DOCSLIB.ORG

Outcomes of Vitrectomy for Retinal Detachment in a Patient with Ehlers

Total Page：16

File Type：pdf, Size：1020Kb

Download full-text PDF Read full-text
Outcomes of Vitrectomy for Retinal Detachment in a Patient with Ehlers Lumi et al. J Med Case Reports (2021) 15:249 https://doi.org/10.1186/s13256-021-02855-w CASE REPORT Open Access Outcomes of vitrectomy for retinal detachment in a patient with Ehlers–Danlos syndrome type IV: a case report Xhevat Lumi1*, Gaber Bergant2, Anila Lumi1 and Mina Mahnic1 Abstract Background: The Ehlers–Danlos syndrome (EDS) is a group of connective tissue disorders characterized by fragile blood vessels and an increased tendency for bleeding and scarring. Here, we report the outcome of a pars plana vitrectomy for the treatment of rhegmatogenous retinal detachment in a patient with EDS type IV (vascular type). Case presentation: A 40-year-old Slovenian man with high myopia, unilateral bullous retinal detachment, and vitre- ous hemorrhage was referred for surgery. The patient had a history of colon perforation, muscle and arterial rupture in both lower limbs, and recurrent shoulder joint luxations. Genetic testing revealed a pathogenic mutation in the COL3A1 gene. The patient underwent a 25-gauge three-port pars plana vitrectomy. The tendency for bleeding during surgery was prevented by endodiathermy applied to the edges of the retinal breaks. Endolaser photocoagulation was performed under air. The surgical procedure was completed with the injection of gas tamponade, followed by the patient remaining for a few days in a face-down position. Mild postoperative vitreous hemorrhage was resorbed in frst week after the surgery. Postoperative extensive pigment dispersion on the posterior lens face persisted for several weeks. After the gas tamponade had resorbed, the retina was fat and remained attached during the follow-up period. Eight months after the surgery, visual acuity continued to improve from a preoperative 6/38 to 6/6.6 (Snellen chart) at the last checkup. Conclusion: A small-gauge pars plana vitrectomy with gas tamponade and laser photocoagulation under air may successfully achieve reattachment of the retina in patients with high myopia with EDS type IV and restore visual acuity. Keywords: Ehlers–Danlos syndrome, Vascular type, Rhegmatogenous retinal detachment, Pars plana vitrectomy, Case report Background scarring [1]. According to the Villefranche nosology, EDS Ehlers–Danlos syndrome (EDS) is a heritable heteroge- is classifed into six major groups [2]. neous group of connective tissue disorders characterized EDS type IV is characterized by changes in the vascu- by joint hypermobility, skin hyperextensibility, and tis- lar structure. Tese patients are prone to arterial, diges- sue fragility leading to signifcant bruising and atrophic tive, and obstetrical complications. Congenitally thin and fragile arterial walls lead to arterial dissection and tears, bleeding, and hematomas [3]. Although this tendency is higher in large- and medium-sized arteries, all ana- *Correspondence: [email protected] 1 Eye Hospital, University Medical Centre Ljubljana, Grablovičeva ulica 46, tomical areas can be afected [3]. It is therefore assumed 1000 Ljubljana, Slovenia that surgery for rhegmatogenous retinal detachment Full list of author information is available at the end of the article (RRD) in patients with EDS type IV has the potential © The Author(s) 2021. Open Access This article is licensed under a Creative Commons Attribution 4.0 International License, which permits use, sharing, adaptation, distribution and reproduction in any medium or format, as long as you give appropriate credit to the original author(s) and the source, provide a link to the Creative Commons licence, and indicate if changes were made. The images or other third party material in this article are included in the article’s Creative Commons licence, unless indicated otherwise in a credit line to the material. If material is not included in the article’s Creative Commons licence and your intended use is not permitted by statutory regulation or exceeds the permitted use, you will need to obtain permission directly from the copyright holder. To view a copy of this licence, visit http:// creat iveco mmons. org/ licen ses/ by/4. 0/. The Creative Commons Public Domain Dedication waiver (http:// creat iveco mmons. org/ publi cdoma in/ zero/1. 0/) applies to the data made available in this article, unless otherwise stated in a credit line to the data. Lumi et al. J Med Case Reports (2021) 15:249 Page 2 of 6 to be complicated by arterial bleeding and consecutive retinal detachment superiorly with two U-shaped retinal scarring. tears (Fig. 1). Very few reports have been published on the occur- Te patient had high myopia and had undergone pho- rence of retinal detachment in patients with EDS [4–7], torefractive keratectomy on both eyes 9 years previously. and only two of these describe a clinical case of RRD His previous refraction was − 9.50 Dsph (diopter sphere) that was managed by a pars plana vitrectomy (PPV) [6, in the right eye and − 5.50 Dsph in the left eye. Ophthal- 7]. In both of the cases described, the patients underwent moscopy of the left eye showed multiple degenerative several surgeries due to redetachment with proliferative changes on the retinal periphery. vitreoretinopathy, ultimately ending up with silicone oil Te medical history of the patient included colon per- tamponade and worse visual acuity [6, 7]. foration, muscle and arterial rupture in both lower limbs, Tere are diferent types of surgical approaches for and recurrent shoulder joint luxation, as well as sus- RRD, including pneumatic retinopexy, scleral buckling, pected EDS. His family history for connective tissue dis- and PPV [8]. Te type of surgery chosen depends on the eases was negative. Te patient underwent genetic testing complexity of the detachment, age of the patient, and the for EDS, which showed a pathogenic mutation in the surgeon’s preference. Primary PPV is indicated in com- COL3A1 gene that is associated with EDS type IV (vas- plex retinal detachments [8]. Here, we report the case cular type). Te inheritance pattern of this type of EDS is of a bullous subtotal retinal detachment and a vitreous autosomal dominant and there is typically a heterozygous hemorrhage managed by a small-gauge PPV in a patient mutation in the COL3A1 gene that encodes type III col- with EDS type IV. lagen [1]. Case presentation Variant description and interpretation A 40-year-old Slovenian man with high myopia was Whole-exome sequencing indicated the presence of a referred to the Eye Hospital, University Medical Centre pathogenic heterozygous missense variant in the COL3A1 Ljubljana, Slovenia complaining of a 2-day deterioration gene. Heterozygous variant c.1052G>T (LRG_3t1) in in the visual acuity of his right eye (OD). He described the COL3A1 gene causes substitution of the amino acid the presentation as a curtain-like dark zone in the infe- glycine with valine at position 351 in the amino acid rior part of the visual feld that progressively enlarged sequence coded by COL3A1. Te variant was previously superiorly. He denied any eye injury. established as pathogenic, in line with the correspond- On presentation, the patient’s best corrected visual ing American College of Medical Genetics and Genom- acuity (BCVA) in the right eye was 6/38 (Snellen chart) ics/Association for Molecular Pathology (ACMG/AMP) and the intraocular pressure was 10 mmHg. Slit-lamp criteria for interpretation of sequence variants, based on examination of the anterior segment revealed pigment the following. First, the variant was reported to be path- dispersion on the corneal endothelium; otherwise, the ogenic in a patient with vascular EDS (PS4_MOD) [9]. status was normal. Indirect ophthalmoscopy showed a Second, the variant afects a glycine residue in a Gly-X- vitreous hemorrhage and a macula-of subtotal bullous Y tripeptide repeat of the triple-helical region, which is a Fig. 1 Left: Color fundus photograph of the right eye shows bullous retinal detachment with mild vitreous hemorrhage. Right: Optical coherence tomography (OCT) scan demonstrates macula-of retinal detachment Lumi et al. J Med Case Reports (2021) 15:249 Page 3 of 6 well-established mechanism of pathogenicity in collagen- During the surgery, bleeding was prevented by endo- opathies (PM1) [10]. Tird, the variant was not present diathermy applied at the edges of the retinal breaks. After among approximately 141,000 controls in the gnomAD shaving the vitreous periphery, fuid/air exchange was project v2.1.1 (PM2) [11]. Tese fndings indicate a mis- done. Laser photocoagulation around the retinal tears sense variant in a gene for which missense variants are was performed under air. Te endotamponade at the end a common mechanism of disease. Fourth, with the gene was 10% perfuoropropane (C3F8) gas. Te patient was also demonstrating evolutionary intolerance for missense instructed to maintain a face-down position for a few variants (PP2) [11], multiple algorithms for theoretical days after the surgery. Immediately after the surgery, we pathogenicity predictions, including MutationTaster2 noted both a mild vitreous hemorrhage which resorbed and MetaSVM, provide a unanimously pathogenic pre- within 1 week and extensive pigment dispersion on the diction of the efects of the variant on protein function, posterior lens face which persisted for several weeks which is further supported by the location of the variant (Fig. 3). Otherwise, there were no other complications. afecting an evolutionary conserved amino acid (PP3) Te patient underwent several postoperative examina- [12, 13]. In accordance with ACMG/AMP standards and tions. At the last checkup, 8 months after
Load more

Recommended publications
  • Ocular Photography - External (L34393)
    Local Coverage Determination (LCD): Ocular Photography - External (L34393) Links in PDF documents are not guaranteed to work. To follow a web link, please use the MCD Website. Contractor Information Contractor Name Contract Type Contract Number Jurisdiction State(s) CGS Administrators, LLC MAC - Part A 15101 - MAC A J - 15 Kentucky CGS Administrators, LLC MAC - Part B 15102 - MAC B J - 15 Kentucky CGS Administrators, LLC MAC - Part A 15201 - MAC A J - 15 Ohio CGS Administrators, LLC MAC - Part B 15202 - MAC B J - 15 Ohio Back to Top LCD Information Document Information LCD ID Original Effective Date L34393 For services performed on or after 10/01/2015 Original ICD-9 LCD ID Revision Effective Date L31880 For services performed on or after 10/01/2018 Revision Ending Date LCD Title N/A Ocular Photography - External Retirement Date Proposed LCD in Comment Period N/A N/A Notice Period Start Date Source Proposed LCD N/A N/A Notice Period End Date AMA CPT / ADA CDT / AHA NUBC Copyright Statement N/A CPT only copyright 2002-2018 American Medical Association. All Rights Reserved. CPT is a registered trademark of the American Medical Association. Applicable FARS/DFARS Apply to Government Use. Fee schedules, relative value units, conversion factors and/or related components are not assigned by the AMA, are not part of CPT, and the AMA is not recommending their use. The AMA does not directly or indirectly practice medicine or dispense medical services. The AMA assumes no liability for data contained or not contained herein. The Code on Dental Procedures and Nomenclature (Code) is published in Current Dental Terminology (CDT).
    [Show full text]
  • Chronic Conjunctivitis
    9/8/2017 Allergan Pharmaceuticals Speaker’s Bureau Bio-Tissue BioDLogics, LLC Katena/IOP Seed Biotech COA Monterey Symposium 2017 Johnson and Johnson Vision Care, Inc. Shire Pharmaceuticals Nicholas Colatrella, OD, FAAO, Dipl AAO, ABO, ABCMO Jeffrey R. Varanelli, OD, FAAO, Dipl ABO, ABCMO Text NICHOLASCOLA090 to 22333 to join Live Text Poll Nicholas Colatrella, OD, FAAO, Dipl AAO, Jeffrey Varanelli, OD, FAAO, Dipl ABO, ABO, ABCMO ABCMO Text NICHOLASCOLA090 to 22333 once to join Then text A, B, C, D, E or write in your answer Live Immediate Accurate Chronic conjunctivitis is one of the most frustrating reasons that patients present to the office (1) Time course Often times patients will seek multiple providers searching for a solution The chronicity of their symptoms is extremely frustrating to the (2) Morphology patient and treating physician alike Some conditions can seriously affect vision and create ocular morbidity (3) Localization of disease process Many of these diseases do not respond to commonly used topical antibiotics, topical steroids, artificial tears, and other treatments for external ocular disease (4) Type of discharge or exudate Our hope during this one-hour lecture is to present a process to help aid in the diagnosis of chronic conjunctivitis help you determine the most likely etiology 1 9/8/2017 Three weeks is the dividing point as it is the upper limit for cases of viral infection and most bacterial infections to resolve without treatment. Acute Conjunctivitis Conjunctivitis that has been present for less than 3 weeks
    [Show full text]
  • Vertical Perspective Medical Assistance Program
    Kansas Vertical Perspective Medical Assistance Program December 2006 Provider Bulletin Number 688 General Providers Emergent and Nonemergent Diagnosis Code List Attached is a list of diagnosis codes and whether the Kansas Medical Assistance Program (KMAP) considers the code to be emergent or nonemergent. Providers are responsible for validating whether a particular diagnosis code is covered by KMAP under the beneficiary’s benefit plan and that all program requirements are met. This list does not imply or guarantee payment for listed diagnosis codes. Information about the Kansas Medical Assistance Program as well as provider manuals and other publications are on the KMAP Web site at https://www.kmap-state-ks.us. If you have any questions, please contact the KMAP Customer Service Center at 1-800-933-6593 (in-state providers) or (785) 274-5990 between 7:30 a.m. and 5:30 p.m., Monday through Friday. EDS is the fiscal agent and administrator of the Kansas Medical Assistance Program for the Kansas Health Policy Authority. Page 1 of 347 Emergency Indicators as noted by KMAP: N – Never considered emergent S – Sometimes considered emergent (through supporting medical documentation) Y – Always considered emergent Diagnosis Emergency Diagnosis Code Description Code Indicator 0010 Cholera due to Vibrio Cholerae S 0011 Cholera due to Vibrio Cholerae El Tor S 0019 Unspecified Cholera S 019 Late Effects of Tuberculosis N 0020 Typhoid Fever S 0021 Paratyphoid Fever A S 0022 Paratyphoid Fever B S 0023 Paratyphoid Fever C S 024 Glanders Y 025 Melioidosis
    [Show full text]
  • Diagnosis and Treatment of Neurotrophic Keratopathy
    An Evidence-based Approach to the Diagnosis and Treatment of Neurotrophic Keratopathy ACTIVITY DIRECTOR A CME MONOGRAPH Esen K. Akpek, MD This monograph was published by Johns Hopkins School of Medicine in partnership Wilmer Eye Institute with Catalyst Medical Education, LLC. It is Johns Hopkins School of Medicine not affiliated with JAMA medical research Baltimore, Maryland publishing. Visit catalystmeded.com/NK for online testing to earn your CME credit. FACULTY Natalie Afshari, MD Mina Massaro-Giordano, MD Shiley Eye Institute University of Pennsylvania School of Medicine University of California, San Diego Philadelphia, Pennsylvania La Jolla, California Nakul Shekhawat, MD, MPH Sumayya Ahmad, MD Wilmer Eye Institute Mount Sinai School of Medicine Johns Hopkins School of Medicine New York, New York Baltimore, Maryland Pedram Hamrah, MD, FRCS, FARVO Christopher E. Starr, MD Tufts University School of Medicine Weill Cornell Medical College Boston, Massachusetts New York, New York ACTIVITY DIRECTOR FACULTY Esen K. Akpek, MD Natalie Afshari, MD Mina Massaro-Giordano, MD Professor of Ophthalmology Professor of Ophthalmology Professor of Clinical Ophthalmology Director, Ocular Surface Diseases Chief of Cornea and Refractive Surgery University of Pennsylvania School and Dry Eye Clinic Vice Chair of Education of Medicine Wilmer Eye Institute Fellowship Program Director of Cornea Philadelphia, Pennsylvania Johns Hopkins School of Medicine and Refractive Surgery Baltimore, Maryland Shiley Eye Institute Nakul Shekhawat, MD, MPH University of California,
    [Show full text]
  • Ablution Exercise – May Prevent Dacryocystitis
    December 2019/ Vol 4/ Issue 8 Print ISSN : 2581-4907, Online ISSN : 2456-6454 Original Research Article Ablution exercise – may prevent dacryocystitis Pandey J. 1, Ranjan A .2 , Gupta R.C. 3, Khan P. 4 1Dr. Jayati Pandey, Senior Resident, 2Dr. Alok Ranjan, Senior Resident, 3Dr. Ramesh Chandra Gupta, Principal, LLRM Medical College, Meerut. Ex-HOD Department of Ophthalmology, 4Dr. Perwez Khan, Professor & Head; all authors are affiliated with Department of Ophthalmology, G.S.V.M Medical College, Kanpur, Uttar Pradesh, India. Corresponding Author: Dr. Jayati Pandey, Senior Resident, Department of Ophthalmology, G.S.V.M Medical College, Kanpur, Uttar Pradesh, India. Email: [email protected] ……………………………………………………………………………………………………………………………………... Abstract Background: Dacryocystitis is an infection and inflammation of the lacrimal sac and most common cause of ocular morbidity in India. It’s accounting for 87.1% of epiphora and causes social discomfort due to continuous watering from the eyes. It is more common in India as being tropical country. It has higher incidence among lower socioeconomic status. Hygiene plays an important role in its aetiology. Objective: This study was aimed to survey the demographic characteristics of patients received external dacryocystorhinostomy (DCR) surgery to correlate with religious aspect of the patients. Material & Methods : The present study is a retrospective study conducted at Ophthalmology Department from the hospital records of patients who underwent external DCR for epiphora from January 2013 to December 2017. Results: Out of 305 cases underwent DCR (n=305), maximum (n=179, 58.69%) were above the age of 40 years out of which maximum were in age group of 41-50 years (n=78, 24.57%), majority of them were females 70.49% (n=215) with males being only 29.51% (n=90).
    [Show full text]
  • Cornea/External Disease 2017-2019
    Academy MOC Essentials® Practicing Ophthalmologists Curriculum 2017–2019 Cornea/External Disease *** Cornea/External Disease 2 © AAO 2017-2019 Practicing Ophthalmologists Curriculum Disclaimer and Limitation of Liability As a service to its members and American Board of Ophthalmology (ABO) diplomates, the American Academy of Ophthalmology has developed the Practicing Ophthalmologists Curriculum (POC) as a tool for members to prepare for the Maintenance of Certification (MOC) -related examinations. The Academy provides this material for educational purposes only. The POC should not be deemed inclusive of all proper methods of care or exclusive of other methods of care reasonably directed at obtaining the best results. The physician must make the ultimate judgment about the propriety of the care of a particular patient in light of all the circumstances presented by that patient. The Academy specifically disclaims any and all liability for injury or other damages of any kind, from negligence or otherwise, for any and all claims that may arise out of the use of any information contained herein. References to certain drugs, instruments, and other products in the POC are made for illustrative purposes only and are not intended to constitute an endorsement of such. Such material may include information on applications that are not considered community standard, that reflect indications not included in approved FDA labeling, or that are approved for use only in restricted research settings. The FDA has stated that it is the responsibility of the physician to determine the FDA status of each drug or device he or she wishes to use, and to use them with appropriate patient consent in compliance with applicable law.
    [Show full text]
  • Amniotic Membrane Transplantation for Symptomatic Conjunctivochalasis Refractory to Medical Treatments
    Cornea 19(6): 796–803, 2000. © 2000 Lippincott Williams & Wilkins, Inc., Philadelphia Amniotic Membrane Transplantation for Symptomatic Conjunctivochalasis Refractory to Medical Treatments Daniel Meller, M.D., Steven L. Maskin, M.D., Renato T.F. Pires, and Scheffer C.G. Tseng, M.D., Ph.D. Purpose. To determine whether preserved human amniotic mem- severe form causes exposure-related problems such as nocturnal brane can restore the large conjunctival defect created during sur- lagophthalmos and dellen formation.7 gical removal of conjunctivochalasis. Methods. Amniotic mem- No treatment is needed if patients with conjunctivochalasis re- brane transplantation was performed at two facilities in 40 con- main asymptomatic. Medical treatments with artificial tears, lubri- secutive patients (47 eyes) with symptomatic conjunctivochalasis cants, steroids, and antihistamines have been advised for symp- refractory to conventional treatments. Results. The majority of tomatic patients. When they fail, surgical removal of the redundant patients were elderly (73.1 ± 9.7 years) and women (75%). Over a conjunctiva becomes necessary.1,3,4,8,9 The first surgical tech- follow-up period of 6.9 ± 4.3 months, 46 (97.8%) eyes recovered 4 1,2,5,6,8 smooth, quiet, and stable conjunctival surfaces. Epithelial defects nique, described by Braunschweig and employed by others healed in 16.5 ± 7.3 days. Episodic epiphora was resolved in 24 of includes a crescent excision of the inferior bulbar conjunctiva at a 30 (83.3%) eyes and improved in five other eyes. Notable relief distance of 5 mm from the limbus followed by suture closure.2,5,8 was also noted for such symptoms as fullness or heaviness (19/19, A modified technique was proposed by Serrano and Mora9 to 100%), sharp pain (6/6, 100%), redness (14/17, 88.2%), tiredness avoid visible scarring or retraction of the inferior conjunctival (17/20, 80.9%), itching (11/13, 78.6%), blurry or decreased vision fornix.
    [Show full text]
  • Amniotic Membrane Transplantation for the Ocular Surface
    Name of Blue Advantage Policy: Amniotic Membrane Transplantation for the Ocular Surface Policy #: 624 Latest Review Date: February 2021 Category: Medical Policy Grade: C BACKGROUND: Blue Advantage medical policy does not conflict with Local Coverage Determinations (LCDs), Local Medical Review Policies (LMRPs) or National Coverage Determinations (NCDs) or with coverage provisions in Medicare manuals, instructions or operational policy letters. In order to be covered by Blue Advantage the service shall be reasonable and necessary under Title XVIII of the Social Security Act, Section 1862(a)(1)(A). The service is considered reasonable and necessary if it is determined that the service is: 1. Safe and effective; 2. Not experimental or investigational*; 3. Appropriate, including duration and frequency that is considered appropriate for the service, in terms of whether it is: • Furnished in accordance with accepted standards of medical practice for the diagnosis or treatment of the patient’s condition or to improve the function of a malformed body member; • Furnished in a setting appropriate to the patient’s medical needs and condition; • Ordered and furnished by qualified personnel; • One that meets, but does not exceed, the patient’s medical need; and • At least as beneficial as an existing and available medically appropriate alternative. *Routine costs of qualifying clinical trial services with dates of service on or after September 19, 2000 which meet the requirements of the Clinical Trials NCD are considered reasonable and necessary by Medicare. Providers should bill Original Medicare for covered services that are related to clinical trials that meet Medicare requirements (Refer to Medicare National Coverage Determinations Manual, Chapter 1, Section 310 and Medicare Claims Processing Manual Chapter 32, Sections 69.0-69.11).
    [Show full text]
  • Twelfth Edition
    SUPPLEMENT TO April 15, 2010 www.revoptom.com Twelfth Edition Joseph W. Sowka, O.D., FAAO, Dipl. Andrew S. Gurwood, O.D., FAAO, Dipl. Alan G. Kabat, O.D., FAAO 001_ro0410_hndbkv7.indd 1 4/5/10 8:47 AM TABLE OF CONTENTS Eyelids & Adnexa Conjunctiva & Sclera Cornea Uvea & Glaucoma Vitreous & Retina Neuro-Ophthalmic Disease Oculosystemic Disease EYELIDS & ADNEXA VITREOUS & RETINA Floppy Eyelid Syndrome ...................................... 6 Macular Hole .................................................... 35 Herpes Zoster Ophthalmicus ................................ 7 Branch Retinal Vein Occlusion .............................37 Canaliculitis ........................................................ 9 Central Retinal Vein Occlusion............................. 40 Dacryocystitis .................................................... 11 Acquired Retinoschisis ........................................ 43 CONJUNCTIVA & SCLERA NEURO-OPHTHALMIC DISEASE Acute Allergic Conjunctivitis ................................ 13 Melanocytoma of the Optic Disc ..........................45 Pterygium .......................................................... 16 Demyelinating Optic Neuropathy (Optic Neuritis, Subconjunctival Hemmorrhage ............................ 18 Retrobulbar Optic Neuritis) ................................. 47 Traumatic Optic Neuropathy ...............................50 CORNEA Pseudotumor Cerebri .......................................... 52 Corneal Abrasion and Recurrent Corneal Erosion ..20 Craniopharyngioma ..........................................
    [Show full text]
  • Acquired Etiologies of Lacrimal System Obstructions
    5 Acquired Etiologies of Lacrimal System Obstructions Daniel P. Schaefer Acquired obstructions of the lacrimal excretory outfl ow system will produce the symptoms of epiphora, mucopurulent discharge, pain, dacryocystitis, and even cellulitis, prompting the patient to seek the ophthalmologist for evaluation and treatment. Impaired tear outfl ow may be functional, structural, or both. The causes may be primary – those resulting from infl ammation of unknown causes that lead to occlusive fi brosis—or secondary, resulting from infections, infl amma- tion, trauma, malignancies, toxicity, or mechanical causes. Secondary acquired dacryostenosis and obstruction may result from many causes, both common and obscure. Occasionally, the precise pathogenesis of nasolacrimal duct obstruction will, despite years of investigations, be elusive. To properly evaluate and appropriately treat the patient, the ophthal- mologist must have knowledge and comprehension of the lacrimal anatomy, the lacrimal apparatus, pathophysiology, ocular and nasal relationships, ophthalmic and systemic disease process, as well as the topical and systemic medications that can affect the nasolacrimal duct system. One must be able to assess if the cause is secondary to outfl ow anomalies, hypersecretion or refl ex secretion, pseudoepiphora, eyelid malposition abnormalities, trichiasis, foreign bodies and conjunctival concretions, keratitis, tear fi lm defi ciencies or instability, dry eye syn- dromes, ocular surface abnormalities, irritation or tumors affecting the trigeminal nerve, allergy, medications, or environmental factors. Abnormalities of the lacrimal pump function can result from involu- tional changes, eyelid laxity, facial nerve paralysis, or fl oppy eyelid syndrome, all of which displace the punctum from the lacrimal lake. If the cause is secondary to obstruction of the nasolacrimal duct system, the ophthalmologist must be able to determine where the anomaly is and what the cause is, in order to provide the best treatment possible for the patient.
    [Show full text]
  • OPTOMETRIC PHYSICIAN SYMPOSIUM January 26Th, 2019
    30TH Annual OPTOMETRIC PHYSICIAN SYMPOSIUM January 26th, 2019 Anterior Segment Grand Rounds Blair Lonsberry, O.D., FAAO 1/25/2019 Dendritic Ulcers Case • 20 year old male presents with a red painful eye – Started that morning when he woke up – reports a watery discharge, no itching, and is not a contact lens wearer • SLE: – See attached image with NaFl stain 3 Herpes Simplex Keratitis: Clinical Features • Characterized by primary outbreak and subsequent reactivation • Primary outbreak is typically mild or subclinical • After primary infection, the virus becomes latent in the trigeminal ganglion or cornea • Stress, UV radiation, and hormonal changes can reactivate the virus • Lesions are common in the immunocompromised (i.e. recent organ transplant or HIV patients) 1 1/25/2019 Anti‐Viral Medication Pediatric HSV Keratitis Drug Mechanism of Action Bioavailability Dosing Side Effects Acyclovir Acyclovir interferes 10‐30% gets Simplex: Overall very safe • pediatric herpes simplex keratitis has an 80% risk with DNA synthesis absorbed 400 mg Nausea, of recurrence, a 75% risk of stromal disease, and inhibiting viral Short ½ life 5x/day vomiting, a 30% rate of misdiagnosis replication *Metabolized in Zoster: headaches, kidneys 800 mg dizziness, • 80% of children with herpes simplex keratitis 5x/day confusion develop scarring, mostly in the central cornea Valacyclovir Acyclovir pro‐drug 95% converted Simplex: Same as acyclovir – results in the development of astigmatism Equivalent to acyclovir to acyclovir* 500 mg tid but better for pain Better
    [Show full text]
  • Dry Eye: the Following Go from Least to Artificial Tears: 4-8X/Day
    www.ManhattanEyeNYC.com Yuna Rapoport, MD MPH Dry Eye: The following go from least to most viscous: Artificial tears: 4-8x/day Gel: at night - Systane Gel - Bottle (with preservatives) - Genteal Gel - Individual Vials Free) o Retaine Ointment: at night o Refresh - Retaine PM o Systane - Refresh PM - Thicker drops (anything with the ingredient Prescription: Carboxymethylcellulose): - Restasis – twice a day o Refresh Plus - Xiidra – twice a day o Refresh Celluvisc - Cequa – twice a day There is no brand preference for the drops, gels and ointments. Drugstore brands are comparable to the branded ones mentioned above. Other Treatments: - Punctal plugs (see separate attachment) - Autologous serum tears (see separate attachment) - Compounded drops from compounding pharmacies (lacosamide, testosterone) - Conjunctivochalasis treatment (Ellman procedure or surgery) Moist Environment: - Humidifier - Moisture Chamber Glasses/ Goggles for outside and overnight- i.e. Tranquileyes (brand) - Drink water www.ManhattanEyeNYC.com Yuna Rapoport, MD MPH Blepharitis/ Meibomian Gland Disease: Step 1: Hot compresses on closed eyes nightly for 1 minute (heat opens the oil glands) Step 2: Apply Ocusoft/ Avenova/ Cliradex Foam onto circular cotton pads and gently wipe eyelids from the nose out Foam (available on Amazon or at Manhattan Eye) is more gentle on eyelids than the presoaked pads (available at drug stores) Stye treatment: - As much heat as possible: -Boiled egg or baked potato wrapped in towels and hold over affected eye. As the heat decreases, unwrap the towel: - Ocusoft/ Avenova as listed above - Steroid/ antibiotic drops 4 times a day (you will be prescribed) - Steroid/ antibiotic ointment at night (pull the lid down/ up and put inside the eye) If needed: steroid injection, incision and drainage .
    [Show full text]