8/26/2019
Speakers Bureau for Aeri, Allergan, Bausch & Lomb, Glaukos, Ivantis, Optovue, Reichert
Robert P. Wooldridge, O.D., F.A.A.O.
Always be able to account for a patient’s VA Always be able to account for a patient’s VF Always be able to account for a patient’s C/O LOV ◦ vague complaint Anatomical Approach
Refractive How to Evaluate Media opacity/distortion Refraction Macula problem ◦ Retinoscopy-lost skill look for scissors/distorted reflex Optic nerve/Neurologic Pinhole VA Amblyopia High order aberrations Hysteria/malingering
1 8/26/2019
Tear film Grade the View! Cornea VA vs View ◦ PEK, Central Cloudy Dystrophy of Francois (CCDF) Anterior Chamber 20/80 ◦ Careful evaluation for C/F hem, etc Lens ◦ Milky white NS vs yellow brown NS; vacuoles Vitreous 20/20 ◦ Hemorrhage ◦ Clarity: variable, cloudy
◦ Punctate Keratopathy Slit Lamp exam PEK, SPK Tear BUT ◦ Opacity: Oculus Topographer Scar Epithelial edema Stromal edema Central Cloudy Dystrophy of Francois (CCDF)
Slit Lamp exam Keratoconus Corneal topography Pellucid Marginal Retinoscopy Degeneration (PMD) Pachymetry Post LASIK/PRK ◦ Ultrasonic Post PKP ◦ OCT CL induced
2 8/26/2019
Unusual cause of Nuclear sclerosis (NS) unclear media ◦ Milky white vs. Careful slit lamp brunescent yellow/brown NS exam ◦ Vacuoles ◦ Cells/flare Cortical cataract ◦ RBC’s ◦ Anterior (ACC) Turn the SL light ◦ Posterior (PCC) up high! Posterior Subcapsular (PSC) Easier to see with dilated pupil Myopic shift is a good hint of cataract progression!
Slit Lamp exam 50yo WM referred as Glaucoma suspect Direct and Retro VA 20/20 OU illumination C/O occasional cloudy vision OD Contrast Sensitivity ◦ Without glare H/O RD repair 1981 ◦ With glare
18yo WF referred: VA uncorrectable to 20/20 Patient unsure of course of VA Wears DWSCL MH: mild congenital hear defect FH: Father has poor VA cc BVA R 20/25- L 20/40 low myopia Pupils, SLE Normal OU CT: Orthophoric Stereo 5/9 SLE NL OU DFE: OD NL OS mild RPE change in macula
3 8/26/2019
Amsler grid Color Vision Corneal Topography Fluorescein Angiogram OCT Disc OCT Macula ERG/EOG MRI Brain and orbits
Fundus Flavimaculatus Autosomal recessive Early stage may show little/no visible retinal signs Fluorescein angiogram often diagnostic ERG may be NL
4 8/26/2019
VA R 20/30 L 20/40 38 yo Nepalese Male moved to US in 1996 Referred for glaucoma evaluation H/O good VA as a child ◦ Began to have decreased vision with light at 18yo ◦ First glasses in 1996; not diagnosed with glaucoma ◦ Has been on glaucoma drops x 1 year ◦ Using Travatan-Z, Cosopt, Alphagan-P OU Medical history: NL FH: 5 siblings; sister has similar symptoms
VAsc R 20/200 L 20/100 NI with refraction Pupils, motility NL OU CT: Orthophoric SLE NL OU with mild hyperemia OU; ◦ lenses clear IOP R 18 L 16 CCT R 542 L 542 Color vision R 2/15 L 2/15 Fundus as seen
5 8/26/2019
Glaucoma Other optic nerve disease Media opacity Macular problem Amblyopia Neurological problem
Corneal Topography Fluorescein Angiogram OCT Disc OCT Macula ERG/EOG MRI Brain and orbits
6 8/26/2019
VEP’s very poor OU mfERG’s abnormal outside central macular area Full field ERG: ◦ Very attenuated photopic responses ◦ Normal scotopic responses No diagnosis given Referred to neuro-ophthalmology for second opinion who then referred him to retinal specialist for third opinion
Retinal Cone Dystrophy 42yo WM Life-long H/O poor VA OU Diagnosed as amblyopia OU since childhood VA R20/30 L 20/30 Pupils NL Neg. APD CT:orthophoric SLE NL OU DFE NL but thin macular RPE, ◦ No foveal reflex
Bilateral amblyopia No strabismus No uncorrected refractive error/astigmatism No H/O ocular surgery
7 8/26/2019
SL with: ◦ HH lens, fundus CL BIO Direct O-scope Amsler Grid OCT Photo Fundus Autofluoresence (FAF) Fluorescein Angiography (FA) Multifocal ERG
2009
Congenital Dystrophies 65yoWF C/O Acquired diseases distorted VA OS ◦ Age-related Macular Degeneration (AMD) ◦ Diabetic retinopathy VA 20/20- OU ◦ Edema Pupils, VF NL ◦ Epi-retinal Membrane (ERM) A Grid ◦ Hole ◦ OD Nl ◦ Hypoplasia ◦ OS distorted ◦ Toxicity-drug SLE 1+ NS OU ◦ Vascular disease/event ◦ Inflammatory diseases Trauma
5/05/2011 5/06/13 20/20-20/25 20/20-20/25
8 8/26/2019
Pre-retinal membrane VERY common Usually due to PVD causing tear in ILM ◦ Glial cells proliferate on retinal surface May also be associated with diabetic retinopathy and other retinopathies Treatment is PPV/membrane peel if visually significant ◦ VA criteria variable
60yo WF referred with VA uncorrectable to 20/20 Previous exam showed no apparent cause VA R 20/20 L 2030 Minimal distortion on A grid OS Pupils, CVF NL OU Cover test orthophoric OU SLE NL OU
9 8/26/2019
66 yo WM C/O “barrel distortion” OD ◦ X1 week; constant, notices at near only ◦ No complaints OS VA R 20/80 L 20/20 A. Grid +distortion OD only Pupils NL SLE 1+ NS OU
Larry Pre PPV/MP Larry Post PPV/MP PPV/MP 12/05/12 Last visit July 2013 VA R 20/80 L 20/25 Still has some distortion OD SLE OD 3+ NS OS 1+ NS DFE OD: Mild RPE change OS 2+ ERM
10 8/26/2019
68 yo WF treated for glaucoma Visual Acuity OS? VA R 20/20 L 20/25 Measured in 2013 as R 20/15 L20/15- with PTMH present
ERM PTMH 20/20- OU
11 8/26/2019
PTMH FTMH Patient may be asymptomatic Patient usually symptomatic VA may be good/excellent 20/15-20/30 VA usually 20/70-20/400 ERM and/or PVD often co-existent Treatment: PPV/gas bubble No treatment indicated
73yo WF 6 weeks postop. phaco patient C/O decreasing VA for past 2 weeks
12 8/26/2019
1995 20/20 OU no complaints; NL exam Young adult 2002 vertical diplopia: LSO; MRI shows UBO’s Males> females ◦ No specific systemic diagnosis made Unilateral 2005: VA R 20/20-25 L 20/25-30 ◦ Central oval RPE change OU noted ◦ Attempted FA; could not find vein ◦ Retinal specialist noted mild macular pigmentary changes, no need to WU further, mfERG if desired ◦ mfERG=Normal 2007: FA at JMEC confirms parafoveal telangiectasia
2012
OD 20/30 OS 20/50-70 S/P multiple Avastin injections
13 8/26/2019
68yo WF C/O poor VA OU S/P phaco/IOL OD Sep. 2009;poor VA since then; no reason given VA R 20 25- L 20/50 Pupils, color VA, CT NL OU SLE: OD 2+ PCO OS Cataract DFE:“Trace central sensory retinal change OU”
28yo WM C/O blurred VA OD x 3 months Corneal topography MH No medical illnesses or complaints OCT macula VAsc R 20/70 L 20/20; NI with refraction OCT disc Pupils NL Neg APD Visual field CVF FTFC OU Fluorescein angiogram Motilities full OU; CT orthophoric MRI brain/orbits Color VA R 4/14 L 13/14 ERG/EOG/VEP Amsler grid OD IT paracentral scotoma; OS nl SLE, DFE completely NL OU
OCT macula is normal VF has some bitemporal flavor Plan: MRI/MRA brain and orbits c/s contrast
14 8/26/2019
Had pituitary tumor resected Jan. 22 VAsc R 20/15 L 20/15 Color Vision R 15/15 L 15/15 Pupils NL Last seen in 2012: all findings normal
Slit lamp with hand-held lens Visual Evoked Potential (VEP) Direct ophthalmoscope MRI/CT Fundus photography Ultrasound ◦ Fundus autofluoresence Fluorescein angiography OCT HRT Visual field Pupil reactions Color vision
Glaucoma Arcuate bundle defect Optic Neuritis Does NOT respect vertical midline ◦ Anterior NO early CENTRAL scotoma ◦ Retro-bulbar ◦ But paracentral possible! Optic nerve drusen Nasal usually worse than temporal Papilledema Temporal to blind spot last to go Ischemic Optic Neuropathy (AION) Remember to correlate with cupping!
15 8/26/2019
57yoWF referred with poor VA OS, cause BVA R 20/25+ L 20/70 unknown Pupils NL Neg APD ◦ Thought to have some AMD OS Motility full; CT orthophoric 3 mos ago pat. was looking at Amsler grid IOP R 13 L 14 with friends at home and noted distortion OS Amsler grid OD NL OS paracentral distortion ◦ Does not know if onset was sudden or gradual SLE NL; lenses clear OU ◦ No VA complaint OD ◦ H/O seeing 20/20 OU in past years DFE as seen MH: Normal, no medical illnesses ◦ 8 children (post traumatic stress??) ◦ No significant HA’s or other complaints
Normal Tension glaucoma Anterior ischemic optic neuropathy Optic atrophy Intracranial mass
Prostaglandin QHS OU MRI CBC, ESR, CRP ◦ reveals Pituitary adenoma Fluorescein angiogram OCT macula Tumor resected MRI brain/orbits
16 8/26/2019
Confrontation VF are Not Enough!! Just Another Day With the Wooldridge Teens
Mental disorder that impairs physical Conscious attempt to deceive for personal functions with no physiological basis; sensory gain motor symptoms include seizures, paralysis, temporary blindness; increase in stress or avoidance of unpleasant responsibilities may precipitate Subconscious response Patient believes he/she has a real problem But may have something to gain
17 8/26/2019
Patient has a true organic disease/problem Hysteria: But also has a functional component ◦ Young: 9-13yo most common Adults possible ◦ Female Malingering ◦ Late teens to adults
Loss of Vision Reads every line at same slow speed, letter by ◦ Monocular or binocular letter ◦ Central or peripheral Ambulates well despite C/O severe LOV ◦ Usually sudden in onset Severely constricted CVF Can be dated/connected to an event ◦ Sometimes vague, uncertain NO APD despite severe unilateral LOV
Careful history 1. Refractive error Refraction 2. Media opacity Full examination 3. Macula Stereo 4. Optic nerve CT 5. Amblyopia-there has to be a cause! PUPILS! 6. Hysteria/malingering Visual Field-Never make a diagnosis without it! DFE
18 8/26/2019
History of poor VA? Optokinetic drum Prior eye exams? (get records) Measuring tape, ruler Have you ever been 20/20? Mirror: eye tracking Must have a reason to have amblyopia ◦ Strabismus ◦ Refractive ◦ Obscuration
Refraction with slow, patient VA Cyclopleged Close OU Telescopic lens suggestion Spin every dial while saying Polaroid slide with OU open I am putting in a very strong telescopic lens If there is anything wrong with your eye, this lens will make you see well Isolated lines; Start at 20/10 Move up chart slowly Lots of positive encouragement be patient for each letter
19 8/26/2019
Perform at normal two feet Spiraling isopters Again across room Inversion of isopters If cylindrical (tubular), not physiologic Mimic finger motions in areas of “blindness”
300.11 Conversion disorder Discuss with parent alone ◦ Hysterical blindness, deafness, paralysis Some attempt to determine reason for childs Def.: Mental disorder that impairs physical response functions with no physiological basis; sensory Assure child of healthy eyes motor symptoms include seizures, paralysis, Give child a way to get better temporary blindness; increase in stress or ◦ Drops avoidance of unpleasant responsibilities may ◦ Glasses precipitate ◦ Voodoo magic Parent to reinforce positive feedback
Careful refraction! Cover test/ 6 base out test/stereo ◦ Rule out amblyopia/suppression Amsler grid ◦ Maculopathy; possible optic neuropathy Color Vision DILATED fundus exam
20 8/26/2019
Visual Field ◦ Rule out neurologic/optic nerve disease ◦ Confrontation VF is not enough! OCT Macula ◦ R/O subtle maculopathy Corneal Topography ◦ R/O keratoconus/distortion from other causes Fluorescein angiography ◦ R/O subtle maculopathy/vasculopathy ERG/EOG/VEP MRI brain orbits
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