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2015 NORTHWEST RESIDENTS CONFERENCE Pacific University College of Optometry – Jefferson 224 Friday, June 12 & Saturday, June 13, 2015 PROGRAM AGENDA Faculty: Carole Timpone, OD, FAAO, FNAP, Associate Dean of Clinical Programs and Director of Residencies, will oversee the event. Each resident will deliver a 30 minute presentation that includes responding to questions and comments from attendees. FRIDAY, JUNE 12, 2015 PAGES Rachael Lloyd, OD 1-11 Idiopathic Intracranial Hypertension – You Down VA Puget Sound Health Care System with PTC? Alisa Nola, OD Post Trauma Vision Syndrome Diagnosis and 12-21 Bright Eyes Vision Clinic Management using Visual Evoked Potentials (VEP) Mackenzie Macintyre, OD Ocriplasmin for Vitreomacular Adhesion: Boom 22-32 VA Portland Health Care System and Bust? Emily Liu, OD Plaque to the Future: Utilizing SD-OCT in the 33-41 VA Puget Sound Health Care System Management of CRAO and Retinal Emboli BREAK Haley McCoy, OD Ocular Sequelae of Common Systemic Medications 42-50 VA Portland Health Care System Magi Labib, OD Retinal Artery Occlusions Secondary to Illicit Drug 51-60 Lebanon VA Medical Center Use Victoria Roan, OD Oral Acetazolamide versus Topical Dorzolamide in 61-69 Jonathan Wainwright Memorial VAMC the Treatment of Retinitis Pigmentosa Kolten Kuntz, OD A Look into Current Trends and Future Advances in 70-76 Spokane VA Medical Center Cataract Surgery Frank Zheng, OD The Effects of Decentering Multifocal Soft Contact 77-87 Pacific University and Associated Clinics Lens Optics and its Relation to Distance Vision Warren Whitley, OD 88-98 Differential Diagnoses of Post-Operative Uveitis Eye Care Associates of Nevada SATURDAY, JUNE 13, 2015 Crystal Thanos, OD Ocular Indications for Carotid Imaging 99-108 Roseburg VA Medical Center Branden McFadden, OD Using Ocular Coherence Tomography for Analysis 109-116 Spokane VA Medical Center of Peripheral Retinal Findings Stacy Hill, OD Bilateral Congenital Superior Oblique Palsy 117-127 Pacific University and Associated Clinics Rachel Lee, OD Case-series of Homonymous or Altitudinal 128-135 VA Portland Health Care System Hemianopia Management Using the Prism Connie Lee, OD Congenital Nystagmus – New Ideas on Treatment 136-143 Vision Northwest BREAK Truyet Tran, OD Cystoid Macular Edema: A Case Report and Review 144-154 VA Portland Health Care System Gleb Sukhovolskly, OD The Effects of Exogenous and Endogenous Jonathan Wainwright Memorial VAMC 155-164 Corticosteroids on Pathophysiology of Central Serous Choriorentiopathy Shannon Currier, OD Understanding Choroidal Folds 165-175 VA Portland Health Care System Janice Pierce, OD Ocular Sequelae of Cranial Nerve Palsies 176-195 VA Southern Oregon Keegan Bench, OD Retrograde Degeneration of Retinal Ganglion Cells Spokane VA Medical Center 196-210 Detected with Optical Coherence Tomography in Patients with Homonymous Hemianopia This program is sponsored in part by an unrestitric ted e duca tiona l gran tft from 2015 NORTHWEST RESIDENTS CONFERENCE 6/5/2015 LEARNING OBJECTIVE By the end of this course, attendees will be able to recognize and provide an overview of the diagnosis, testing, treatment, and management of idiopathic intracranial hypertension. Two case studies will be reviewed. IDIOPATHIC INTRACRANIAL HYPERTENSION –YOU DOWN Learning objectives Definition of IIH WITH PTC? Diagnosis Diagnosis, management, and treatment – Two cases Pertinent testing Rachael Lloyd, O.D. Treatment VA Puget Sound – American Lake Division Management Tacoma, Washington [email protected] IDIOPATHIC INTRACRANIAL HYPERTENSION (IIH) – WHAT IS IT? MODIFIED DANDY CRITERIA2 IIH otherwise known as Pseudotumor Cerebri Diagnosis of exclusion Causes of increased intracranial pressure (ICP) 1 Modified Dandy Criteria Obstructive hydrocephalus, Chiari I malformation, 1. Symptoms of increased ICP various drugs, vitamin A (retinoids), venous sinus 2. No neurological signs except sixth nerve palsy allowed thrombosis/stenosis, idiopathic 3. Patient is awake and alert 1 Risk factors 4. Normal CT/MRI findings without thrombosis Obese females b/t ages of 15-40 5. LP opening pressure of >25 cmH20 Recent weight gain 6. No other explanation for increased ICP Presenting symptoms1 Headache, pulsatile tinnitus, TVOs, diplopia, and VF constriction Modified Dandy criteria COURSEBOOK Page 1 of 210 1 6/5/2015 USE OF OPTICAL COHERENCE DIAGNOSIS TOMOGRAPHY Must have imaging before lumbar puncture (LP) CT/CT venogram, MRI/MRV (less urgent) 3 Normal opening pressure on LP: <25 cm H20 Negative imaging studies Lack of SVP (in most patients) Use of OCT Lenworth, N., et al. Differentiating optic disc edema from optic nerve head drusen on optical coherence tomography. Archives of Ophthalmology. 2009. 127(1): 45-49. TREATMENT CONTINUED –MEDICAL TREATMENT THERAPIES Weight loss – have shown disease resolution with Acetazolamide (Diamox) 3 6% weight loss CAI Bariatric surgery 1000mg daily1,3 Discontinue known drugs that cause increased Negative side effects ICP Topiramate (Topamax) Acetazolamide therapy CAI Topiramate therapy Can mediate headache Can cause weight loss Furosemide therapy Furosemide (Lasix) Optic nerve sheath fenestration (ONSF) CAI Lumboperitoneal (LP) shunting Ventriculoperitoneal (VP) shunting COURSEBOOK Page 2 of 210 2 6/5/2015 TREATMENT CONTINUED –SURGICAL TREATMENT CONTINUE –SURGICAL PROCEDURES PROCEDURES Optic Nerve Sheath Fenestration Ventriculoperitoneal (VP) shunt Series of slits in ONH sheath Most successful – 30% require revision7 Procedure of choice for progressive VF loss Must have mild HA or manageable HA Venous Sinus Stenting Lumboperitoneal (LP) shunt Very successful – 12% required revision8 5 60% required revision in trial within 5 years Major morbidity – Subdural Hematoma http://www.jirehdesign.com http://neuroanimations.com/Hydrocephalus/graphics/VP_Shunt_Final_lateral.jpg http://www.koraszulott.com/cikkek/Hydrocephalus http://weillcornellbrainandspine.org/sites/default/files/pseudotumor-cerebri-trial-3-lg.jpg CASE 1 CASE 1 CONTINUED - EXAMINATION 28 yo American Indian/Hispanic male Rx Presents with complaints of TVOs OD>OS OD: -3.75-1.25x090 – no improvement in VA h/o weight gain since discharge OS: -4.50-0.75x079 – no improvement in VA Strong history of mental health issues, PTSD, clinical depression, and a suicide attempt GAT OD/OS: 17/18 DVA Anterior segment exam unremarkable OD: 20/30 PHNI OS: 20/20 Posterior segment exam Trace RAPD OD Optic nerve: unable to determine C/D ratio d/t grade Confrontation VF – unable to tolerate automated perimetry 4 disc edema OD and grade 3 disc edema OS Constriction 360 with distortion/missing spots on facial amsler Paton’s lines OU Color plates Macula: clear, flat, dry OD: 3/14 Periphery: scattered white without pressure OS: 3/14 BP: 133/82 COURSEBOOK Page 3 of 210 3 6/5/2015 ODOD: OS OS: Modified Frisén Papilledema Scale Grade II Grade I CASE 1: SPECTRALIS SD-OCT OD: Grade III Grade IV Grade V OS: COURSEBOOK Page 4 of 210 4 6/5/2015 DIFFERENTIAL DIAGNOSIS CASE 1 CONTINUED Pt very likely had increased ICP based on MRI w/o contrast – no evidence of mass findings/symptoms Lumbar puncture opening pressure: 48 cm H20 Space-occupying lesion/mass in brain CSF lab results unremarkable Obstructive hydrocephalus Chiari I malformation Treatment Drug-induced Begin Acetazolamide 1000mg daily Vitamin A, retinoids, indomethacin, lithium, and Taper Depakote over next two weeks anabolic steroids RTC 2 weeks for follow up Venous Sinus Thrombosis/Stenosis OD CASE 1 CONTINUED Did not return as scheduled Returned two months later Discontinued acetazolamide due to side effects few days after initiating med On follow up: Pt reporting constant headache/TVO’s Trouble walking Ran into door frame and broke a tooth Upon observation while walking to exam room, pt was using wall as guide and refused any assistance. Has not kept visits with neurology or neuro- ophthalmology COURSEBOOK Page 5 of 210 5 6/5/2015 Initial Visit OS OD Two months later OS CASE 2 CASE 2 CONTINUED - EXAMINATION 25 yo Hispanic female VA OD: 20/30 PHNI CC: PAL not working OS: 20/20 Presents with floaters/flashes x 3 wks, pressure EOM testing – mild adduction deficit OD OD, light/dark adaptation issues, longstanding FDT C-20-5 – non-specific, non-repeatable peripheral diplopia, pulsatile swishing sound x 1 year defects h/o 60 lb weight gain over last 3 mos No RAPD, pupils 7mm, minimal reactivity Denies pregnancy Rx OD: -3.50-0.50x175 – no improvement in VA Strong history of mental health disease, PTSD, OS: -2.75-1.00x175 – no improvement in VA clinical depression, and suicide attempts Color : h/o esotropia surgery OU before she was 3 yrs old OD: 8/11 OS: 11/11 h/o seizures – last episode 6 mos ago Anterior segment exam unremarkable COURSEBOOK Page 6 of 210 6 6/5/2015 OD CASE 2 CONTINUED - EXAMINATION GAT OD/OS: 10/12 Posterior segment exam Optic nerve: C/D ratio: 0.30/0.30 OU OD: no SVP OS: (+)SVP Grade 3 disc edema OU, flame hemes around disc OU, Paton’s lines OU Macula: clear, flat, dry Periphery OD: clear OS: vitreoretinal tuft superiorly OS OD OS Initial visual field testing COURSEBOOK Page 7 of 210 7 6/5/2015 CASE 2 CONTINUED - TESTING CASE 2 CONTINUED Differentials? Poor reaction to acetazolamide – poor compliance CT without contrast Metallic taste, increased fatigue, increased No evidence of cerebral edema depression, kidney stones No evidence of mass Pt has allergy to Topiramate – contraindicated CT venogram
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