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Home , Chemosis, Optic disc

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 …AND MORE

1 1/17/2019

COMPLICATED CORNEA COMPLICATED CORNEA HISTORY EXAM

 33 year old Hispanic Female  VA  CC: Here for 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 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, 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   No 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 : 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 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  Spherical equivalent >-6D  Axial length >26.5mm  Tessellated  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

 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  : 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  Head Drusen  Congenitally Full Disc  Optic disc edema ≠  Malinserted Disc  Tilted Disc  Papilledema is optic disc edema due to  elevated intracranial pressure  CRVO  Papilledema ≠ Pseudotumor Cerebri or  Idiopathic Intracranial Hypertension   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   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 History  Headache  Transient visual obscurations  Tinnitus, Vertigo 

 Medical Hx  Medications  Systemic risk factors

DDx by Dr. Freedman OPTIC DISC DILEMMA EXAM

 Acuity 

 EOM and Cover test  VI palsy most common with PE (38%)   Abduction deficit

12 1/17/2019

OPTIC DISC DILEMMA OPTIC DISC DILEMMA EXAM ANCILLARY TESTING

Visual Field  Papilledema  Enlarged blind spot  Peripheral Constriction Evaluation of the Optic Disc  Can also be present in ONHD  Size OCT  Cup  Papilledema: thickened RNFL  ONHD: thinning of RNFL  Margins  Can also show nodular shadows (drusen)  Vasculature FAF  SVP  ONHD can show auto-fluorescence B-Scan  ONHD show as highly reflective FA  Papilledema: ONH will show https://www.ophthalmologymanagement.com/archive/2015/December/images/omd_dec_3401.jpg hyperfluoresence and peripapillary https://imagebank.asrs.org/Content/imagebank/001.jpg/image-full;max$643,0.ImageHandler http://www.coavision.org/files/CA%20Journal%20article%20ONHD%20PDF(1).pdf leakage

DDx by Dr. Freedman OPTIC DISC DILEMMA HISTORY AND EXAM

Key Features ONHD Papilledema Visual Symptoms TVL, VFD TVL, VFD, Diplopia Headaches None If Present are worse upon awakening and/or postural changes

Neurological Symptoms None Tinnitus, vertigo, nausea/vomiting, peripheral neuralgias

Optic Nerve Elevation confined to disc, Elevated swollen nerve, hyperemia, Appearance SVP peripapillary vessel obscuration, +/- FSH, +/- CWS, +/- Paton’s lines, SVP absent

Vasculature Anomalous branching Microvascular dilation pattern

13 1/17/2019

OPTIC DISC DILEMMA OPTIC DISC DILEMMA WORKUP WORKUP

 Brain MRI with and without  Follow Up contrast  Weeks to month(s)  Urgent/Emergent  Monitor Symptoms  Consider symptoms and exam  Fundus Photos  Visual Field  Lumbar Puncture  After imaging  Treatment – IIH  Opening pressure  Stop any causative  CSF Study medications  Weight Loss  MRV  Acetazolamide or Lasix  Venous sinus thrombosis

OPTIC DISC DILEMMAS OPTIC DISC DILEMMAS CASE #1 CASE #2

Optic Disc  Size: Normal  Cup: Crowded  Margins: Sharp  Vasculature  No obscuration  SVP: Absent

 HVF: Full

OD OS  Plan:  Optic Disc  Optic Disc  0.10  0.10  F/U 3-4 months  Moderate elevation worst nasally  Moderate elevation worst nasally  Optic Disc Eval  Blurring of nasal disc margin; sharp margin  Blurring of nasal disc margin; sharp margin temporally temporally  No Pallor, No hemorrhage  No Pallor, No hemorrhage

14 1/17/2019

OPTIC DISC DILEMMAS CASE #2 – 3D OCT

OPTIC DISC DILEMMAS OPTIC DISC DILEMMAS CASE #2 - HVF CASE #2 – B-Scan

OD OS

15 1/17/2019

OPTIC DISC DILEMMAS OPTIC DISC DILEMMAS CASE #2 CASE #2

 Optic Disc  Diagnosis  Size: Normal  Suspected Optic  Cup: Crowded Nerve Head Drusen  Margins: Blurred nasally  Vasculature OU  No obscuration  Early bifurcations OS  Plan:  SVP: Absent  F/U 2 months

 HVF: Full  Optic Disc Eval

 OCT: Suspected ONHD  HVF

 B-Scan: Suspected ONHD

OPTIC DISC DILEMMAS OPTIC DISC DILEMMAS CASE #3 CASE #3

 Optic Disc:  Optic Disc:  Severe disc edema; 360 elevation  Severe disc edema; 360 elevation  FSH  No hemorrhages  Blurred margin, large vessel obscuration  Blurred margin, large vessel obscuration  Temporal exudate extending into macula  Temporal exudate extending into macula  Vessels: WNL  Vessels: WNL  Macula: nasal thickening d/t disc edema  Macula: nasal thickening d/t disc edema

16 1/17/2019

OPTIC DISC DILEMMAS CASE #3 – 3D OCT

OPTIC DISC DILEMMAS CASE #3

 Optic Disc  Size: ?  Cup: obscured  Margins: blurred 360  Vessels:  large vessel obscuration  FSH  SVP: Absent

 HVF:  Enlarged blind spot  Constriction

 OCT  Severe 360 elevation

17 1/17/2019

OPTIC DISC DILEMMAS OPTIC DISC DILEMMAS CASE #3 CASE #3 – FOLLOW UPS

 1 Week  Diagnosis:  MRI normal  Bilateral optic disc edema  Vision stable  Suspicious for  Symptoms stable papilledema  LP within 1 week

 2 week  Plan  LP - opening pressure 25  MRI head within 1 week  CSF study normal  F/U 1 week  Start acetazolamide 500mg BID  Follow up 1 month

Initial 1 month 2 month 3 month

18 1/17/2019

 Case 1  Congenital disc anomaly  F/U 3 months PEARLS

 DON’T PANIC!  Case 2  Comprehensive History  Suspected buried optic nerve head drusen  Optic Disc Evaluation  F/U 2 months  HVF  OCT

 Case 3   Papilledema Consider all exam findings  Pseudotumor cerebri  Workup, Refer, Follow  Normal MRI  High Opening Pressure  Resolving on acetazolamide

BACKUP HISTORY

 67 year old, white male  CC: cloudy circle in vision OD  Referred by endocrinologist for cloudy vision  Woke up 10 days ago and OD had a cloudy circle in vision; “looks like a donut” central vision is good  No new neurological symptoms

 Medical Hx  Type 2 Diabetes BLESSED BY BACKUP  HTN  HLD

19 1/17/2019

BACKUP EXAM

OD: OS:

 VA: 20/25  VA: 20/25  Pupils: PERRL, no APD  Pupils: PERRL, no APD  EOM and Alignment:  EOM and Alignment:  Smooth and full  Smooth and full   Ortho Ortho  Optic Disc:  Optic Disc:  0.30  Confrontations: FTCF  Confrontations: FTCF  0.30  No edema or pallor  No edema or Pallor  SLE: 1+ NS  SLE: 1+ NS  Macula: WNL, flat  Macula: appears flat  DFE:  DFE:  Vessels:  Vessels: CWS along temporal  Few scattered DBH arteries; sluggish perfusion  Periphery: WNL  Periphery: WNL

BACKUP BACKUP OCT DDX

 DDx:  BRAO  CRAO 

 Assessment and Plan:  Central retinal artery occlusion  With patent cilioretinal artery  Next day referral to retina clinic  Patient education about diagnosis and OD: Inner retinal thickening with trace CME systemic complications including risk of stroke OS: flat

20 1/17/2019

BACKUP WORKUP

 Systemic Workup (within 1 week)  Holter  Echocardiogram  Carotid Ultrasound  ESR/CRP

 80% blockage of right carotid artery  Now s/p angioplasty  Maintains 20/25 VA OD

FA REPORT OD: delayed arterial filling with hyperfluorescent changes in veins

CRAO CRAO RISK FACTORS PATHOLOGY

 Age  Obstruction of the retinal vessel by  Male>Female embolus, thrombus, trauma,  Smoking inflammation or spasm  HTN  Obesity  Diabetes  Hyperlipidemia  Cardiovascular disease  Coagulopathy

21 1/17/2019

https://www.memorangapp.com/flashcards/86923/Using+the+Ophthalmoscope%3A/

CRAO CRAO EXAM TREATMENT

 Vision loss  First 3-4 hours  Sudden  Lower IOP  Painless  Topical drops  Worse than 20/400 (75%)  A/C Paracentesis  Ocular Massage  APD  Contact gonio lens  Cherry Red Spot  Develops within a few hours  Emergency Room?  Resolves in 4-6 weeks

22 1/17/2019

CRAO PEARLS

 Ocular findings are a warning sign for an ischemic stroke  High correlation with ischemic finding on brain MRI

 Systemic workup is key

 Visual prognosis is poor ARE YOU SER(I)OUS!

ARE YOU SER(I)OUS! ARE YOU SER(I)OUS! HISTORY EXAM

 49 year old, white male OD: OS

 CC: spot in OS that blocks central vision  VA: 20/20 cc  20/20 cc  Pupils: PERRL, no APD  Pupils: PERRL, no APD  Onset 5-6 weeks ago  EOM: full  EOM: full   Seems to be intermittent; present more  Confrontations: full Confrontations: full  SLE: unremarkable when he pays attention to it  SLE: unremarkable  DFE:   DFE: Looks like a dim disc floating around  C/D: 0.20  C/D: 0.20  Macula: round serous elevation  Macula: WNL  Vessels: WNL  Vessels: WNL  Periphery: WNL  Periphery: WNL

23 1/17/2019

ARE YOU SER(I)OUS! DIAGNOSIS

 DDx:  Central Serous Chorioretinopathy  CNVM

 Diagnosis: Central Serous Chorioretinopathy  Amsler grid provided OCT:  F/U 1 month  Neurosensory Detachment OS  Small PED temporal to fovea

ARE YOU SER(I)OUS! ARE YOU SER(I)OUS! 6 WEEKS 4 MONTHS

 CC: Left eye seems to have improved

 VA: OS 20/25

 SLE: unremarkable

 DFE: stable serous CC: Stable, no changes elevation OS VA: 20/20 OS Macula: unchanged  OCT: slightly worsened OCT: unchanged F/U: 1 Month NSD

 F/U 1 month in retina clinic

24 1/17/2019

ARE YOU SER(I)OUS! 5 MONTHS CSCR

 CC: Distortions dissipating OS  RISK FACTORS  PATHOLOGY  VA:20/20- OS  Stress  Increased vascular  DFE:  Corticosteroids permeability of  Flat  H. Pylori  RPE changes with few drusen like opacities temporal macula  Autoimmune diseases

 OCT:  Sleep Disturbances  Small PED, no NSD  Hypertension  F/U  6 Months

CSCR CSCR EXAM EXAM

 Blurry vision  Visual distortion  Treatment  Dark area in central vision  Self Limiting (weeks to months)

 VA: 20/20 – 20/200  Stop steroids  Hyperopic shift (+1.00)  Anti-corticosteroid therapy  Round serous elevation of macula  Anti-VEGF  OCT  Laser photocoagulation  Neurosensory detachment  PDT  Pigment epithelial detachment

25 1/17/2019

CSCR PEARLS

 Treatment = Observation

 Associated PED is not uncommon

 Referral and FA for un-resolving or atypical presentation …WAIT FOR IT

…WAIT FOR IT …WAIT FOR IT HISTORY EXAM – DAY 1

 30 year old, white male OD OS  3 day history of redness and irritation OD  Watery discharge, crusting in the AM  20/20 sc  20/20 sc  Adnexa: WNL  No pain, no  Conjunctiva:  Conjunctiva:  No vision changes  WNL  2+ injection  Vigamox QID  2+ follicles  Cornea  Got lidocaine in eyes 7 days prior during dermatology  1+ papillae  WNL laser session  Cornea:   Irrigated in ED; diagnosed with abrasion A/C:  1+ diffuse SPK  F/U 2 days later with TTUHSC Ophthalmology was  Deep and quiet normal  No abrasion  No infiltrate  Medical History  A/C: Deep and quiet  Colorectal cancer

26 1/17/2019

…WAIT FOR IT …WAIT FOR IT EXAM – DAY 1 EXAM – DAY 3

 Exam Dx: Viral OD  No subjective improvements  Tobradex QID OD  Very slight improvement clinically  Good hygiene discussed  No involvement OS  F/U 3 days

 Plan  Continue Tobradex QID OD  F/U 3-4 days

https://dovemed-prod-k8s.s3.amazonaws.com/media/images/Keratoconjunctivitis_epidemica_2.width-750.jpg https://dovemed-prod-k8s.s3.amazonaws.com/media/images/Keratoconjunctivitis_epidemica_2.width-750.jpg

…WAIT FOR IT …WAIT FOR IT EXAM – DAY 6 EXAM – DAY 6

OD OS  DDx:  Viral Conjunctivitis  Worsening  Symptoms starting  EKC  20/50 sc  20/20 sc  Adnexa: moderate edema of UL and LL  Adnexa: WNL   Conjunctiva:  Conjunctiva:  Delayed lidocaine toxicity  3+ chemosis  2+ chemosis   3+ injection  2+ injection BAK allergy  2+ follicles  1+ follicles  3+ papillae  2+ papillae  Significant mucoid discharge  Significant mucoid discharge  Treatment  Cornea:  Cornea:  Durezol QID  2+ diffuse SPK  trace diffuse SPK  No infiltrates  No infiltrates  Stop Tobradex  A/C: Deep and quiet  A/C: Deep and quiet  PFATs

https://www.researchgate.net/profile/Birthe_Stemplewitz/publication/51545352/figure/fig1/AS:394014084878337@1470951686214/A- man-with-an-acute-EKC-infection-Massive-chemosis-with-swelling-of-the-lid-and_Q320.jpg

27 1/17/2019

…WAIT FOR IT …WAIT FOR IT EXAM – DAY 9 EXAM – DAY 16

OD OS OD OS

 Mild improvement  Mild Worsening  Improving – mild irritation, matting  Improving – mild irritation, matting  20/40 sc  20/20 sc  20/60 sc  20/70 sc  Adnexa: moderate edema of UL and LL  Adnexa: mild edema of UL and LL  Adnexa: mild edema of UL and LL  Adnexa: mild edema of UL and LL  Conjunctiva:  Conjunctiva:  Conjunctiva:  Conjunctiva:  trace chemosis  trace chemosis  Chemosis resolved  Chemosis resolved  2+ injection  2+ injection  2+ injection  2+ injection  2+ follicles  1+ follicles  Significant mucoid discharge  Pseudomembrane inf conjunctival sac  2+ papillae  2+ papillae  Significant mucoid discharge  Significant mucoid discharge  Cornea:  Cornea

 Cornea:  Cornea:  3+ diffuse SPK  3+ SPK  2+ diffuse SPK  1+ diffuse SPK  No infiltrates  No infiltrates  No infiltrates  No infiltrates  A/C: Deep and quiet  A/C: Deep and quiet  A/C: Deep and quiet  A/C: Deep and quiet

Girlfriend and father have redness and irritation

…WAIT FOR IT …WAIT FOR IT EXAM – DAY 16 EXAM – DAY 38

 Removed pseudomembrane OS OD OS

 Betadine treatment OU  Improved  Improving – mild irritation, matting  20/20 sc  Ocufen QID OU x 4 days  20/25 sc  Adnexa: WNL  Adnexa: WNL  Continue Durezol QID  Conjunctiva:  Conjunctiva:  Trace injection   Trace injection Call back for f/u  Trace papillae  Trace papillae  Cornea:  Cornea  Trace diffuse SPK  Trace diffuse SPK  No infiltrates  No infiltrates  A/C: Deep and quiet  A/C: Deep and quiet

28 1/17/2019

…WAIT FOR IT EXAM – DAY 38 EPIDEMIC

 Taper Durezol  Adenovirus  TID x 3 days, BID x 2 days, QD x 2 days  Continue PFATs  RTC for refraction if blur continues

EKC EKC SIGNS AND SYMPTOMS TREATMENT

 Conjunctival hyperemia  Treatment  Chemosis  Palliative  Photophobia  Artificial tears  Blurred Vision  Cool compresses  Subepithelial infiltrates  Topical Steroid  Eyelid Swelling  Betadine Rinse  Pseudomembrane  Dexamethasone-Betadine combo  Follicular reaction  Punctate Epithelial

29 1/17/2019

EKC Pearls

 Steroids can help control inflammation but may lengthen course of infection

 Betadine rinse can help decrease viral load but is highly toxic to the cornea

 Topical betadine-dexamethasone combo may be the future NUMB AND NUMBER

NUMB AND NUMBER NUMB AND NUMBER HISTORY EXAM

 Medical Hx:  50 year old, white female  DM, HTN, HLD, Kidney disease OD: OS:  CC: DM eye exam  Ocular Medications:  EOM: Full  history of abrasion OD  EOM: Full  Prednisolone acetate QD OD  Confrontations: constricted  Long history of things to “fix her  Restasis BID OU  Confrontations: Full cornea”  Valacyclovir 1g QD  Adnexa: lateral tarsorrhapy  Adnexa: WNL  Denies pain, redness, irritation  Refresh TID-QID  Conjunctiva: WNL   Ocular Hx:  Cornea: 2-3+ SPK, worst Conjunctiva: WNL  Systemic medications  2017 centrally; faint stromal scar?  Cornea: 1-2+ inferior SPK  Atorvastatin  PCIOL – 2015  A/C: deep and quiet  Levothyroxine  A/C: deep and quiet  Lateral tarsorrhaphy OD  Gabapentin  Lens: PCIOL in good position  Lens: PCIOL  Poorly healing abrasion OD  NovoLog  Presumed herpetic in nature  Warfarin  No pain thru this episode

30 1/17/2019

NUMB AND NUMBER DDX

 DDx for cornea  Dry eye  Neurotrophic keratitis  Topical drug toxicity  Chemical injury  Limbal stem cell  Vitreous: VH inferiorly  Vitreous: no heme deficiency  C/D: 0.40  C/D: 0.40

 Macula: flat, no fluid  Macula: flat, no fluid

 Vessels: arteriolar narrowing  Vessels: arteriolar narrowing

 Periphery: s/p full PRP  Periphery: s/p full PRP

NUMB AND NUMBER NEUROTROPHIC KERATITIS PLAN RISK FACTORS

 Neurotrophic keratitis  HZV, HSV  CPM  Topical Anesthetic  Prednisolone acetate QD OD  Restasis BID OU  Diabetes  Valacyclovir 1g QD  Ocular Surgery  NPAT’s Q1-2 hr OU   F/U 1 month LASIK/PRK  Retinal laser  PDR  Any damage to V  Active VH OD  Surgical  Inactive OS  Traumatic  Retina follow up 2 weeks

31 1/17/2019

NEUROTROPHIC KERATITIS NEUROTROPHIC KERATITIS PATHOLOGY STAGES

 Stage 1  Degenerative disease of cornea resulting from impaired corneal  Irregular epithelium; SPK  Corneal edema innervation  Corneal neovascularization  Lack of neuromodulation leads to  Corneal scarring degeneration  Stage 2  Recurrent or persistent epithelial defects  Stage 3  Stromal involvement  Ulcer  Melting  Perforation

NEUROTROPHIC KERATITIS NEUROTROPHIC KERATITIS TREATMENT PEARLS

 Stage 1  Artificial tears/ointment  Can be easily confused with  Autologus serum tears  Bandage contact lens moderate/severe dry eye  Stage 2   Bandage contact lens Consider NK in patients with a history  Amniotic membrane graft of HSV or HZV  Antibiotic drops  Steroid?  Educate patient on potential vision  Tarsorrhaphy  Stage 3 threatening complications and  Ulcer treatment and healing  Prevention of perforation importance of follow up  Oxervate  Nerve growth factor  Surgical

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