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EYE CATCHING CASES Financial Disclosures Objectives A 1/17/2019 Financial Disclosures I do not have any financial interest in any of the parts of the lecture today. EYE CATCHING CASES MATTHEW MAHEK, OD TTUHSC Ophthalmology and Visual Sciences Objectives Review some of the common and uncommon cases seen in optometric practice Discuss key elements of examination and ancillary testing for proper diagnosis Discuss management of these pathologies and A COMPLICATED referral when appropriate CORNEA…AND MORE 1 1/17/2019 COMPLICATED CORNEA COMPLICATED CORNEA HISTORY EXAM 33 year old Hispanic Female VA CC: Here for cataract evaluation OD: 20/100 LEE: 6 months ago – no mention of cataract OS: 20/80 Progressively decreasing vision over last year Light sensitivity and glare with sunlight and night driving Current Glasses Itching and irritation after spraying insecticide in eyes 10 days ago OD: -6.50 -2.50x043 Went to ER – eyes were irrigated extensively, no drops prescribed. OS: -3.50 -4.75x097 Improving symptoms with AT’s and cool compresses Keratometry Past Medical Hx High cholesterol OD: 47.25 / 50.50 @ 146 Past Ocular Hx OS: 48.50 / 55.00 @ 30 None Manifest Refraction Family Hx OD: -7.75 -3.50x065 20/70 No blindness, glaucoma or AMD OS: -5.50 -3.75x089 20/80 COMPLICATED CORNEA COMPLICATED CORNEA EXAM TOPOGRAPHY AND SCLERAL Adnexa Optic Disc WNL OD/OS C/D: 0.30 OD/OS Conjunctiva No edema or pallor 1+ papillae Trace injection Macula Cornea Normal OD/OS Munson’s Sign OD/OS Vessels No striae, no scarring OD/OS Normal OD/OS A/C Deep quiet OD/OS Periphery Scleral Contact Lens: Scleral Contact Lens: Lens No holes/tears RD OD/OS Clear OD/OS BC: 49.00 BC: 50.00 Dia: 15.6 Dia: 15.6 Power: -10.25 Power: -13.00 VA: 20/25 VA: 20/25 2 1/17/2019 COMPLICATED CORNEA COMPLICATED CORNEA SCLERAL FITTING #2 SCLERAL FITTING #2 Adnexa Optic Disc OCT 2017 (2 ½ Years later) WNL OD/OS C/D: 0.30 OD/OS Blurry vision, film over contacts Conjunctiva No edema or pallor 1+ papillae Filling scleral lens with multipurpose Macula Cornea solution Normal OD/OS Munson’s Sign OD/OS VA (w/scleral) No striae, no scarring OD/OS Vessels Normal OD/OS 20/300 A/C Deep quiet OD/OS 20/70 Lens Clear OD/OS COMPLICATED CORNEA COMPLICATED CORNEA TOPOGRAPHY COMPARISON SCLERAL FITTING #2 2015 2017 MAY 2015 OD: OD: BC: 49.00 BC: 52.00 Dia: 15.6 Dia: 15.6 Power: -10.25 Power: -13.50 VA: 20/25 VA 20/20 OS: OS: BC: 50.00 BC: 54.00 Dia: 15.6 Dia: 15.6 OCT 2017 Power: -13.00 Power: -16.50 VA: 20/25 VA: 20/20 3 1/17/2019 COMPLICATED CORNEA COMPLICATED CORNEA SCLERAL DISPENSE #2 …AND MORE Scleral Dispense (5 months later) Scleral F/U –2 months 20/40 OD 20/80 OD PH 20/25 distortion to left side of fixation Plano Over-refraction OR: Plano Good fit and comfort Fitting: good clearance, limbal and edge fit 20/20 OS 20/20 OS Good fit and comfort F/U 1 month OD: flat, round, grey OS: WNL subretinal lesion under macula 4 1/17/2019 COMPLICATED CORNEA COMPLICATED CORNEA …AND MORE …AND MORE Differential Diagnosis Suspected Myopic CNVM Myopic CNVM Referred to retina clinic AMD CNVM IVA F/U 1 month Ocular Histoplasmosis Retina F/U (1 Month) Multifocal Choroiditis 20/60 with scleral lens Idiopathic CNVM Improved vision and distortion IVA #2 F/U 1 month COMPLICATED CORNEA …AND MORE 5 1/17/2019 MYOPIC CNVM RISK FACTORS Pathological myopia Spherical equivalent >-6D Axial length >26.5mm Tessellated Fundus Posterior Staphyloma Fuch’s Spot RPE Atrophy (Patchy > Diffuse) Lacquer Cracks https://img.medscapestatic.com/fullsize/migrated/575/933/eop575933.fig3.gif https://www.reviewofoptometry.com/CMSImagesContent/2016/2/112_ro0216_rq-2.jpg https://imagebank.asrs.org/Content/imagebank/OD%20laquer%20crack.JPG/image-full;max$643,0.ImageHandler MYOPIC CNVM MYOPIC CNVM PATHOLOGY EXAM Lacquer cracks induce intracellular Highly myopic patient changes in RPE that release VEGF with sudden decrease Mechanical stretching of RPE cells up- in VA (20/40 to regulates pro-angiogenic factors, 20/100) or onset of including VEGF metamorphopsia New vessels grow thru breaks in Bruch’s Small (<1DD) flat, membrane (Lacquer cracks) or result greyish subretinal from an atrophic area within the RPE membrane 6 1/17/2019 MYOPIC CNVM MYOPIC CNVM TREATMENT PEARLS Anti-VEGF ~30% will develop mCNVM in the Lucentis = Eylea = Avastin other eye Average improvement in BCVA was 13.8 letters after 12 months Early detection and treatment is key Don’t forget about pathological myopia and CNVM in high myopes Educate on risk factors Amsler Grid OPTIC DISC DILEMMAS Case #1 42 year old, white male CC: blurry distance vision; headaches with extended periods of computer work and reading Ocular Hx: unremarkable Medical Hx: unremarkable Medications: None OPTIC DISC DILEMMAS 7 1/17/2019 OPTIC DISC DILEMMAS OPTIC DISC DILEMMAS Case #1 Case #1 MR: +0.25-0.50x135 MR: +0.75-1.00x060 20/20 20/20 SLE: unremarkable SLE: unremarkable DFE: DFE: <0.10 <0.10 Elevation 360 Elevation 360 Sharp disc margins Sharp disc margins No pallor No pallor OD OS <0.10 <0.10 Elevation 360 Elevation 360 Sharp disc margins Sharp disc margins No pallor No pallor OPTIC DISC DILEMMAS OPTIC DISC DILEMMAS Case #2 Case #2 11 year old, white female OD: OS: CC: referred for exam due to result of VA: 20/20 sc VA: 20/20 sc convergence insufficiency survey at school Pupils: PERRL, no APD Pupils: PERRL, no APD Headaches when she reads EOM: smooth and full EOM: smooth and full 2-3x per week Binocular Vision Binocular Vision Forehead and brow area CT: 4 XP CT: 4 XP NPC: nose NPC: nose Relieved with ibuprofen Amps: 13 Amps: 14 Do not disrupt daily activities BO: 20/25/20 BO: 20/25/20 Cyclo MRx: Plano -0.75x010 Cyclo MRx: Plano -0.25x175 Medical Hx: Unremarkable SLE: WNL SLE: WNL Medications: None DFE: DFE: 8 1/17/2019 OPTIC DISC DILEMMAS Case #3 36 year old white female Medical Hx CC: vision will turn all white Unremarkable sometimes Patient passed out and fell onto face Radiology 6/1/18 (3 months ago) C/T done at ER was normal per Headache starting at the base of the patient; no MRI performed neck and extending thru right temple and behind right eye Medications: OD OS Exacerbated by stress and activity Tramadol Optic Disc Optic Disc Variable pain from 4-8 Metaxolone 0.10 0.10 Moderate elevation worst nasally Moderate elevation worst nasally Present daily Blurring of nasal disc margin; sharp margin Blurring of nasal disc margin; sharp margin Improved with use of Excedrin Vital Signs temporally temporally BP: 148/85 No Pallor, No hemorrhage No Pallor, No hemorrhage Episodes of vision turning white, this BMI: 35.2 (Obesity) Macula: WNL Macula: WNL will last a few seconds and then Vessels: WNL Vessels: WNL return to normal Periphery: WNL Periphery: WNL Occurs multiple time per day OPTIC DISC DILEMMAS Case #3 OD: OS: VA: 20/40cc VA: 20/40 MRx: -1.00 -1.00x095 MRx: -0.75-1.00x093 20/25 20/25 EOM and Alignment: EOM and Alignment: Full, Ortho Full, Ortho Optic Disc: Optic Disc: Severe disc edema; 360 elevation Confrontations: Full Confrontations: Full Severe disc edema; 360 elevation No hemorrhages FSH Blurred margin, large vessel obscuration SLE: WNL SLE: WNL Blurred margin, large vessel obscuration Temporal exudate extending into macula Temporal exudate extending into macula DFE: DFE: Vessels: WNL Vessels: WNL Macula: nasal thickening d/t disc Macula: nasal thickening d/t disc edema edema Periphery: WNL Periphery: WNL 9 1/17/2019 OPTIC DISC DILEMMAS Differential DDx: Disc Edema IMPORTANT TERMINOLOGY Psueudopapilledema Optic Nerve Head Drusen Congenitally Full Disc Optic disc edema ≠ Papilledema Malinserted Disc Tilted Disc Papilledema is optic disc edema due to Optic Nerve Hypoplasia elevated intracranial pressure CRVO Papilledema ≠ Pseudotumor Cerebri or Optic Neuritis Idiopathic Intracranial Hypertension Diabetic Papillopathy Hypertensive Disc Edema NAION Compressive Papilledema DDx by Dr. Freedman OPTIC DISC DILEMMAS Pseudopapilledema Papilledema Optic Nerve Head Intracranial Tumor Drusen Malignant HTN Congenitally Full Disc Venous sinus thrombosis Chiari malformation Malinserted Disc AV Malformation Tilted Disc Meningitis/Encephalitis Optic Nerve Idiopathic Intracranial Hypoplasia Hypertension 10 1/17/2019 Crowded Disc Malinserted Disc Asymptomatic Smaller than average disc Oblique insertion of optic 1.2 – 2.5 mm nerve to the globe Average 1.88mm Tilted along vertical axis Correction Factor Nasal elevation, temporal 78D x 1.11 depression 90D x 1.33 Scleral crescent Hyperopic eyes Myopes Slightly hyperemic https://www.reviewofophthalmology.com/CMSImagesContent/2010/10/1_14712_1.gif Tilted Disc Syndrome Optic Nerve Head Drusen Buried or Visible Triad of findings: Elevation of disc Tilted Disc With or without blurred margins Vertical axis itself is Anomalous vasculature rotated downward Early branching at disc Superior elevation, Tortuosity inferior depression Move to surface as patient ages Decreased acuity Scalloped borders Bi-temporal visual field Usually Asymptomatic defects Can have VF defects https://c1.staticflickr.com/9/8083/8438912126_70b6e20590_b.jpg https://www.aao.org/image.axd?id=29292cde-7c22-4180-934e-24b1eabdb277&t=635260125860400000 https://imagebank.asrs.org/Content/imagebank/67f09dcd-196f-4fe4-a639-27830e629cb2.jpg/image-full;max$643,0.ImageHandler 11 1/17/2019 OPTIC DISC DILEMMA The Real Diagnostic Dilemma… EXAM Comprehensive
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