specialist
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Exposure keratitis management (2005)
Cataract surgery, OD, (2005)
Lateral tarsorrhaphy, OD, (2005)
Recommendation: Cataract surgery OS
 Retinal Specialist
 More PRP (2006)
 Cataract surgery, OS, (2006)
 Low Vision Service
 VA:
OD: 10/100
OS: 10/350
Hx (continued):
 Retinal Specialist
 PRP, OU, (2007)
 Anti-VEGF, OU (2007)
 Vitrectomy and Retinal Detachment
Repair, OS, (2007)
 Low Vision Service
 VA:
OD: 6/80
OS: HM at 2 feet
Specialty Care Exam (4/22/08)
 “I was advised to get my eye lid fixed
again.”
 “No pain; I’ve gotten used to it.”
 “Sometimes I forget to use my artificial
tears, but not often.”
 Mx: insulin, Fosthopace, Systane, Theratears, Erythromycin ophthalmic ointment
(prn use)
 VA:
OD: 20/400 at 4 feet
OS: Light Projection
 Ext: Severe right face droop—full facial palsy
Significant edema below right lower lid.
Mild ectropion, right lower lid
Grossly incomplete lid closure, OD.
Mild red eye reaction OD—watery
Blue tinge to right lower lid
Solid nodule palpable within edematous right
lower lid
 Assessment: Atypical for ectropion
Consult with our clinical
ophthalmologist
 Additional Hx obtained: Patient last seen by her
primary care physician in January, 2008. He
recommended eye lid evaluation.
 In late November, 2007, the PCP had removed
a “skin lump” from outer canthus, right lower lid.
 Pathology report identified basal cell carcinoma.
 At March, 2008 exam, PCP expressed concern
to patient that residual tumor may exist, and
again recommended eye lid surgery.
Lesson Learned
 PATIENT EDUCATION IS CRITICAL
 This patient thought that the
recommendation for ectropion repair and
the recommendation for evaluation of the
right lower lid for residual basal cell
carcinoma were “one-and-the-same”
Management
 Assessment: Probably deep basal cell
carcinoma spread—potentially orbital
invasion.
 Plan: Made immediate referral to
oculoplastic surgeon--Tulsa
22 y/o male
college student
 Presented with c/o mild decreased vision
OD associated with scratchy FB sensation
and photophobia
 Reports is being treated for a “stye” on his
OD upper lid with lid scrubs and tobradex
drops for 1 week – no improvement – in
fact, getting worse
 OD red, questions allergy to drops?
The Exam
 Healthy young male no systemic
conditions, no meds p.o.
 VA sc OD 20/30 OS 20/20
 All entrance visual skills normal
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Assessment / Treatment
 Herpetic lid lesion and HSK
 D/C Tobradex
 Begin Viroptic q1h OD
 Begin 400mg Acyclovir p.o. 5 x day
Herpes Simplex Keratitis
The Leading Cause of Corneal
Blindness in the US
Ocular Herpes Simplex
 Each year in the U.S. 25 million people have flare-ups
of facial Herpes (95% of population exposed by age 6yrs)
 1/3 of the population worldwide has had HSV infection
 700,000 have developed HSV-related ocular disease in the US
 20,000 – 50,000 new cases/yr 28,000 reactivations/yr
 Rarely is this bilateral however, has been seen bilaterally in children
 After the first corneal infection, 25% re-occur with in 2 years
 It is the most common cause of infectious blindness in the Western
World
Ocular Herpes Simplex
 After the second infection odds of further recurrences
greatly increases
 40% of these patients have more than one recurrence
Infectious Epithelial keratitis
Neurotrophic Keratopathy
Necrotizing Stromal Keratitis
Immune Stromal Keratitis (ISK)
Endotheliitis
(Keratouveitis or trabeculitis)
 One of the leading indications for PK in the US
Diagnostic Pearls
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Evaluate lid margin and lash follicles closely
Look for a follicular vs. papillary response
Look for more of a serous vs. mucous discharge
Don’t forget decreased corneal sensitivity
Cotton wisp test (check before staining!)
Multiple raised epithelial defects vs. medium
to large classic dendrites
 Be careful with steroids on garden variety eye
inflammation
Oasis Medical Inc.
909-305-5400
Treatment - Oral Antivirals
 Valacyclovir hydrochloride
 Trade name – Valtrex
 Acyclovir
 Trade name – Zovirax
 Both inhibit viral DNA replication by
interfering with viral DNA polymerase
Acute Phase
Dosages and Precautions
 Valtrex 500mg 1 p.o. bid x 7 days ($88)
 Zovirax 400mg 1 p.o. 5 x a day
for 10-14 days (14 days $20)
 Contraindicated in patients with
kidney disease, liver disease, and
immunosuppressed patients (HIV)
Acute Phase
Treatment - Topical Antivirals
 Trifluridine ophthalmic drops
 Trade name – Viroptic ($125, generic $95)
 1 drop q1h (8 times a day)
 Vidarabine ophthalmic ointment (UNAVAILABLE EXCEPT BY SPECIALORDER)
 Trade name – Vira-A ung (5 times a day)
 Effective against strains unresponsive to
Viroptic and Acyclovir
What about steroids to decrease scarring?
Treatment of Ocular
Herpes Simplex
 HEDS –Herpes Eye Disease Study
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(Archives of Ophthalmology,121,Dec.03’)
Longterm use of oral Acyclovir greatly
reduces the recurrence of HSK
400mg daily, compliance is mandatory
Patients who stopped early – re-infected
12 months vs. 18 months vs. Indefinitely
Diagnosis
We’ve all heard “Herpes Zoster
the Great Imposter” however,
Ocular Herpes Simplex can be
cunning as well
Pearls
 Consider superficial wipe with weck cell sponge or cotton
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tip applicator with HSK
Remember subsequent epithelial infections are not as
irritating or painful
Family and friends watch for “red eye”
Do not miss multiple doses of oral Acyclovir can lead to
reactivation
Think of it as BC or a daily Vitamin
If nonresponsive try Vira-A ung
 LeiterRX.com – 800-292-6773
 Be cautious with steroids!!
60 y.o. white male
 POAG diagnosed 3 years previously
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IOP
Disks
24-2’s
GDX
 (+) Family History
 Mother
 Significant field loss
 Managed with Timoptic .5%
 Baseline IOP consistently around 21mmHg
C.E.O. of major academic
institution
 Engaged in major capital fundraising
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campaign
Anticipating program’s 100 year
anniversary celebration week
Prominent lecturer on CME circuit
Professionally, very active
Personally, Physically, very active
Initial Treatment
 Timoptic .25%
 Rx: 1gt OD + OS, once per day, a.m.
 IOP OD: 20 and OS: 19
 Rx: 1gt OD + OS, twice daily, a.m. + p.m.
 IOP OD: 19 and OS: 19
 Patient complains of difficulty with daily
early-morning jogging
Timoptic discontinued
 Xalatan treatment initiated
 Rx 1 gt OD + OS at night, prior to sleep
 IOP OD: 16 OS: 15
 Complaint of “red eye reaction”
 Daily dosing schedule altered
 Rx 1 gt OD + OS at dinner time
 “Red eye reaction” complaint persists
Xalatan discontinued
 Travatan initiated
 “Red eye reaction” complaint intensifies
Argon Laser Trabeculoplasty
discussed with patient
 Selective Wavelength Laser
Trabeculoplasty mentioned to patient
S.L.T. performed OD + OS
 Inferior 180-degrees
 IOP at 2 months: OD 21 OS 21
Second S.L.T. performed
 Superior 180-degrees
 IOP at 1 month: OD: 16 OS: 15
 IOP stable at 15 – 18 at this time
52 y/o Female
 “I want to have LASIK”
 Previous CL wearer (monovision) started
to have comfort issues and previous doc
told her to go to glasses – “hates them!”
 Med Hx: menapausal, mild controlled HTN
 C/O VA is blurry with glasses in distance
OD > OS
The Exam
 VA cc OD 20/40 OS 20/25
 Pupils, EOM’s, CVF normal OU
 BVA OD -3.00-75 x 040, 20/30OS -4.00-1.00 x 025, 20/25 SLE: Lids and lashes clear, A/C deep and
quiet, 1+NS OU,
 See corneal photos
 Internal: .25 C/D OU, Macula and periphery
clear OU
 Corneal photo
 Corneal photo
?? LASIK Candidate ??
 Is a patient with Fuch’s Dystrophy a
candidate for LASIK?
 Is a patient with Cogan’s (MDF) Dystrophy
a candidate for LASIK?
Fuch’s Endothelial Dystrophy
 Females 3:1
 Autosomal Dominant
 Slowly progressive formation of guttate lesions
between the corneal endothelium and
Descemet’s membrane
 Guttate are thought to be abnormal elaborations
of basement membrane and fibrillar collagen
from distressed or dystrophic endothelial cells
 So does performing laser on the corneal stroma
effect this condition in any way?
Refractive Surgery and Fuch’s
 Incisional refractive surgery, AK, RK,
LASIK and ALL-LASER LASIK, is
contraindicated in Fuch’s patients (?)
 Surface Ablation, PRK, LASEK, Epi-LASIK
are relative contraindications
 It is estimated that there is 3-8% of
endothelial cell loss during laser ablation
DSEK or DSAEK
 Descemet’s Stripping Endothelial
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Keratoplasty
Descemet’s Stripping Automated
Endothelial Keratoplasty
Impressively mild post-op
Minimal corneal edema or anterior
corneal compromise
Rapid rehab with minimal to no astig.
DSAEK VIDEO
Cogan’s Dystrophy
 MDF, ABMD, EBMD, Microcystic Epithelial
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Dystrophy
Nonprogressive but fluctuating in course
F>M
1/3 of patients have RCE
Irregular Astigmatism common cause of
VA loss
VA loss does not match clinical picture via
slit lamp exam
Cogan’s Dystrophy
 Pathophysiology: Corneal epi adheres to
underlying BM
 Faulty BM – thickened, multilaminar,
misdirected into epi: “maps & fingerprints”
 Deeper epi cells don’t migrate to the
surface: “dots, intraepithelial microcysts”
 Epi cells ant. To the BM difficulty forming
hemidesmosomes results in RCE
Cogan’s Dystrophy
 Treatments: AT’s, Muro 128 gtts and ung
 2005 only prospective study to date no
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difference between AT”s and NaCl
Irregular Astig. CL fix? RGP vs. Soft
Superficial Keratectomy
Polish BM w/ diamond burr or alger brush
ASP for erosions or post Keratectomy, consider
donut approach and spare visual axis
PTK or PRK if going for refractive correction
Not great LASIK candidates
Cogans Dystrophy
 For decreased VA w/ suspect irregular
astigmatism look at placedo disc vs.
topography
 Consider Silicone Hydrogels however,
beware most of these patients have some
degree of dry eye and are more likely to
have torsion marks / RCE
 Daily vs. EW? Poor dexterity in elderly