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Home , Exposure keratopathy, Nystagmus

Melanie Hope Kane O.D., Michelle Serrano O.D., Sandra Fox O.D. South Texas Veterans Health Care System

Ocular Complications Following Vestibular Schwannoma Excision

Abstract: A vestibular schwannoma and its excision can cause multiple ocular complications. Close observation and long-term treatment may be required to preserve both vision and ocular health.

I. Case History  26 year-old Hispanic male  Chief complaint of constant film over right eye causing blurred vision since schwannoma excision 2015. He also reports that the room appears to be spinning but resolves with eye closure.  Ocular history includes right corneal abrasion 04/2016, neurotrophic keratopathy right eye 04/2016 with element of secondary .  Medical history includes a right vestibular schwannoma, right retro sigmoid craniotomy with tumor resection 12/12/2015, posterior fossa hemorrhage with persistent clot where the craniotomy had to be re-opened. The eighth cranial nerve was cut. Palsy of the right fifth and seventh .  Ocular included preservative free artificial in the right eye 4-6 times per day. The patient was not taking any systemic medications  This is an inpatient at the polytrauma rehabilitation unit, admitted 05/17/2016

II. Pertinent findings  17 visits from 05/19/2016-08/25/2016, pertinent exams listed.  Visit 1:  VA cc: OD: 20/150 PH:20/60+2 OS: 20/40+2 PH:20/30-2 OU: 20/30-2  Fixation: , erratic in nature with a torsional component  EOMS: nystagmus worsens in right end gaze. Null point appears to be in primary gaze.  : cc Distance: Inaccurate fixation secondary to nystagmus. Near: Inaccurate fixation secondary to nystagmus.  Habitual specs: OD: -1.50+1.00x065 OS: -3.00+2.75x090  SLE: OD: right side facial droop, , 4+ conjunctival injection, 4+ SPK, stromal horizontal band scarring below , central corneal haze  Visit 7: 06/15/2016  VA cc: OD: 20/40+ PH 20/30-2 OS: 20/30-1 PH 20/25-2 OU: 20/30-2  SLE: OD: right side facial droop, lagophthalmos, 4+ conjunctival injection, 3+ SPK, stromal horizontal band scarring below pupil, central corneal haze  Visit 9: 07/22/2016  VA cc: OD: 20/400 PH 20/150 OS: 20/40-2 PH 20/25+2 OU: 20/30  SLE: OD: right side facial droop, lagophthalmos, 4+ conjunctival injection, 4+ SPK, stromal horizontal band scarring below pupil, central corneal haze, infiltrate temporal with overlying epithelial defect.  Visit 17: 08/25/2016  VA cc: OD: 20/100 OS: 20/30  SLE: OD: right side facial droop, lagophthalmos, 7.5mmx2.0mm H/V stromal scar, haze inferior to pupil, diffuse 4+ intrapalpebral staining. (-)infiltrate (-)epithelial defect

III. Differential Diagnosis  Primary/leading:   Neurotrophic Keratopathy  Corneal Abrasion  Exposure keratopathy  Lagophthalmos  Nystagmus  Others:  Bacterial  Herpes Simplex  Herpes Zoster  Recurrent Corneal Erosion   Sjogren Syndrome

IV. Diagnosis and Discussion  Corneal ulcer  An inflammatory condition of the involving disruption the epithelial layer with stromal involvement.  Exposure keratopathy  Decreased lubrication of the ocular surface due to inadequate closure or decreased blink.  Neurotrophic keratopathy  A degenerative disease of the resulting from impaired corneal innervation. Secondary to cranial nerve five palsy.  Lagophthalmos  The inability to close the completely. Secondary to cranial nerve seven palsy.  Nystagmus  Secondary to the cutting of cranial nerve eight.

V. Treatment, management  Corneal Ulcer  Topical antibiotics, bandage contact , introduce topical steroid once resolving  Exposure keratopathy  Topical artificial tears and ointments, topical cyclosporine, moisture chamber googles, Scleral lens  Lagophthalmos  Tarsorrhaphy, gold weight implantation  Nystagmus  Botox injections, monitor

VI. Conclusion  Vestibular schwannomas and the to remove them can cause lifelong ocular issues needing lifelong treatment.  Constant follow-ups may be needed to preserve both vision and ocular health.  Consulting with physicians and making the appropriate referrals is very important in the preservation of vision and ocular health.  Bibliography 1. Amescua, G., Miller, D., & Alfonso, E. (2012). What is causing the corneal ulcer? Management strategies for unresponsive corneal ulceration. Eye, 26, 228-236. doi:10.1038/eye.2011.316 2. Ehrhardt, D., & Eggenberger, E. (2012). Medical treatment of acquired nystagmus. Current Opinion in , 23(6), 510-516. doi:10.1097/ICU.0b013e328358ba6e 3. Gire, A. O. D., Kwok, A. O. D., & Marx, D. M. D. (2013). PROSE treatment for lagophthalmos and exposure keratopathy. Ophthalmic Plastic and Reconstructive Surgery, 29(2), 38-40. doi:10.1097/IOP.0b013e3182674069 4. Kim, C., & Lelli, G. J. (2013). Current considerations in the management of facial nerve palsy. Current Opinion in Ophthalmology, 24(5), 478-483. doi:10.1097/ICU.0b013e3283634869 5. Lambiase, A. M.,PhD, Sacchetti, M. M.,PhD, Mastropasqua, A. M., & Bonini, S. M. (2013). Corneal changes in neurosurgically induced neurotrophic keratitis. JAMA Ophthalmology, 131(12), 1547-1553. doi:10.1001/jamaophthalmol.2013.5064 6. Rogers, N. K., & Brand, C. S. (1997). Acoustic neuroma and the eye. British Journal of Neurosurgery, 11(4), 292-297. 7. Sacchetti, M., & Lambiase, A. (2014). Diagnosis and management of neurotrophic keratitis. Dovepress, 2014(8), 571-579. doi:10.2147/OPTH.S45921 8. Tos, T., Caye-Thomasen, P., Stangerup, S., Thomsen, J., & Tos, M. (2003). Need for facial reanimation after operations for vestibular schwannoma: Patients perspective. Scandinavian Journal of Plastic & Reconstructive Surgery & Hand Surgery., 37(2), 75-81. 9. Dutton, J., & Fowler, A. (2007). Botulinum toxin in ophthalmology. Survey of Ophthalmology, 52(1), 13-31. doi:10.1016/j.survophthal.2006.10.003 10. Gersthenblith, A., et al, eds. The Wills Eye Manual. Sixth Edition ed. Wolters Kluwer Pvt Ltd, 2012. Print. Neurotrophic keratopathy. 105-107. 11. Friedman, N., P. Kaiser, and R. Pineda. The Massachusetts Eye and Ear Infirmary Illustrated Manual of Ophthalmology. 3rd ed. China: Elsevier, 2009. Print.