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It Is Only Rare Until It Is in Your Chair

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It Is Only Rare Until It Is in Your Chair 6/11/2021 What do do: The Rare in the OD Chair Dr. Chad Morgan Raleigh NC 1 Disclosures • Paid Consultant/Lecturer -Synergeyes -Alcon Clinical Case Contributor -Art Optical Medical Science Liaison -Dompe 2 1 6/11/2021 The Rare in the OD Chair: Objective Increase awareness of rare ocular Increase awareness of the possibility Increase management skills for rare disease of rare disease in your exam disease when found in your chair 3 Recognize the Rare #1: 2018 • 9/24/2018 • 57yof pt was last seen March 2018, has rx gls for distance and rx readers updated at last exam, states that distance and near is blurry with gls and contacts, contacts are really uncomfortable after 2hrs and has to take them out, states that she thinks her eyes might be dry too, a1c: 6.8 bsl: 145(this am). Pt uses alcon re-wetting drops, uses every hr when contacts are in otherwise uses as needed. • Prolia, atorvastatin, clonipen, Lyrica • +0.25-1.25x092 to 20/80- OD plano-0.75x100 to 20/60- 4 2 6/11/2021 Walk in Train Wreck Alert 5 What I Really See 6 3 6/11/2021 Recognize the Rare #1 • The Plan:Given the substantial change in refraction, an updated Rx was not given today. Pt ed on need to gain control of surface before prescribing. Good view of central lens shows no evidence of a cataract that would be causing the decrease in vision. Pt last dilated diabetic exam at Duke all WNL concerning posterior pole. 90 D used. Normal macular health noted given reduced acuity ACUITY REDUCTION FROM OCULAR SURFACE DISEASE • Pt has severe dry eye with 3-4+ SPK OS>OD with conjunctival hyperemia. Mild pannus noted inferior OS Pt ed on possible systemic involvement given arthritis diagnosis and management. Pt reports no other area of dryness on body. Ed on unlikeliness of acute condition given the dramatic dropout of meibomian glands. The patient presented today for a ctl check and rx check. We turned this into a medical office visit and the patient appreciates the attentiveness to detail. The TBUT is 1-2 seconds OU. Permanent plug procedure discussed and performed successfully. Rx sent for lotemax taper with a xiidra Rx. Ed on T-Cell component of dry eye and benefit of xiidra given autoimmune condition. PT ED ON NEED FOR LONG TERM THERAPY THAT MAY INCLUDE SCLERAL LENSES. Ed on PROKERA PLACEMENT AS POSSIBILITY AS WELL BASED ON RESPONSE TO TOPICAL THERAPY. DISCUSSION OF LIPIFLOW WILL BE HAD AT THE NEXT VISIT AS WELL. OK to RTC 4-6 weeks. • Quick Scleral lens evaluation determines vision corrects to 20/25 • Rx Lotemax and Xiidra 7 Recognize the Rare #1 2018 • October 22, 2018 • I last saw the patient 4 weeks ago. She has no other complaints today. Eyes feel okay, has been using lotemax and xiidra as directed, didn't go to knightdale for a lipiflow. Hasn't been wearing her contacts. • OD: +0.75-1.75x090/+2.25 to 20/25 (sc 20/40) • OS: -0.25-1.25x101/+2.25 to 20/25 (sc 20/40) 8 4 6/11/2021 Results of Visit • lipiflow at some point in next 2-3 months • 1.) severe pannus OS>OD that is not within the visual axis. Pannus from long term consequences of dry eye. OS FL pattern resembles that of Map-Dot Dystrophy. To monitor in future for any change in FL patter. Consider External photography in future when available. • 2.) Dry Eye / KCS Pt is perceptually 80 to 90 percent better. Pt has clear central cornea OU with a continued reduced TBUT at 5 seconds which is up from 1-2 seconds. The patient is to continue xiidra for the foreseeable future. To taper lotemax bid x 1 week and then qday until next seen. Pt ed on need for continued aggressive treatment of Dry Eye Disease in future as well. UNDERSTANDS THAT SHE WILL NEED TO COME OFF LOTEMAX TO PREVENT LONG TERM COMPLICATIONS. UNDERSTANDS THAT SHE WILL NEED LIPIFLOW TREATMENT IN THE FUTURE TO MAINTAIN CURRENT STATE. 3.) Spec Rx given today. Pt ed on need for up to date lenses as alternative to medically necessary contact lenses in the future. eval once insurance change known. spec rx given today • 4.)Pt understandably frustrated that condition had not been picked up on by the Ophthalmologists that she sees annually for her Diabetic exam. I did inform her that this condition is not acute and that it has been developing over a long period of time when asked by patient. 9 Skip forward • 11/6 to 11/20 to 11/29/2018 • The patient did not adapt to monovision in scleral lenses. Though seeing 20/20 distance and near. Single vision computer Rx provided of +1.50 OD and +0.25 OS. • The evaluation of Dry Eye and corneal dystrophy in the presence of a scleral lens today with dispense. Pt reports comfort and the feeling of “water” on her eyes. • The patient was ed on masking effect of scleral lens and the continued need to treat the condition. Continue Xiidra and report for Lipiflow 10 5 6/11/2021 • Pt doing very well using scleral lens as treatment of SYMPTOMS ONLY for dry eye. • Pt responding very well with Xiidra. • Ed on perceptual difference between spec Rx and Was that all contact lens vision given degree of dryness OU. • Check overall rx power in 2-3 months once the that Rare? surface is known to be fully healed 11/29/2018 • Pt is surprisingly sensitive to imbalance in vision. Rx for computer only single vision • Case series study shows healing of epithelial defect • 5 with scleral lens only. 3 with scleral + cipro +celluvisc. • All epithelial defects healed Khan M, Manuel K, Vegas B, Yadav S, Hemmati R, Al-Mohtesab Z. Case series: extended wear of rigid gas permeable scleral contact lenses for the treatment of persistent corneal epithelial defects. Cont Lens Anterior Eye. 2019;42(1):117-122. 11 Patient is having trouble reading up close. Computer is good Recognize the Patient very particular with Rare #1: vision 1/2/2019 Lined bifocal 12 6 6/11/2021 Recognize the Rare #1 1/16/19 • You are right… Still not 2-3 months. • Chief Complaint: • Pt still having problems with progressives. Received prescription for specs at recent specialty exam. The specialist wrote a different Rx • Results: • Start at retina specialist refraction. Subjective change towards old refraction. Exact OS refraction. Additionally specialist refraction shows 20/20. Pt has not seen 20/20 in both eyes without aide of scleral lens. • OD: Plano-1.75x090 20/25- • OS: -0.25-1.00x100 20/25-- 13 June 28, 2019 • That’s right still not 2-3 months. • But she does do LipiFlow 14 7 6/11/2021 Same Case… 9/4/2019 • Presents for Lipiflow F/U Still feels vision in specs and contact lenses are blurry. Would like this checked. Compliant with Xiidra • Results: 20/20 vision corrected with exact refraction • The Notes: • Scleral system working well. Cornea shows resolution. I am not changing Rx at this point given the system that is successfully working. RTC 6 months for exam 15 Recognize the Rare #1: 12/12/2019 • Progressives are not working. Goes to Duke for retina check. A1C 7.6 and is going in January. Wears contacts 8-10 hours per day. Thinking about bifocal this time. • LipiFlow, DFE for Diabetic Exam, Dry Eye • Pt is now correcting to 20/20. OD and OS Care separately. • Comprehensive Care • Cornea shows healing with current system: scleral, xiidra and post Lipiflow. • Pt requests second LipiFlow treatment. • Decides she would like everything under one roof: • RTC for LipiFlow, DFE, Fundus. 16 8 6/11/2021 Recognize the Rare #1: LipiFlow #2 1/18/2020 • Things have changed in my office. I now actively check for corneal sensitivity on any ocular surface that shows signs without symptoms. • Zero • Zero corneal sensitivity • LipiFlow Performed • AND Rx for Oxervate • RTC 3-4 weeks after starting oxervate for lipiflow f/u and oxervate f/u 17 Recognize the Rare#1 : 02/20/20 • Returns for DFE. Has not started Oxervate • My technician has already told the patient to blink more while not in contact lenses • DM: Normal and patient is pleased that she does not need to see specialist. Informed her we would send her to retina prn in future • Neurotrophic Keratoconjunctivitis: The conversation. 18 9 6/11/2021 Recognize the Rare #1: 4/20/2020 • Yes… She is essential • Pain and tearing in both eyes. Has been on oxervate for 4 weeks. • Pt reports improvement in vision when utilizing medication. Pt was able to cry tears for the first time in years recently with movie. • Pt ed on improvement in vision d/t increase in tear production with improvement in condition • Walk through REFRACTION IN 4 WEEKS 19 Recognize the Rare #1: 6/12/2020 • Pt reports back: • Unable to tolerate drops for full treatment. Stopped 4 days short d/t excessive burning • BSL in control • Patient cannot wear contacts anymore because they feel too strong • Patient cannot wear glasses anymore. • Patient has stopped xiidra and is unsure if this is necessary • Vision • Sc distance: 20/25 sc near 20/25 • OD +1.75-2.25x085 20/25 • OS +1.00-2.50x100 20/25 • And it was easy 20 10 6/11/2021 • Pt is doing exceptionally well post oxervate. • Pt vision continues to shift in the positive direction and pt tear film is very healthy • Pt tolerates natural vision better than trial She is happy.
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