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Sclera, Choroid, Retina, Oh My! AMIEE HO, OD, FAAO PACIFIC UNIVERSITY

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Sclera, Choroid, Retina, Oh My! AMIEE HO, OD, FAAO PACIFIC UNIVERSITY Statement of Disclosures No financial disclosures https://en.wikipedia.org/wiki/The_Wizard_of_Oz_(1939_film)#/media/File:Judy_Garland_in_The_Wizard_of_Oz_trailer_2.jpg Sclera, Choroid, Retina, oh my! AMIEE HO, OD, FAAO PACIFIC UNIVERSITY Cases The Red Eye The Black Spot Good Vision Super Healthy Guy The Red Eye A little bump in the road 64 year old African American male Ocular History CC: Eye pain and redness OD x 3 days Ocular Hx: ◦ >> Pain with bright light ◦ Age‐related cataracts OU ◦ Pain is dull(?) ◦ Dry eye OU vs. mild mucus fishing syndrome ◦ Gradually more painful ◦ Mild blurred vision ◦ Slightly more scleral show OS>OD ◦ Exophthalmometry nearly symmetric ◦ A little watery https://pixabay.com/photos/cat‐wink‐funny‐fur‐animal‐red‐1333926/ ◦ First time, no previous Hx of similar pain ◦ Refractive error OU and presbyopia ◦ (‐)trauma; (‐)FB; (‐)itchiness; (‐)mucus; (‐) CL wearer LEE: ~1 month ago Medical History Medications and Vitals Medical Hx: Medications Vitals o HEMOGLOBIN: 13.5 g/dL ◦Anemia o DILTIAZEM o HEMATOCRIT: 40.0 % o ALBUTEROL ◦Asthma o PLATELETS: 295 k/uL o BUDESONIDE/FORMOTEROL o INR: 1.3 RATIO ◦COPD o TIOTROPIUM o HEMOGLOBIN A1C: 5.9 % H o CARBOXYMETH 0.5% (REFRESH TEARS) ◦GERD o GLUCOSE: 101 mg/dL o OMEPRAZOLE ◦Hypertension o MICROALBUMIN: 1.6 mg/dL o ESTIMATED GLOMERULAR FILTRATION o Allergies: NKDA ◦Hyperlipidemia RATE: 70 mL/min/m2* o CHOLESTEROL: 183 mg/dL ◦Primary Hyperparathyroidism https://pixabay.com/illustrations/doctor‐african‐oncology‐orthopaedic‐3187935/ o HDL: 30 mg/dL L ◦Prostate Cancer o LDL: 129 mg/dL ◦Substance Abuse o LAST BLOOD PRESSURE: 134/87 Exam Findings Yikes! ENTERING VAcc: OD: 20/20 OS: 20/20 EOMs: SAFE OU https://pixabay.com/photos/cat‐wink‐funny‐fur‐animal‐red‐1333926/ CVFs: FTFC OD, OS PUPILS: ERRL, (‐) APD OD, OS https://www.atlasophthalmology.net/photo.jsf?node=506&locale=en SL Exam Findings 3+ MG stasis, LIDS, LASHES, 3+ MG stasis, Posterior Exam Findings (‐) lids tender to touch; (‐) lid swelling LACRIMAL (‐) lids tender to touch; (‐) lid swelling Clear Media Clear Pinguecula; melanosis; chemosis 3‐9:00; CONJUNCTIVA Pinguecula; melanosis hyperemia temporal>inferior>nasal>superior Distinct Margins Distinct Pink and healthy Rim Pink and healthy Arcus 360; trace endo pigment OD>OS; CORNEA Arcus 360; trace endo pigment OD>OS; (‐) NaFl staining (‐) NaFl staining 0.30x0.30 C/D ratio (VxH) 0.30x0.30 4x4 ANGLES 4x4 AV 2/3; ALR ¼ Blood vessels AV 2/3; ALR ¼ (+)1+ cell; (+) 1+ flare ANTERIOR Deep and quiet CHAMBER Homogenous Background Homogenous Flat IRIS Flat Flat, even pigment Macula Flat, even pigment 1+ NSC LENS 1+ NSC No holes, tears or breaks 360; Periphery No holes, tears or breaks 360 Clear VITREOUS Clear RPE dropout along vessel vs 16 IOP 08 vessel sheathing superior Reliable, full field FDT Reliable, full field (elevated vessel?) SL Exam Findings 3+ MG stasis, LIDS, LASHES, 3+ MG stasis, (‐) lids tender to touch; (‐) lid swelling LACRIMAL (‐) lids tender to touch; (‐) lid swelling Pinguecula; melanosis; chemosis 3‐9:00; hyperemia CONJUNCTIVA pinguecula; melanosis temporal>inferior>nasal>superior (‐) conj blanching after phenyl Arcus 360; trace endo pigment OD>OS; CORNEA Arcus 360; trace endo pigment OD>OS; (‐) NaFl staining (‐) NaFl staining 4x4 ANGLES 4x4 Interesting observation (+)1+ cell; (+) 1+ flare ANTERIOR Deep and quiet CHAMBER AFTER DILATION…… Flat IRIS Flat 1+ NSC LENS 1+ NSC Clear VITREOUS Clear 16 IOP 08 Reliable, full field FDT Reliable, full field Assessement/Plan ~5 day f/u Assessment/Plan: 1. Anterior uveitis vs. scleritis OD ◦ Start 1% cyclopentalate BID + PRED FORTE q1h OD only 2. Vessel sheathing vs RPE dropout along vessel OD ◦ RTC in 1 day for DFE, IOP check, A/C check ◦ RTC immediately if symptoms worsen 5 day F/U Assessment/Plan: 1) Scleritis OD ◦Rx’d indomethacin 25 mg PO TID + ranitidine 150 mg PO BID ◦D/C cyclopentolate ◦Continue topical Pred Forte TID for now Recommend full physical examination by internist Ordered CBC, ESR, uric acid, RPR, FTA‐ABS, rheumatoid factor, ANA, C3, C4,ACE, serum ANCA, CF 50 17 day F/U Labs Ordered CBC, ESR, uric acid, RPR, FTA‐ABS, rheumatoid factor, ANA, C3, C4,ACE, serum ANCA, CF 50 Assessment/Plan: Test Results Norms Scleritis OD Immunoglobulin E 3438.0 <114 ◦ Taper Pred Forte down BID x 1 week, Qday x 1 week and then stop ◦ Stop NSAIDs/ranitidine ESR 64 0‐20 ◦ AFTs PRN Red cell distribution width 15.8 12‐15 ◦ Return precautions Monocytes 11.3 2‐10 Eosinophils 8.8 1‐6 Complement function activity <10 31‐60 ~1 month F/U Assessment/Plan: Improving scleritis OD ◦ Now with subconjunctival hemorrhage OD ◦ Cont Pred Forte daily OD for 1‐2 weeks then stop ◦ Return precautions Scleritis RTC general 2 months for follow up ◦ No showed Posterior Scleritis Classification Scleritis Anterior (98%) Posterior (2%) Non‐necrotizing Necrotizing Diffuse Nodular Diffuse Nodular Necrotizing Necrotizing without with inflammation inflammation (Scleromalacia Perforans) https://www.retinarocks.org/ Indian Journal of Ophthalmology https://www.atlasophthalmology.net/photo.jsf?node=506&locale=en Kumawat D, Chawla R, Hasan N. Retinochoroidal fold https://www.atlasophthalmology.net/photo.jsf?node=514&locale=en with severe discedema in a case of posterior scleritis. Indian J Ophthalmol [serial online] 2020 [cited 2020 Dec 31];68:647-9. Available https://www.atlasophthalmology.net/photo.jsf?node=3255&locale=en from: https://www.ijo.in/text.asp?2020/68/4/647/280786 https://www.atlasophthalmology.net/photo.jsf?node=4072&locale=en https://www.ncbi.nlm.nih.gov/books/NBK499944/#:~:text=The%20main%20differential%20diagnosis%20of,foreign%20body%20sensation%2C%20and%20tearing. Signs and Symptoms Etiology Anterior Posterior 50% have associated systemic disease o Chorioretinal folds o Pain o Retinal detachment o Rheumatoid arthritis (10‐30%) oSyphilis o Injection o Vitritis o Most common oSurgically induced necrotising scleritis (SINS) o Scleral edema o Optic disc edema o Cotton wool spots o Connective tissue disease (30%) oGout o Scleral nodule(s) o Decreased VA (wide range) o Granulomatosis with polyangiitis oTB o Globe tenderness to palpation o May be with or without o Replapsing polychondritis oLyme disease o Normal or decreased VA o Ocular pain o Ocular redness o Lupus oSarcoidosis o Photophobia o Discomfort with EOMs or have EOM o Reiter’s restriction oHypertension o Corneal infiltrate/thinning o B‐scan o Polyarteritis nodosa oForeign body o Scleral thinning (30%) o Thickening of sclera and choroid o AS “T” sign oViruses, bacteria, fungi, parasite (4‐10%) A/C cells/flare (30%) o o o Enhanced depth imaging OCT o Behcet o Thickening of choroid https://www.ncbi.nlm.nih.gov/books/NBK499944/#:~:text=The%20main%20differential%20diagnosis%20of,foreign%20body%20sensation%2C%20and%20tearing. https://www.ijo.in/article.asp?issn=0301‐4738;year=2020;volume=68;issue=9;spage=1818;epage=1828;aulast=Murthy https://www.reviewofoptometry.com/article/how‐to‐play‐the‐shell‐game Epidemiology Differentials Episcleritis Pingueculitis Middle age Conjunctivitis Phlyctenule Females>Males Trauma Retrobulbar mass African Americans Ocular rosacea Myositis https://www.atlasophthalmology.net/photo.jsf?node=506&locale=en Herpes zoster Scleral ectasia Anterior uveitis Staphyloma https://www.atlasophthalmology.net/photo.jsf?node=514&locale=en Evaluation Treatment History ◦ Oral NSAID o Immunosuppressive agents Examine sclera in all directions of gaze by gross inspection in adequate room light ◦ Oral Steroids o Biologics Slit‐lamp examination ◦ Add H2 blocker or PPI o Infectious etiologies: o Topical and systemic antibiotics DFE Complete physical exam o*Recommend glasses or eye shield Lab work‐up and imaging (for significant thinning/perforation risk) ◦ CBC, ESR, C‐reactive protein, uric acid, RPR, FTA‐ABS, RF, ANA, ACE, ANCAs, HLA‐B27, Lyme serology ◦ B‐scan, OCT, UBM, MRI or CT, Chest x‐ray, https://www.ncbi.nlm.nih.gov/books/NBK499944/#:~:text=The%20main%20differential%20diagnosis%20of,foreign%20body%20sensation%2C%20and%20tearing. Prognosis Mild or moderate scleritis – relatively good Necrotizing and posterior scleritis – higher risk of VA loss Recurrences are common The Black Spot 42 year old African American Male 42 year old African American Male New patient Ocular history: Medications: ◦ Unremarkable ◦ Hydrocortisone 1% ointment CC: black spot in vision OD x 1 week Medical history: Allergies: ◦ Constant, stable ◦ Eczema ◦ NKDA ◦ Blurred vision FOHx: ◦ Darker color vision ◦ Unremarkable BP: 138/96 ◦ Denies headaches, pain, flashes, curtain over vision, floaters FMHx: ◦ Unremarkable 42 year old African American Male 42 year old African American male VAsc Anterior segment: unremarkable OD/OS ◦ OD: 20/25 ◦ OS: 20/20+2 IOP: 20 OD/ 20 OS GAT Pupils: PERRL (‐)APD OD/OS EOMs: SAFE CVF: FTFC OD/OS Posterior segment: ◦ OD: 1.0DD central circular edema CT: Ortho (distance); 2XP (near) ◦ OS: unremarkable Red cap: equal between eyes ◦ OU: mild arterial attenuation Amsler grid: yellow shadow‐central circle, no metamorphopsia OD 42 year old African American Male Assessment: ◦ Central serous chorioretinopathy OD ◦ Pt reports elevated stress for the last few months ◦ Pt reports using hydrocortisone for eczema on eyes and regularly gets it into eyes ◦ Elevated BP Plan: ◦ Pt edu on findings and relation to stress and cortisol use ◦ Recommended avoiding use of hydrocortisone, especially getting into eyes ◦ Exam summary letter written to PCP to encourage f/u for elevated BP ◦ RTC in 1 month for f/u Why CSCR?? The Choroid Central serous is a pachychoroid disease! Choroid is very important! What does pachychoroid mean? ◦ Pachy (Greek) –thick Thickened choroid Changes in choroid can indicate disease https://commons.wikimedia.org/wiki/File:Blausen_0388_EyeAnatomy_01.png ENHANCED DEPTH IMAGING OCT The Choroid Layers of the choroid ◦ Bruch’s Membrane ◦ Choriocapillaris ◦ Sattler’s layer https://www.opticianonline.net/cet‐archive/153 ◦ Haller’s layer ◦ Choroid/sclera transition zone (suprachoroid) Park, Byeong & Chung, Hye & Kim, Hyung Chan. (201).3 Effects of Diabetic Retinopathy and Intravitreal Bevacizumab Injection on Choroidal Thickness in Diabetic Patients.
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