Title: The Improvement of Photophobia with Pilocarpine Treatment in Bilateral Maculopathy

Author(s): Rolandy Dumornay, O.D. (Resident, Harbor Health Veteran Affairs/SUNY College of Optometry) Patrice Grant, O.D. (Resident, Harbor Health Veteran Affairs/SUNY College of Optometry)

Abstract: A 51 year-old white male with history of bilateral maculopathy presents with chronic photosensitivity, likely secondary to history of maculopathy (MEWDS vs AMPE vs PIC vs multifocal choroiditis). Symptoms of photophobia reduced with usage of Pilocarpine 1%.

Outline

I. Case History

 Patient Demographics: 51-year-old White Male  Chief Complaint: chronic photosensitivity that increases in intensity with headaches and bright lights. Intolerance to bright light has increased over years. Currently uses sunglasses and a hat to reduce symptoms.  Ocular History: o Bilateral non-senile maculopathy of unknown etiology OU for over 14 years o History of vision loss OU for > 14 years with full recovery  Medical History: o Hepatitis C Virus o Chronic Headaches o Bipolar disorder  Social History: o Marijuana use o Alcohol abuse o Cigarette smoker  Medications: o Gabapentin 100mg o Ibuprofen 800mg o Nicotine 7mg/24Hr Transdermal patch o Pilocarpine HCL 1% 15ml QID o Sumatriptan succinate 25mg

II. Pertinent Findings:  Visual Acuity: cc o OD: 20/20 o OS: 20/20  Pupils: o OD/OS: PERRL(-)APD OD/OS  SLE: o OD/OS: Unremarkable (-) Cells /flare  Tonometry (GAT): o OD:18mmHg, OS:18mmHg @10:10am  DFE: Macula o OD: mottling/RPE changes with central non-foveal hypopigmented subretinal lesions in macula, small PED o OS: mottling/RPE changes with central non-foveal hypopigmented subretinal lesions in macula  Amsler grid: o paracentral distortion/blurred lines OS>OD.  Ishihara Color plates: o OD: 7/7+ o OS: 7/7+  OCT RNFL/autoflurescence (Zeiss): o OD/OS: areas of Inner and outer photoreceptor layer atrophy with hyper-reflectivity scattered throughout macular region, PED  IVFA: o OD/OS: Macular hyper-fluorescent spots OU secondary to window defects and staining

III. Differential Diagnosis  Multifocal choroiditis Panuveitis (MCP) o Demographics: Women>Men, 20 - 60 years-old o Laterality: Bilateral o Symptoms: decreased visual acuity, enlarged blind spot, photopsias o DFE: Pigmented punched out lesions in the retinal pigment epithelium, similar to histoplasmosis. Cystoid macular edema and choroidal neovascularization may occur. o Cells: Mild panuveitis o Fluorescein angiography (FA): early hypofluorescence and late hyperflurorescence/or window defects. o Visual field: enlarged blind spot; may have peripheral field loss

 Multiple Evanescent White Dot Syndrome (MEWDS) o Demographics: Women>Men, 20-50 years-old o Laterality: Unilateral (typically) o Symptoms: Photopsia, dyschromatopsia, blurred vision, and paracentral scotoma. o Visual acuity: varies from 20/20 to 20/400 o Duration: weeks to months; Vision returns in 7 to 10weeks in most cases without treatment. o DFE: White lesions in RPE (Retinal Pigment Epithelium), photoreceptor cells, or outer retina. May also have hyperemic optic nerve, or granular appearance at fovea. o Cells: Mild vitritis o Fluorescein angiography (FA): punctuate hyperfluorescent lesions, may have hyperemic optic nerve in late phrase o ICG angiography: hypoflurorescent spots, (more pronounced in FA). o Visual field: enlarged blind spot; may have scotoma temporal or paracentral

 Punctate Inner Choroidopathy (PIC) o Demographics: Women>Men, <40 years-old o Laterality: Bilateral o Symptoms: Sudden decreased visual acuity, scotoma, photopsias o DFE: Round lesions scattered throughout RPE-choroid layer; eventually scars; CNV may occur. o Cells: No vitreous cells o Fluorescein angiography (FA): early hypoflurorescence with late staining in beginning stage of disease; in later stage, window defects.

 Acute Posterior Multifocal Placoid Pigment Epitheliopathy (AMPEE) o Demographics: Men = women, 20-30 years-old o Laterality: Bilateral o Symptoms: Asymmetric loss of vison, that occurs in one eye first then days to weeks later the other eye. Occurs along with influenza like illness. o Cells: Quiet A/C with few cells. o DFE: Creamy Placoid lesions found at RPE and choriocapillaris, and outer retina. o Fluorescein angiography (FA): early hypoflurorescence , late staining. (Crawford, 2013)

IV. Discussion While patient’s history is significant for headaches, etiology of photosensitivity cannot be solely attributed to them. The chronicity of the patient’s photosensitivity suggests that bilateral macular disease is contributing factor.

White dot syndromes describe a group of inflammatory conditions involving the retina and choroid. They are similar in appearance, but differ in terms of management and etiology (Crawford 2013). The patient presented with a limited history, therefore we were unable to pinpoint the exact etiology of maculopathy.

V. Treatment and Management  Prescribed Pilocarpine HCL 1% QID OU  1 month follow-up: Reduction of photophobia with use of Pilocarpine OU. Patient reported an adverse effect of nausea.

VI. Conclusion Due to adverse effects associated with Pilocarpine use, clinicians must weigh out benefit of reducing photophobia to potential risk to patient. Some adverse effects include: brow aches, frontal headaches, accommodative spasm, miosis, conjunctival injection, acute angle closure, retinal thinning and retinal detachment (Webster 1993). Systemic adverse effects include: nausea, vomiting, sweating, pulmonary edema, lacrimation and salivation. Through punctal occlusion these systemic side effects may be reduced (Wheeler 1982).

References: Crawford, C.M. & Igboeli, O. (2013). Review of the Inflammatory Chorioretinopathies: The White Dot Syndromes. Hindawi Publishing Corporation. 2013 (783190), 1-9.

Webster, A., Luff, A., Canning, C., & Elkington, A. (1993). The Effect of Pilocarpine on the Glaucomatous Visual Field. British Journal of Ophthalmology. 77, 721-725

Zimmerman, T.J. & Wheeler, T.M. Miotics: side effects and ways to avoid them. Ophthalmology. 1982. 89(1), 76-80