Ocular Potpourri by mikesanye

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									Ocular Potpourri -Anterior and Posterior Segment                                                                   Saturday, June 7, 2008
Case Presentations to Help You Clinically



                                 COPE ID #

                             14214-AS
                             14214-                                                        Disclosures
                    Ocular Potpourri                                    I will mention many products, instruments
                                                                       and companies during our discussion, I
                                                                       don’t have any financial interest in any of
        Anterior and Posterior Segment Case                            these products, instruments or companies.
        Presentations to Help You Clinically
                                                                       All of these cases have entered/referred to
                Greg Caldwell OD, FAAO                                 my practice.
               Pennsylvania Optometric Association
                          June 7, 2008
                          3:00-
                          3:00-5:00 PM




                                                                                   25 year old man
                                                                        Patient has been to 3 ophthalmologists and 1
                                                                       optometrist in the past year
                                                                        Patient complains of a “ghost image” OS
                               Case 1                                   Has had 4 dilated exams in past year, and no
                                                                       diagnosis yet
                                                                        He is very passionate that his vision is clear OD
                                                                       and “ghosty”OS. He wants to know why.




                    “Ghost Image” OS                                   Any Thoughts About “Ghost Images”?

          Va 20  20                   Current Correction                    Causes of “ghost images”
                                      R -2.50-1.00 x 180                       Refractive
          cc    20                                                                Uncorrected astigmatism
                                      L -3.25-1.00 x 180                       Corneal
                                                                                  Irregular astigmatism
                                                                                     –   EBMD
          EOMS: full, unrestricted    PERRL (-)APD                                   –   Saltzman nodules
                                                                                         Keratoconus
          CT: ortho D/N               CF: full by FC OU                              –
                                                                                     –        kerato-
                                                                                         Post kerato-refractive surgery
                                                                               Crystaline lens
                                       Previous unremarkable tests                Opacity                     Previous unremarkable tests
          SLE-
          SLE-unremarkable                                                     Retina, macula
                                             Topography                                                           Topography
          Fundus-
          Fundus-unremarkable                                                     Epiretinal membrane
                                             Fluorescein angiography              Edema                           Fluorescein angiography
                                             CAT scan                                – CME, CSME                  CAT scan
                                             MRI                                                                  MRI




Greg Caldwell, OD, FAAO
Grubc@aol.com                                                                                                                               1
Ocular Potpourri -Anterior and Posterior Segment                          Saturday, June 7, 2008
Case Presentations to Help You Clinically



                                                     How I felt when I finally realized
                                                      keratoconus starts posteriorly




            Forme Fruste Keratoconus
           Treatment
           RGP lens in office and trial frame over
          refraction
            Eliminated “ghost image”
                                                                 Case 2
          Patient currently only in spex
            Not interested in RGP lens
          RTC 1 year, B VA and topographies




               Advanced Keratoconus                         Topography OD




Greg Caldwell, OD, FAAO
Grubc@aol.com                                                                                 2
Ocular Potpourri -Anterior and Posterior Segment                                Saturday, June 7, 2008
Case Presentations to Help You Clinically



                                                    What happens when the posterior cone gets
                 Topography OS                     too steep and Descemet’s membrane ruptures?


                                                                       Hydrops




                                                     Descemet’s Stripping Endothelial Keratoplasty
                                                                         DSEK



                 Corneal Transplant




                                                               28 year old man
                                                   Had LASIK 14 months ago
                                                   His right eye is now very blurry
                     Case 3                        He tried calling for an appointment the center is
                                                   now closed




Greg Caldwell, OD, FAAO
Grubc@aol.com                                                                                          3
Ocular Potpourri -Anterior and Posterior Segment                                                            Saturday, June 7, 2008
Case Presentations to Help You Clinically



         Va 20  40         Current Correction
         cc    20          R -6.50+7.00 x 130
                           L -0.25 sphere
                                                                                                                           Topography
                                                                                                                              OD
          EOMS: full, unrestricted   PERRL (-)APD
          CT: ortho D/N               CF: full by FC OU

          SLE-
          SLE-trace fibrosis at flap edges, no stain
          SLE-     multi-
          SLE-few multi-directional striae OD>OS
          SLE-
          SLE-clean interface OU                              Diagnosis:
          Fundus-
          Fundus-unremarkable                                    Keratoectasia 2° LASIK
                                                                     20/20-
                                                              RGP OD 20/20-2
                                                                This lasted for about 3 months
                                                                                                                                    20/50-
                                                                Multiple RGPs later due to progression of astigmatism to 8.5 D (BVA 20/50-2)
                                                                Finally PKP was done Jan 2006




                                                                               43 year old man
                                                             Called your office today
                                                             Eye pain in the right eye since this morning
                               Case 4                        OD 20/80 OS 20/20
                                                             Externals: normal
                                                             Review of Systems: unremarkable




                  Slit Lamp Evaluation                         43 year old male
                                                             further history reveals
                                          Corneal abrasion     Fourth time in past 24 months
                                                                                                                                           OS
                                          Corneal ulcer        Uses Muro 128
                                                                  Gtts qid
                                          Herpetic lesion         Ung qHS

                                                               Diagnosis:
                                                                  Recurrent Corneal Erosion secondary
                                                      OS          to Epithelial Basement Membrane
                                                                  Dystrophy (EBMD)
            OD




                                                                                                                         OD




Greg Caldwell, OD, FAAO
Grubc@aol.com                                                                                                                                   4
Ocular Potpourri -Anterior and Posterior Segment                                                                               Saturday, June 7, 2008
Case Presentations to Help You Clinically




                                     Treatment                                                             Map-Dot-
                                                                                                 Review of Map-Dot-Fingerprint
          Antibiotic, Vigamox tid
          Pain management
             Depending on severity
                 Bandage contact lens
                 Oral ibuprofen (200 mg)
                   – Maximum 3200 mg daily
                 Oral acetaminophen (500 mg)
                   – Maximum 4000 mg daily
                 Oral narcotic (need DEA number)
                   –            N-
                     Darvocet N-100 (650/100)
                   – They provide good pain relief
                   – A degree of sedation
                   – Tend to minimally impact the
                     digestive system and kidneys
                   – It's not that they're dramatically more
                     potent than OTC analgesics like
                     aspirin, acetaminophen, ibuprofen or
                     naproxen
                                                                    OD
                 Topical NSAID




                        Treatment Options                                                        Excimer Phototherapeutic Keratectomy (PTK)
          (Once Abrasion Resolved, to Help Prevent Recurrence)

          Medically                                    When is it time for surgical procedure?
             Hypertonics                                                                           Corneal Opacities
                 Gtts
                 Ung                                                                                Scarring
             Bandage contact lens                                                                   Granular dystrophy
          Surgical/Procedures
             Anterior stromal micropuncture              Answer: medical treatment failure         Surface Irregularity
             Debridement
                 Chemically
                                                                                                    Saltzman nodules
                 Mechanically
                   – Beaver blade/diamond burr                                                     Surface Breakdown
             Excimer phototherapeutic
             keratectomy (PTK)
                                                                                                    Epithelial basement membrane dystrophy




                             PTK Procedure                                                                               PRK

          Removal of epithelium
          Manual debridement
          Polish with excimer




Greg Caldwell, OD, FAAO
Grubc@aol.com                                                                                                                                      5
Ocular Potpourri -Anterior and Posterior Segment                                          Saturday, June 7, 2008
Case Presentations to Help You Clinically




                                 PTK                                Post op Regimen
                                                                        Pred-      q2°
                                                            Vigamox and Pred-Forte q2°
                                                             Until wound is closed
                                                            Bandage contact lens (B CL)
                                                            Vitamin C, 1000 mg/day x 1 month
                                                            NP-
                                                            NP-artificial tears
                                                            Sunglasses in any UV




                       Before & After


                                                                            Case 5




               Patient Wants Second Opinion
                                                             Slit Lamp         Findings
                                                                                     OD only red and injected
                                                            Evaluation               Stuck shut this morning

                    42 year old woman                                          Diagnosis
                                                                                     Bacterial conjunctivitis
                    OD red and painful                                         Ocular history reveals
                                                                                     3rd time in past 10 months
          Va 20  20               Current Correction                                 Vigamox
                                  R -2.00-1.00 x 180                                                             2-
                                                                                        Successfully resolves in 2-3 weeks
          cc    20
                                  L -3.00-1.00 x 180

                                                                                 Why recurrent and slow to resolve?
            EOMS: full, unrestricted   PERRL (-)APD
            CT: ortho D/N               CF: full by FC OU




Greg Caldwell, OD, FAAO
Grubc@aol.com                                                                                                                6
Ocular Potpourri -Anterior and Posterior Segment                                                      Saturday, June 7, 2008
Case Presentations to Help You Clinically




                 New Diagnosis?                                                                       Treatment
                                                                                                         Vigamox gtts TID
                           Recurrent bacterial                                                           Azithromycin (Zithromax)
                          conjunctivitis secondary                                                                       z-
                                                                                                             Disp: 5 day z-pak
                          to dacryocystitis                                                                  Use as directed PO

                           Discussion
                            Treatment
                                                                     Discussion
                               Vigamox, tid
                               Oral antibiotic, which one?
                                                                        Dilation and Irrigation
                                 – Patient is allergic to                   Contraindication or indication?
                                   Penicillin and Keflex                    This case dilation and irrigation…system open
                                                                     If confirmed nasolacrimal duct blockage
                                                                        Surgical consult for dacryocystorhinostomy (DCR)




                                                                     84 year old woman
                                                             Right eye red and painful
                      Case 6                                 Started about 10 days ago
                                                             See photos for discussion




                                                                                1 Week Later
                    Diagnosis?
                    Treatment?




                                                             Treatment Plan?                               Reminder 1 week ago
                                                                    Continue with topical and oral antibiotics
                                                                    Surgical consult for dacryocystorhinostomy (DCR)




Greg Caldwell, OD, FAAO
Grubc@aol.com                                                                                                                       7
Ocular Potpourri -Anterior and Posterior Segment                                               Saturday, June 7, 2008
Case Presentations to Help You Clinically




                                                        After Dacryocystorhinostomy (DCR)




                     Tube Removal


                                                                                Case 7




                   35 year old man                                    35 year old man
           Wants another opinion due to                 BVA 20/100 OD, 20/70 OS
                                                          Hx of amblyopia OD
          “hemorrhage on my right eye”                    Current Rx OD +5.50 OS +4.50
           Happened 3 days ago after vomiting           Any concerns?
                                                        Patient noticed blurry vision OS
            Claims food poisoning from chicken Caesar     Started 2 weeks ago
            salad                                         Did not mention because he is more
                                                          concerned about the blood on his
            Still feels a little nauseated                right eye
                                                        Headaches for 2 weeks, decrease
           Saw ophthalmologist 3 days ago, told he      if patient stands up
          had a bruise on his eye and it should go      ROS: unremarkable
                  1-
          away in 1-2 weeks                             Decide to dilate OU




Greg Caldwell, OD, FAAO
Grubc@aol.com                                                                                                      8
Ocular Potpourri -Anterior and Posterior Segment                                             Saturday, June 7, 2008
Case Presentations to Help You Clinically




                      Retinal Findings                              Differential Diagnosis
                        Discussion                            Hypertensive retinopathy
                                                              Blood dyscrasia
                                                              Terson’s syndrome
                                                              Valsalva retinopathy
                                                              Purtscher’s retinopathy
                                                              Shaken baby syndrome




                  Terson’s Syndrome                                           Treatment
           Terson’s syndrome originally was defined by the     Emergency referral to neurologist due to
          occurrence of vitreous hemorrhage in association
          with subarachnoid hemorrhage.                       high suspicion of intracranial hemorrhage
           Terson’s syndrome now encompasses any              and elevated intracranial pressure
          intraocular hemorrhage associated with
          intracranial hemorrhage and elevated intracranial    Intracranial hemorrhage confirmed with
          pressures.                                          MRI
           Intraocular hemorrhage includes the
          development of subretinal, retinal, subhyaloidal,    Patient later diagnosed with Hairy Cell
          or vitreal blood.                                   Leukemia and cryptococcal meningitis
            The classic presentation is in the subhyaloidal
          space.




                                                                     37 year old woman
                                                                     OD red and painful
                                                              Va 20  30             Current Correction
                            Case 8                            cc    20              R -2.50-1.00 x 180
                                                                                    L -3.25-1.00 x 180


                                                                 EOMS: full, unrestricted   PERRL (-)APD
                                                                 CT: ortho D/N               CF: full by FC OU




Greg Caldwell, OD, FAAO
Grubc@aol.com                                                                                                    9
Ocular Potpourri -Anterior and Posterior Segment                                                      Saturday, June 7, 2008
Case Presentations to Help You Clinically




                 Slit Lamp Evaluation                                                1 week later
                               Diagnosis
                               Ocular history
                                  First episode
                                                                                                Resolved
                               Treatment
                                  Viroptic                                                      Chance of occurring again
                                  Artificial tears                                              within 12 months?
                                  Steroid                                                          25%
                                      Always, never or sometimes?
                                    anti-
                               Oral anti-herpetic needed…?
                                  Probably not
                                  Unless….?
                                      Failure to respond to topical
                                      treatment




                    Cranium Keeper                                           Slit Lamp Evaluation
          Viroptic should be used for how long?
                                                                                                      5 Months Later
            21 days via package insert/instructions
                                                                                                      Treatment
                                                                                                         Viroptic
                                                                                                         Artificial tears
                                                                                                         Steroid
                                                                                                      Orals…?
                                                                                                         Possibly
                                                                                                            Educate patient on
                                                                                                            treatment options
                                                                                                              – 43% occurring again
                                                                                                         Failure to respond




                              4 Months Later                                Herpetic Eye Disease Study

                             Ocular history                           HEDS I
                                Third episode                           Benefit from steroids in stromal keratitis
                             Treatment                                  No benefit from oral Acyclovir in stromal keratitis
                                Viroptic
                                                                        Benefit from steroids if iritis present
                                Artificial tears
                                Steroid
                             Oral anti-herpetic?
                                  anti-                               HEDS II
                                Probably                               No benefit from Acyclovir to stop progression to
                                What dosage?                           stromal or iridocyclitis
                                                                       Maintenance dose 400mg BID, decreases recurrence
                                                                       by 41% within 1st year




Greg Caldwell, OD, FAAO
Grubc@aol.com                                                                                                                         10
Ocular Potpourri -Anterior and Posterior Segment                                  Saturday, June 7, 2008
Case Presentations to Help You Clinically




                                                                  Cranium Keeper
                                                          Percentages in HSV keratitis
                           Treatment                       25%
                             Viroptic                      43%
                             Artificial tears              41%
                             Acyclovir
                                800mg 5x’s/day po
                                400mg bid po




                                                                    8 year old girl
                                                         Mom noticed the left eyelid has become red
                                                        and has pimples
                      Case 9                             Started two days ago
                                                         Slowly getting more pimples on the eyelid
                                                         Globe not affected




               Slit Lamp Evaluation
                          Diagnosis
                           Herpes simplex blepharitis
                          Treatment
                           400 mg Acyclovir 5x/day
                                                                         Case 10
                           Call to pediatrician




Greg Caldwell, OD, FAAO
Grubc@aol.com                                                                                         11
Ocular Potpourri -Anterior and Posterior Segment                                                          Saturday, June 7, 2008
Case Presentations to Help You Clinically




                 58 year old woman                                                Axial length 29.85 mm

           VA OD 20/200 OS 20/400
           Longstanding history of macular degeneration
           Anything suspicious here?
             ?? Longstanding AMD in 58 year old??
           History of cataract surgery OU
           Glasses Rx OD -1.00 OS -1.00


                                                                             OD -18.00 OS -18.50 prior to cataract surgery




                                                                                   Degenerative Myopia
                               At what diopter value is a patient            Differs from refractive myopia
                                 considered a degenerative or
                                     pathological myope?
                                                                               There is an alteration of globe structure that is
                                                                               progressive
                                                                               Primary alteration is a posterior elongation of
                                                                               eyeball as a result of progressive thinning of
                                                                               sclera
                                                                                  Posterior staphyloma




                                                                                Conditions Associated With
                Degenerative Myopia
                                                                                  Degenerative Myopia
                                                                             Fetal Alcohol Syndrome
           Findings
            Lacquer cracks                                                   Ocular albinism
            Posterior staphyloma                                             Down’s Syndrome
            Fuch’s spot
            RPE and choroidal atrophy                                        Low birth weight
            Scleral crescents                                                Infantile glaucoma
            Vessel straightening                Can be found in refractive
            Disc tilting                        and degenerative myopes
                                                                             Retinopathy of Prematurity
            Peripheral retinal changes                                       Marfan’s Syndrome




Greg Caldwell, OD, FAAO
Grubc@aol.com                                                                                                                      12
Ocular Potpourri -Anterior and Posterior Segment                                        Saturday, June 7, 2008
Case Presentations to Help You Clinically




                       Treatment                            Which patient is at higher risk of
                                                                 retinal detachment?
           BVA with glasses/contact lenses
                                                                              Two patients are in your office
           Education regarding trauma and possible                            -8.00 D refractive myope
          eye hazards                                                         -14.00 D degenerative myope
           Monitor for neovascularization and
          peripheral retinal changes
           Follow-up at least yearly
           Follow-




                                                                        Clinical Pearl
                                 Refractive myopia
                                  Peripheral retina         Refractive myopia
                                  concerns                   Peripheral retina is general concern
                                                            Degenerative/Pathological myopia
                                                             Posterior pole is general concern
                                                               Posterior staphyloma

                                 Degenerative myopia
                                  Posterior pole concerns




            Peripheral Fundus Findings

                      Pavingstone
                      Degeneration
                                                                             Case 11

         Pigmented                        Lattice
            Holes                      Degeneration




Greg Caldwell, OD, FAAO
Grubc@aol.com                                                                                                   13
Ocular Potpourri -Anterior and Posterior Segment                                         Saturday, June 7, 2008
Case Presentations to Help You Clinically



                   88 year old man                           Recommend psyche consult?
         I see faces of friends that I have not
         seen for years, wheels of cars and at               Alert and Oriented x 3
                    times pine trees                          Person
                                                                Knows who he is, who is with him

                                      Current Correction
                                                              Place
                   BVA                                          Knows where he is, knows where he lives
                                      R plano
         Count fingers at 2 feet OU
                                      L -1.00 sphere          Time
                                                                Knows what month, day, date and year

         EOMS: full, unrestricted    PERRL (-)APD
         CT: ortho D/N by Hirschberg CF: central defect OU




              Diagnosis and Treatment?                         Charles Bonnet Syndrome
                                                               “Release Hallucination”
                                                             Visual hallucinations
                                                              Irritative (brief)
                                                                Epilepsy
                                                                Migraine
                                                              Release (continuous)
                                                                Stroke
                                                                Sensory deprivation




                                                                          Clinical Pearl
                            Treatment                            Is there a difference between
                                                             Geographic Atrophy and Disciform Scar
           Reassurance
             That this is normal for patient with severe
             vision loss to experience hallucinations




Greg Caldwell, OD, FAAO
Grubc@aol.com                                                                                               14
Ocular Potpourri -Anterior and Posterior Segment                                                                Saturday, June 7, 2008
Case Presentations to Help You Clinically




                                                                            48 year old man
                                                                   OU red, gritty, sandy and dry feeling

                                                                        Va 20 20                        Current Correction
                             Case 12                                    20                              R -2.00 sphere
                                                                        cc    20                        L -3.00 sphere



                                                                           EOMS: full, unrestricted            PERRL (-)APD
                                                                           CT: ortho D/N                        CF: full by FC OU




                                                                                          A Closer Look
                                      Diagnosis
                                         Rosacea
                                      What findings support your
                                      diagnosis?
                                         Telangiectasias
                                         Erythema of the cheeks,
                                         forehead and nose
                                         Rhinophyma
                                            Indicates chronic
                                      Let us get a closer look




                  Rosacea Blepharitis                                               Minocycline
                                                                                Tetracycline Analog
                 (Inflammatory Blepharitis, MGD)
          Diagnosis?                                                   Staph Aureus
                                                                                          Lipase
                                                                                                    Meibomian Gland Secretions
                                                                     Staph Epidermis                         (Lipid)
          Treatment?
            In my opinion, most under treated condition
                                                                                                                       Phospholipids
            Warm compresses                                                  Turbid            Marginal Foam
                                                                         Inspissated MG           (Soap)
            Lid hygiene
                                                                                                                      Arachidonic Acid
            Artificial tears
            Omega 3 fatty acid, flaxseed oil
                                                                                                                Prostaglandins    Leukotrienes
            Dermatological consult (Acne Rosacea)                                                               Thromboxines
            Oral antibiotics…???
              Which one and why??
                                                                   How About Steroids?




Greg Caldwell, OD, FAAO
Grubc@aol.com                                                                                                                                    15
Ocular Potpourri -Anterior and Posterior Segment                                                                           Saturday, June 7, 2008
Case Presentations to Help You Clinically



                                                                                                       My Paradigm for
              Minocycline / Doxycycline                                                             Minocycline / Doxycycline
          Drug of choice for marginal inflammatory                                           Status of MG       Minocycline / Doxycycline Paradigm
          blepharitis (posterior blepharitis)                                                                                           2-
                                                                                                                     Maximum dosage for 2-12
          AB, anti-inflammatory and anti-collagenase
              anti-                    anti-                                                   Inspissated           weeks (pulse)
                                                                                                                       100 mg BID, QD
          Inhibits lipase enzyme
          No renal adjustment                                                                                        50-
                                                                                                                     50-100mg qd while turbid
                                                                                               Turbid
          50-          qd-    2-
          50-100 mg qd-bid 2-12 weeks (pulse)                                                                        20 mg longer treatments
              Lower maintenance dose                                                                                   Periostat (Doxycycline)

          20 mg Periostat (Doxycycline)                                                        Clear                 20 mg if maintenance dose
              Helpful in those with stomach or GI sensitivity
                                                                                                                     needed
              Excellent for those requiring long maintenance dose




         Precautions With Oral Tetracycline Analogs                                                          Minocycline
          Enhanced photosensitivity                                                          Less photosensitivity
          Avoid in children and pregnancy
          (Category D)                                                                       Less GI upset
          Can enhance Coumadin
          Can enhance the action of digoxin                                                  Less bacterial resistance
          ?Long term use with increase risk
          of breast cancer?
              1 paper/study, not regarded as
              highly reliable study
              Further investigation discredited
              the association
          Benign intracranial hypertension,
          reported cases
                            1978-
              17 cases from 1978-2002




                        Successfully Treated                                                      Minocycline for Ulcers?

                                                                                                      anti-
                                                                                              Are the anti-
                                                                                             inflammatory benefits
                                                                                             useful to help reduce
                                                                                             the corneal
                                            Warm Compresses                                  degradation that
                                            Lid Scrubs                                       occurs in sterile and
                                            Artificial Tears, Systane                        infectious keratitis?
                                            Mino 100 mg PO 6 weeks, 50 mg 3 months,
                                            20 mg maintenance (Doxy)
                                            Steroids, Tobradex qid (5 weeks with taper)
                                                  Moderately red and thickened lid margins
                                                  Marginal infiltrates




Greg Caldwell, OD, FAAO
Grubc@aol.com                                                                                                                                        16
Ocular Potpourri -Anterior and Posterior Segment                      Saturday, June 7, 2008
Case Presentations to Help You Clinically



                                                   I Can’t Believe It’s Not Butter!®
           What is an Inspissated MG?
                                                                Squeeze


             Inspissated Meibomian Gland




                                                          Thank-You!
                                                          Thank-
                    Questions
                                                        Greg Caldwell, OD, FAAO

                                                            Grubc@aol.com




Greg Caldwell, OD, FAAO
Grubc@aol.com                                                                            17

								
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