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Retinal Cases: Not Rare If It's in Your Chair

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Retinal Cases: Not Rare If It's in Your Chair Goals Retinal Cases: Not rare if it’s in your chair Review cases of uncommon retinal diseases Discuss differential diagnoses Evaluate retinal diagnostic test and how they can KELLEN KASHIWA, OD BENNETT EYE INSTITUTE help with diagnosis Case 1 Fundus Photo 19 yo AF – CC: Blurry vision at near, annual visit VA: 20/20 OD, OS, OU IOP: 12, 13mmHg Anterior segment: Unremarkable Posterior segment: Next Slide Differential Diagnosis Roth Spots Diabetic Retinopathy White centered round, flame-shaped retinal heme Hypertensive Retinopathy First seen in patient with subacute bacterial Vein occlusion endocarditis Vasculitis Lab testing if suspicion for endocarditis includes CBC with differential HIV Retinopathy Erythrocyte sedimentation rate Leukemia C-reactive protein Anemia Blood cultures Preeclampsia Lab Results Leukemia Retinopathy Patient 1 Normal Normal Male ESR – Normal Female Leukemia Retinopathy ESRC-Reactive Protein 4 mL per hour 0-20 ml 0-15 ml per hr Most case diagnosed prior to eye exam per hr In a 2020 review, 25% of leukemia cases were diagnosed after CBC CRP eye exam CBC RBC– 65g/L Posterior segment manifestations WBC – 109 x 10^9 Secondary to direct invasion of leukemic cells Platelet – 40.2 x 10^9/L Serum lactate 950 U/L <250 Retinal grayish white nodules surrounded by hemorrhage dehydrogenase U/L Roth spots – retinal hemorrhage with white-center Pale gray swelling of the optic nerve head Case 2 Fundus Photos 32 yoAF Sudden vision loss OD Vision: OD: 20/40; OS: 20/30 IOP: OD: 13; OS: 13mmHg OU Anterior segment: Unremarkable, NSC OU Posterior segment: Next Slide Differentials Purtscher Retinopathy Diabetic Retinopathy Similar findings to DR Hypertensive Retinopathy Retinal hemorrhage (65%) Retinal whitening BRVO Cotton wool spots (93%) Purtscher retinopathy Optic disc edema Purtscher flecken (areas of inner retinal whitening Mostly associated with trauma Typically bilaterally seen Purtscher-like Retinopathy Case 3 In absence of trauma other causes: 43 year old Hispanic female Acute pancreatitis CC: sudden vision loss OU Renal failure Hx: Hypertension Preeclampsia and childbirth BCVA: OD: 20/400 OS: CF @1’ Connective tissue disorder Valsalva maneuver IOP: 12, 13mmHg Anterior segment: MGD, s/p LASIK, NSC trace OU Posterior segment: Next Slide Fundus Photos OCT Findings Differential Diagnosis Bilateral optic nerve Papilledema head edema grade 4+ CRVO Scattered Exudates Subretinal fluid Optic neuritis Diabetic papillopathy Hypertensive disc edema NAION AION Compressive optic neuropathy Posterior scleritis Additional Testing Blood pressure Hemoglobin A1C/Serum glucose Fasting lipid profile If secondary hypertension suspected: Urinary cortisol – Cushing’s Plasma renin to aldosterone ration – hyperaldosteronism Angiograpy – renal vascular disease Results Posterior Reversible Encephalopathy Syndrome In office blood pressure Rapid onset of symptoms 210/104 mmHg Headaches Sent to Emergency room Seizures for immediate Vision loss/disturbance hypertensive crisis treatment Often due to acute hypertension Chronic/Acute kidney disease/injury Pre-eclampsia Treatment Case 3 Hypertensive control -> Stent to circumflex artery 54 year old Brazilian female Blood pressure next visit 128/82mmHg CC: blurred reading vision Optic nerve head neuroprotection 20/20 OD, OS, OU Alphagan BID OU for optic nerve head protection IOP: 13, 14 Macular edema Recent diagnosed with pneumonia and recovered Subtenon kenalog for macular edema Anterior Segment: Pterygium, mild bleph VA responded 2 wks post from 20/400 -> 20/60 Posterior segment: 4 wks post 20/60 -> 20/40 8 wks post 20/40 ->20/20! Cotton Wool Spots Not a normal finding In a series of patients with CWS Diastolic BP was >90mmHg Elevated blood sugar in 20% Secondary to ischemia from retinal arteriole obstruction Eosinophilic segments of ganglion cell axons that are swollen – defective axoplasmic flow Etiology COVID Ischemic: HTN, Diabetes, RVO COVID-19 caused by SARS-CoV-2 uses the ACE2 Infectious: HIV retinopathy, Cat-Scratch receptor to gain entry into cells Idiopathic ACE2 receptor is widely expressed in multiple organs – including the retina Trauma Coronavirus have been shown to cause optic neuritis Medication: Interferon Retinopathy and retinitis Inflammatory: Lupus, GCA Conjunctivits Hyperreflectivity at the Ganglion cell layer and Inner 7% of COVID-19 patients had viral RNA in the plexiform layers conjunctival secretions Cotton-wool spots and microhemorrhages seen Autoimmune response Animal model suggest retinitis and optic neuritis can Possible macrophage activation syndrome be seen Case 4 18 yoAM complains of sudden decreased vision and photophobia. BCVA IOPs OD: 20/50 OD: 11mmHg OS: 20/400 OS: 12mmHg Ant Seg: 3+ cells/flare in the anterior chamber and vitreous OU. Keratic percipitates OU and Koeppe nodules OU. Post Seg: See next slides. General Health is excellent. No recent illness/malaise, systemic changes or medications. Case One - OCT Case One – Fundus photos Case one - FA Case One – Thoughts? Differentials??? Findings: Panuveitis Bilateral serous RDs Multiple hyperfluorescent dots at RPE Differential Diagnosis Vogt-koyanagi-Harada Syphilis Sypathetic ophthalmia Autoimmune Disease Treatment Tuberculosis Vogt-Koyanagi-Harada Higher Rate in Asian, Systemic Corticosteroids Syndrome Behcet’s disease Latin, Mediterranean Multiple White Dot descent InVit / SubTenon Posterior sclertis Corticosteroids Syndrome Chronic, bilateral Acute Posterior granulomatous uveitis Surgery Lupus Multifocal Placoid Disease vs. Syndrome Epitheliopathy Sarcoidosis Triad (APMPPE) Ocular Lyme Disease Alopecia Poliosis Vitilgo Case 5 OPTOS 39 year old Filipino male CC: Cloudy, FB sensation OS, chef – rubbed his eyes with gloves and may have got something in it VA: OD: 20/20 OS: 20/60 Anterior segment: OS: Arcus, 3+ KPs, 3+ cells / 2+flare Posterior segment: OS: Vitreal cells Differential Diagnosis Findings Sarcoidosis Panuveitis Focal chorioretinitis RPE tracks with white Toxoplasmosis lesions Histoplasmosis Peripheral subretinal FB Multifocal choroiditis Acute multifocal placoid Further questioning pigment epitheliopathy reveals MEWDs Often consumes raw meats and poltry! DUSN Ophthalmomyiasis Ophthalmomyiasis Interna Outcome Parasitic disease Treatment Followed closely and affecting the outer retinal Immediate treated with oral and RPE photocoagulation antihelminthic for Nematode Patient is at risk for a months significant inflammatory Strongyloides stercoralis Vision returned to 20/20 response once larva dies OS! Careful monitoring and prompt treatment of inflammation is essential Albendazole 400mg Pred forte QID CASE 6 CASE 6 72 YOWF CC: Sudden, painless vision loss OD BCVA IOP OD: 20/200 14mmHg OS: 20/30 15mmHg Ant Seg: Unremarkable other than 2+ NSC OU Post Seg: See following slides Medical Hx: Thyroid cancer 20+; Treated 1980s Medication: None CASE 6 Optos and RNFL OD Optos and RNFL OS Findings Findings Differentials??? Optic nerve head AION edema OD NAION Optic nerve pallor OS Papillitis Slight Attenuation Multiple Sclerosis Differential Diagnosis? Diagnosis of Exclusion Differentials??? Additional Testing? PSEUDO – FOSTER KENNEDY SYNDROME Foster Kennedy Imaging – CT/MRI Optic nerve head Treatment Syndrome CSF edema in one eye Similar to GCA Papilledema CRP vs Sed Rate Optic nerve head pallor High level IV steroids Pseudotumor Carotid Dissection in the fellow eye Followed by oral steroids AION No mass / tumor Carotid dissection NAION underlying cause Active NAION with old NAION in fellow eye Case 7 Case 7 65 year old male with Mp1 shows central loss, reduced VAs decreased sensitivity OD 20/20->20/50 OCT shows RPE changes OS 20/20->20/60 ERG shows reduced high Retinal exam and OCT contrast function show no intraocular fluid (photopic) MP1 shows significant reduced central sensitivity What’s your differentials? Cone Dystrophy Cone-Rod dystrophies Vision loss ranges from Treatment Leber’s congenital 20/40 to CF Increased anti-oxidant amaurosis Color vision loss supplementation Beta-carotenoids Stargardt disease RPE loss Increase omega 3 fatty Bardet-Biedl syndrome ERG best test for acid consumption diagnosis Refsum disease Electrical current Batten disease stimulation? Spinocerebellar axtaia type 7 Electrical Current Therapy MiraGel Implant Frequency specific microcurrent electrical stimulation RPE function Coat’s Disease Juvenile Retinoschisis Splitting of OPL Typically in the macula VA ranges 20/200 – CF Responds very well to magnification No Treatment Von Hippel Lindau Choroidal Melanoma Pars Planitis Histoplasmosis Histoplasmosis Mahalo For Coming! Please feel free to contact me if you have any questions [email protected] 808-398-3766 www.bennetteyeinstitute.com.
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