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5/15/18 1 Challenging Cases: Front to Back Disclosure Case SS Case Case SS Case SS: Labs 5/15/18 2 Case SS Retinal Plaques R

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5/15/18 1 Challenging Cases: Front to Back Disclosure Case SS Case Case SS Case SS: Labs 5/15/18 2 Case SS Retinal Plaques R R@NR@NU R@NR@NU $.'*.0- . Retinal Plaques • - . )/ -$.*).+ & -.+) '*!'*)8'' -")8 • -*/$: • Several different types of plaques can 80.#Z *(8 - 80*!/8 8 – $"#/:)*)# (*4)($''4.$")$!$)/.*!/ often be visualized in the retinal -0 -8 $# -/ '$!$+',0 /' !/-*/$$!0-/$*) vasculature #'' )"$)". .:-*)//*& • #$- – !/:RMASVY / )*.$. • Pt is typically elderly, has HTN, CAD, • A./- .$ )/ • .0'-'$)$: hypercholesterolemia/hyperlipidemia, and/ -;'**( )./ $)8 • - . )/ -#.!$))$'$)/ - ./$))4 – *)$/*-' !/-*/$,S(*..)*.4(+/*(.$) or atherosclerotic disease *//.' 8 +-*0/.( )/$*) • 3 +/# * .#1 ./*&$) -/$)*!! './4 - • Often totally asymptomatic and found on *(+)4;;; – /-//# -+4 routine exam . . - 1' ) • TN4 -*'- /$- $'$/-4). - /. -1$ • " • 1 -(4 /04:N;PY " )/ • • .(*&$)"8 ) • .)=/# 4 .# & $)! 24 -. • V3(*- '$& '4!/ -" TR1.;QPARQ • .0'-$. – !/ -TR8P;NY+- 1' ) • OM@OM2$/#'*2#4+ -*+$@./$"(/$ • ./1.0'-.0-" -4 – ,0/ ./*N;O($''$*)+ *+' 2$/# (*'$QPAUS » QRM8MMM- TRAUS • – /'./-*& P3.'$& '4*1 -U4 -.$)+/.2$/# (*'$8 • :($'' +#8/- • %0./$)"!*-*/# -!/*-. $"# #*' ./ -*' • • *./ -$*-+*' : ^ • )^2*( ) • $'/ -'1 -4$)!- ,0 )/'4 . . : . - 1' ) Retinal Plaques • : +',0 • . • '0 *0)/$)4 /04N;QY • May present with amarosis fugax, • :- ! -!*--*/$*++' - – :NPQ@UU • 8.(*&$)"8.0'-$. transient episodes of monocular blindness – . – $"#/:OPS • /$)*4 /04:M;QY • Rarely, may report transient ischemic – - ! -/*!*-()" ( )/*!*/# --$.&!/*-. – :PU;O • (*&$)"88#@* 8 attack (TIA) , which is above with – .0'-'$)$ + ) )/*)-*/$./04 – N:V;VD E • $)"+*- 4 /04:M;SY hemiparesis, parasthesia or aphasia – -$"'4 -$ .:NTPD E • (*&$)"8#$"##*' ./ -*'8#@*)"$) – :PN;OD E • :$ /8 0/$*)8./-/$).0'$) N O R@NR@NU R@NR@NU /$)'+',0 . Retinal Plaques Fibrino-platelet Plaques Retinal Plaques • Three different types of plaques, but all • Cholesterol (Hollenhorst) plaque • Calcific share strong association to significant – Most common – Appears more whitish than HH cardiovascular disease – shiny yellow-orange in appearance – Dull, non-reflective, white – HH 80% > fibrino-platelet 14% > calcific 6% – from plaque in the ipsilateral carotid artery – Classically within arteriole, not at bifurcation – Rarely causes occlusion, unless multiple – Typically immobile – Typically occurs at bifurcations – Most dangerous, as often cause BRAO – Mobile in nature – Often from cardiac arethromas of heart valves Cholesterol Plaques Calcific Plaques Retinal plaques • Talc retinopathy – Represents an exogenous plaques as opposed to others – Appears typically as multiple shiny yellow plaques within capillaries in posterior pole – Typically smaller than other plaques – Typically seen in IV drug users – Rarely cause complications, but reported cases of associated NV and occlusions Retinal Plaques Talc Retinopathy Others • Fibrino-platelet • Tamoxifen Maculopathy (Nolvadex) – Appear as dull white to gray, long plugs – Typically within arterioles, not at bifurcations – May break-up and dissolve with time – May lead to BRAO or CRAO – Often associated with carotid disease or mitral valve insufficiency P Q R@NR@NU R@NR@NU Canthanxine Maculopathy Retinal plaques -*/$'/-.*0) Retinal Plaques • No direct management of plaques is • $-./'$) .- )$)"/ ./ • After ruling out underlying etiology, see needed • patient regularly, q 6 -12 mos, to evaluate • Management is aimed at discovering 66 for additional plaques or other disease source of embolus to decrease risk of • )/$!$ .!'*2-/ )Y associated with vascular disease other emboli, occlusion, or stroke ./ )*.$. – BRVO/CRVO • Pts need referral to internist for complete • *((*)8$)/ -)'8) – BRAO/CRAO 3/ -)' physical – NTG • )'4\OMY*!.4(+/*(/$ (*'$2$''#1 .$")$!$)/ -*/$./ )*.$. /$)'',0 . -*/$'/-.*0) Is it worth working up these patients? • Assess risk factors with PCP • $-./'$) .- )$)"/ ./ – DN, HTN, lipid panels • 66 • 18% of pts with retinal emboli had internal • Carotid ultrasound or common carotid stenosis>75% PCE • )/$!$ .!'*2-/ )Y./ )*.$. • MRA: non-invasive image with 2D/3D • Higher incidence of stroke • *((*)8$)/ -)'8) 3/ -)' >? • TEE: invasive, probe into esophagus to – 8.5% with emboli vs 0.8% w/o per year image heat valves • )'4\OMY*!.4(+/*(/$ (*'$2$''#1 • Pts with cholesterol HH emboli have 15% – Helpful with calcific .$")$!$)/-*/$./ )*.$. mortality at 1 yr, 29% by year 3, and 54% by 7 years • CTA: CT scan of arteries construct 3D images /$)'',0 . /$)'',0 . BA.%#" – > ! '/'$& .*( /#$)"2. LC>6D>J%"*( %$ ME>6GGJ • Assess risk factors with PCP ./$)"(4 4 ? VA: 20/100 PH 20/30 – DN, HTN, lipid panels • ORAL TREATMENT • SURGICAL TREATMNET SLIT-LAMP: • Carotid ultrasound – >#$.#++ ) )*/# - – Anti-Platelet – Carotid /$( )/# */*-/*' SUPERFICIAL SUPERIOR • MRA: non-invasive image with ( /*0. *$)/( )// • ASA edarterectomy ABRASION 2D/3D )$"#/? + STAINING – Anti-coagulation – Angioplasty • TEE: invasive, probe into • 4+ $ / . • Comadin, platelet esophagus to image heat valves • – Cholesterol meds – Reduces risk of – Helpful with calcific future stroke! • CTA: CT scan of arteries construct 3D images DX: CORNEAL EROSION > ? R S R@NR@NU R@NR@NU 87% of all RCE occurs in what part of the cornea? #/- .*( ' $)"0. .*! 7 Inferior Cornea Reidy JJ, Pauli MP et al. Cornea 2000 Nov. 46% of all patients in this study Non-Treatment: had EBMD • James Reidy et al. Recurrent erosions • What medications should of the cornea: epidemiology and treatment. Cornea 2000 Nov; 19(6): be avoided? 767-71 • Bland Artificial Tear • The remainder had trauma induced Ointments Epithelial Basement causes Membrane Dystrophy: – Fingernail Eke T, et al. Recurrent symptoms Map Dot Fingerprint – Paper cut, etc. following traumatic corneal abrasion. Eye 1999 June. ..$1 - /( )/! • – &A '+ - – '" --0.# • )" ). • -*A.+ /-0( T U R@NR@NU R@NR@NU TREATMENT Long Term TX Regimen Recalcitrant RCE STANDARD PROTOCOL: • BCL • FreshKote TID x 2 months • ANTI-BIOTIC • ANTI-INFLAMMATORY • Lotemax Gel QID x 2 weeks then BID • RTC x 6 weeks • NEW REGIMENT Active Treatment….Dry or Wet?? • Doxy (20 or 50mg) BID x 2 months NON-HEALING ABRASION • AMNIOTIC MEMBRANE • LATERAL TAPE • Restasis Bid! TARSORAPHY • PATIENT EDUCATION • RTC 5 DAYS R A ()$*/$ (-) P A Amniotic membrane is the inner most lining of the Cryopreserved amniotic membrane is a • “MY EYE FEELS GREAT” placenta (amnion) and shares the same cell origin as “THE PAIN IS GONE” • VASC: 20/15 the fetus biologic therapy that can: • REMOVEDPROKERA • SLIT-LAMP: CLEAR CORNEA Promote regenerative healing Contains cytokines and growth factors • VASC: 20/15 • DX: Anti-Inflammatory (protease inhibitors) Reduce inflammation SLIT-LAMP: Anti-Angiogenic Minimize scar formation CORNEAL CLEAR PCE (PREVENTED CORNEAL EROSION) Aids in rapid wound healing and re-epithelialization Inhibit angiogenesis Anti-Scarring TX: CPM(RESTASIS) Minimize pain TX: RESTASIS BID RTC 4-6 WEEKS • SU4 -*'(' • - . )/.2$/#@*!'.# .!'*/ -.3O4. – *+$) – *#)" $)0$/4 • #3:4+ O3O4 -.82 ''*)/-*'' 9 9 • .: /!*-($)8 8 $+$/*-8$"- • 3:)- (-&' V NM R@NR@NU R@NR@NU The Vitreous Humor Physiologic Changes • )/ -$)":OM@OR • $/- *0.//# (*./!$-('4/ – 0' • With age, liquifaction • : • due to reduction in – $/- *0.. • NQ(( – -*0)*+/$) -1 # hyaluronic acid • : • $..=$)" causes loss of – '.*8.*( /-/$*) support. *)'**1 .. '. • This process is • $/# ( referred to as synchesis. )$ ) *! Physiologic Changes • .. ..( )/: • ''4)**). ).0. $ $ • Vitreous shrinkage, – 0/ • 4(+/*(/$2$/#*0/- /$)'- & ^PM contraction and – :NAO2 &. collapse can cause PMARV NMY – 2&$ $%$(.#&)%#(0' (!)%'($ • '): traction. SMASV OTY " $ " $ $(2 • This process is – / 0/$*) • ?6D,!( ^TM SPY referred to as • $")[email protected](+/*(.*! • $D#%()%?.' ^UM TRY syneresis. – ,$/ – ' 1 ')'$)$:QAS &. – /# -.:$!)*# ( *-*/# -$..0 .81 -4'*2-$.& .*)*) /*. /*& • SRY^SR ''*…;-;$ .. )$ ) *! . • • '*/ -.- /4+$''4(*./*((*).4(+/*( • )$ ) (4 ' -/ 4 ** 2.: – /$)' -.@- &.!(*!,0)*((*) – *2 . – 4*+$ • ) ./04:*)'4TANRY*!.4(+/*(/$.#1 - /$)' - & – – $' . -0( – UAOSY0/ .#1 )..*$/ @//# – $-. – -$*-1$/- *- /$)'$. /$( /# 4+- . )/D+#/#'(*'*"4OMNQE • '.# . – 0-" -4 • ) 2.: – )$/$1 *!/-/$*)*)- /$)80/)*/) ..-$'4 – )!'((/$*) – TANRY#1 - /$)'- & – / -*-- & • 4(( /-$'VMY*!/# /$( # #) .*!/# - !/ -$.]OARY • ++ )./*. *) 4 2$/#NAO4 -. NN NO R@NR@NU R@NR@NU 4- *(( )/$*). QU 34 Risk Factors 2,&'$ • • $) ./-/$)"'/) - $)".: • $"( )/ • @ – [NTANV(( " – # !! -G.$") • S – [NUAOM(( " • )$/ .- &$.+*..$' • • (*-#" • 8 • – VMY#1 - & - 1$*0.*/*-! '//#/+/$ )/2. $)" .! '4/- / //#$. ' 1 '; • )!'((/*-4 ''. – $/- *0.# ( – /$. 24 -@!/# -A$)A'28 / – 0./* .)=/! '-$"#/ QU QU )$/$'3($)#* )$3 !/4 :#* )$3)$''-4/ ./. • OM@OM • A *1 …; Case • [NT(( "[NU(( " • 0% /$1 '48/# +/$ )/ – +*-/. 3 '' )/*(+'$) – )$ .)4.$ A !! /. QU $.0'$ '-*"- ..$*) '"$&&')'(' QU - /( )/ $./*-4 $)0++++ -/ ). %%&(#'& !$+#$) • $")*. 2$/#NVVR • )$/$'/# -+4$(*'*'M;RY • $")*.$.( 4*+#/#'(*'*"$./$) – $.*)/$)0 !/ -O(*)/#. $)) .*/ – $ !! /.*!-4-$H!/$"0 • '*/ /*#* )$38 ..0( - • )/- / + & • 0-- )/ $' "$( ): – [OT(( " – '/)*0,(3O4-. – [OV(( " NP NQ R@NR@NU R@NR@NU Hysteresis: Not a New Concept "(( 4 .()'( ( %%&5 Basic Parameters ' #("', $ )/$!$ /# +# )*( )*) *!#4./ - .$.)*$) /# / -($)NUVM C A*'())*-- '/ C A*-) '*(+ )./ • ( .0- ( )//#/#-/ -$5 .- .+*). /* 7 ++'$/$*))- (*1'*!!*- D'*@0)'*EN C A*-) ' 4./ - .$. – *0)$)(/ -$'.*-.4./ (./#/*)*/$)./)/'4 C A*-) ' .$./) /*- !*''*2!*- .++'$ /*/# (0/- /.'*2'48$& ''%(%$&($#$(%%!#&,N ORA Reichert • *- /#)TRMM++ -.+0'$.# *)#4./ - .$.$)1-$ /4*!( $'!$ '.O – -$*0./$..0 .)./-0/0- .D/ )*)8'0)"8-/ -$ .8 /E MORE TESTING IS – #
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