Grand Rounds - Amazon S3 · 2019-10-14 · Grand Rounds Anthony DeWilde, OD 1 Patient 1 72 year old African American male Blur OD x 3 months Last eye exam 10 years ago 2 Ocular History

Grand RoundsAnthony DeWilde, OD

1

Patient 1

72 year old African American male

Blur OD x 3 months

Last eye exam 10 years ago

2

Ocular History

Mixed Mechanism Glaucoma

S/P LPI OU

Was on Xalatan qhs OU – no longer taking

Blunt trauma OD

3

Medical History

HTN

Anemia

CVA x 2

Hyperlipidemia

Kidney Disease

4

Medications

Amlodipine

Atenolol

HCTZ

Simvastatin

ASA

5

Exam

BCVA OD: 20/320, OS: 20/25

+APD OD

Anterior Segment Normal

Except Mild NS OU

6

Exam

Gonio: Narrow with old PAS

S/P LPI OU

IOP 14/14

7

Posterior Segment

Optic Nerve

0.75 OD - Pallor

0.90 OS

No maculopathy

No vasculopathy

Peripheral retina normal

8

Pallor Vs. Excavation9

Pallor Vs. Excavation10

11

12

13

14

Differential

Glaucoma

Other Optic Atrophy

Traumatic

Compressive

Inflammatory

15

What Tests?

VF?

OCT?

Imaging?

16

VF - OD17

VF - OS18

New Differential

Glaucoma

Compressive Lesion

CVA

19

MRI20

MRI21

Diagnosis

Pituitary Adenoma – 2.5 x 1.6 cm

22

Treatment

Monitor only

Due to other health factors

Patient reports vision is fine

23

Pituitary TumorsHormone-Producing

Prolactinoma

Growth Hormone Secreting

ACTH Secreting (Cushing’s)

Hormone Inactive

Size

24

Treatment

Goals

Normalize hormone levels

Pituitary gland function

Reduce signs/symptoms of tumor

25

Treatment

Medication (Micro)

Bromocriptine – Dopamine agonist

Hormone stabilization

26

Treatment

Surgery (Macro)

Transsphenoidal

Transcranial

27

Treatment

drarunlnaik.com

28

Take Home

Check both eyes

Pituitary vs. Glaucoma

Pallor vs. Excavation

29

Patient 2

72 YO Hispanic Male

Blur OD/OS - Worse at night

IOP 16/14

BCVA 20/40, 20/30

30

Removal of tumor on “Left Optic Nerve” x 1990

31

Anterior Segment Unremarkable except

2+ NS OU

32

33

34


2+ NS OU

35


2+ NS OU

36

Bitemporal Hemianopsia

Old or new??

37

Patient 1.138

Old or new??

39

Old or new??

40

Followed by Endocrinology

Tumor resected

Cataract removed

41

“The best place to find a brain tumor is a glaucoma clinic”

42

Patient 3

59 Y/O White Male

Medical HX

HTN, COPD, Arthritis, Kidney Failure

Peripheral Vascular Disease, Anemia

Carotid Artery Stenosis, Hyperlipidemia

Amputee – Bilateral

43

Medications:

HCTZ

Norvasc

Metoprolol

Lisinopril

Simvastatin

Warfarin

44

Examination

Blur for 1 month

BCVA: 20/40 OD, 20/100 OS

+ APD OS

IOP 6/10

Anterior Segment:

Mild Cataract OS>OD

45

Posterior Segment

Mild artery attenuation

Mild ONH nerve pallor

Retina appears perfused

46

47

48

49

50

Lessons Learned

“Classic” Presentation of CRAO

Giant Cell Arteritis

Consider Ophthalmic Artery

Neovascularization

Risk to Brain and Heart

Have a Heart

51

Lesson #1

“Classic” Presentation of CRAO

Presentation of CRAO after reperfusion

52

53

54

55

Differential Diagnosis

Central Retinal Artery Occlusion

Ophthalmic Artery Occlusion

Ocular Ischemic Syndrome

Giant Cell Arteritis

56

Lesson #2

5-15% of CRAOs are from Temporal Arteritis

57

Additional Tests

ESR = 31 (slightly elevated)**

CRP = 0.5 (normal)

CBC = Abnormal RBC, HCT, HGB (Anemic)**

Carotid Doppler

Carotid Angiography

58

Carotid Doppler ResultsStent in the right distal common carotid artery

Interval occlusion of the common carotid artery

Degree of stenosis in the right internal carotid artery cannot be measured

Low flow to internal carotid

59

Follow – Up

1 month later (2 months after start of blur)

Very sluggish pupil and VA Hand Motion

60

Follow – Up

5 month follow-up:

Dense, hypermature cataract

Neovascularization of the Iris

Neovascularization of the Angle 360 degrees

61

Lesson #3

Consider an Ophthalmic Artery Occlusion/OIS

62

Lesson #4

CRAO can develop anterior segment NV

63

Treatment

Avastin for Neovascularization

Didn’t help regress NV

Otherwise, monitor only

Goal of this eye is no pain

Still weighing Risk/Benefit of Cataract Extraction

64

Lesson #5

Increased risk for CVA/MI

Risk for Heart Attack is greater

65

Lesson #5

AHA and ASA recommend urgent referral

CRAO/BRAO requires ER visit

66

Lesson #5

79% OF CRAO HAD ACUTE SYSTEMIC CHANGE

MEDICATION CHANGE 92%

CAROTID DISEASE 37%

CVA 37%

ECHOCARDIO 20%

Am J Ophthalmol 2018;196:96-100

67

Lesson #5

Amaurosis Fugax requires ER visit

68

Lesson #569

Lesson #5

Asymptomatic retinal emboli??

70

Lesson #5

TIA used to mean timing

TIA now means location

Eye is part of the Central Nervous System

71

Lesson #6

Compassion

72

Patient 4

30 year old white female

CC: Headache and vision loss

H/O vision loss OD, diplopia

Improved now

73

Currently on

Diamox

Butalbital

74

BCVA 20/40 OD, CF OS

APD OS

Confrontation VF Full OD, Limited OS

Color Vision: 10/10 OD, 1/10 OS

Anterior Segment Unremarkable

75

76

77

Differential

Papilledema

Intracranial Hypertension

Malignant Hypertension

Space Occupying Lesion

Cerebral Venous Thrombosis

78

Inflammatory

Infectious vs Non-infectious

ONH Drusen

Uveitis

Optic Neuritis??

79

62 inches (157 cm)

462 lbs (210 kg)

BMI 85

BP: 110/80

80

MRI Normal

LP – 490 then 310

Normal opening pressure up to 250 mm H2O

in obese patients

81

1 Month Later…

BCVA 20/20 OD, 20/200 OS

S/P VP shunt x 1 month

On Diamox still

OD swollen, OS swollen and atrophic

82

83

84

8 years later…

no Diamox

20/20 OD - minimal VF loss

20/200 OS - stable VF loss

85

86

87

Why is one eye 20/20 and the other 20/200?

88

Idiopathic Intracranial Hypertension

Old names:

'Benign' Intracranial Hypertension

Pseudotumor Cerebri

89


1 in 100,000 people

Young women

10% overweight = 13x more likely

90


Causes are unknown

91


Symptoms are varied

Asymptomatic

Headache

Blurred vision

Diplopia

Nausea

92


Diagnosis of exclusion

MRI/MRA/MRV

Lumbar Puncture

Blood Pressure

93


Treatment

Weight loss

Diamox

VP shunt

94

Patient 5

58 year old Black Male

Consult for Transient Vision Loss

Pain behind eyes

Photophobia

95

Currently inpatient

+DM

+HTN

+Kidney Disease

96

VAcc 20/20 OD/OS

Anterior Segment healthy

97

98

99

100

Malignant Hypertension

101

Malignant HTN

BP > 180/120

Kidney Disease

Adrenal Tumor

Illicit drug use (i.e. cocaine)

Collagen Vascular Disease

102

Malignant HTN

Headache

Blurred Vision

Shortness of Breath

103

Malignant HTN

This is a medical emergency

104

Patient 6

39 Year Old White Male

Consult for vision loss OU

105

Vision loss gradual

20/200 OD/OS

Mild APD OS

106

History of Testicular Cancer

Patient has slow gait

VERY!! Sick Appearance

107


IOP 22/22

108

109

110

111

112

Toxic/Nutritional Optic Neuropathy

113

Lack of B Vitamins/Folic Acid

Bariatric Surgery

Malnutrition

Alcoholism

114

Cuban Epidemic Optic Neuropathy

American Journal of Ophthalmology

Vol 193. September 2018. Pages xix-xxvii

115

Management

Find source

Vitamin B supplement

116

Patient 7

74 YO WM

C/O Blur

No pain or discomfort

117

BCVA 20/40 OD/OS

Anterior Segment normal except

2+ NS OU

118

Diagnosis: Cataract

119

But…what about this?

120

Patient 14121

Nevus OD - 2007

122

Fast forward to 2013

123

124

Patient 14125

126

127

Small Choroidal Melanoma

128

Risk Factors

1. Tumor thickness greater than 2.0 mm

2. Subretinal fluid

3. Visual symptoms

4. Orange pigment

5. Posterior tumor margin touching the disc

6. Lack of drusen

129

Shields CL, et al. Risk factors for growth and metastasis of small choroidal melanocytic lesions. Ophthalmology 1995;102:1351-1361.

The Collaborative Ocular Melanoma Study Group. Factors predictive of growth and treatment of small choroidal melanoma. Arch Ophthalmol 1997;115:1537-1544.

130

Treated with Radioactive Plaque Therapy

Developed Radiation Retinopathy

Optic nerve edema, Macular edema

Treated with Anti-VEGF

131

What is the likelihood of Nevus changing to Melanoma?

Nevus = 3-20% of population

Melanoma = 6 per 1 million

About 15,000 nevi per 1 melanoma

132

COMS

Small Melanoma

< 2.4 mm height

5-16 mm diameter

133

COMS

Small Melanoma

5-year all cause mortality = 6%

134

COMS

Medium Melanoma

2.5–10 mm height

≤16 mm diameter

135

COMS

Medium Melanoma

Mortality with enucleation = 19%

Mortality with brachytherapy = 18%

136

COMS

Large Melanoma

>10 apical height

>16 mm diameter

137

COMS

Large Melanoma

Mortality with enucleation = 43%

Mortality with enucleation and pre-op radiation = 38%

138

COMS

COMS excluded tumors near optic nerve

139

COMS

New evidence supports using Low-dose Iodine-125 plaque brachytherapy

140

Meta-analysis

5-year all cause mortality

Large = 53% Medium = 32% Small = 16%

141

Radiation Retinopathy

Exposure to External Beam Radiation or Brachytherapy

Usually within 6 months to 3 years

Can happen 15 years later

142

http://www.med.unc.edu

143


Signs

Retinopathy similar to DM

Macular edema

Optic nerve edema

144


Symptoms

Typically asymptomatic

Can develop floaters and/or visual acuity loss

145


Treatment

Monitor

Laser (focal/grid or PRP)

Intravitreal triamcinolone

Intravitreal Anti-VEGF

146

Patient 8

52 year old Black Male

CC: Working on car. Got something in eye

Blur, photophobia, pain

147

VA: 20/40, CF

A/C: 3+ Cells

Vitreous: 3+ Cells

148

149

150

Penetrating foreign body

Corneal and iris laceration noted on Slit Lamp

151

Same day retinal surgery

Extra capsular cataract extraction

S/P PPV

Patient left aphakic

152

Now S/P Tube Shunt

Secondary IOL

20/50

153

154

155

Patient 9

64 year old WM

CC: Blurred vision OS - present since last year

+DM

BCVA: 20/25 OD, 20/40 OS


156

157

158

Impending Lamellar Macular Hole

159

2011 160

2016 161

162

Patient 8

74 Y/O Hispanic Male

CC: Blurry vision

+DM, +Cataract

BCVA: 20/40 OD, 20/25 OS

163

164

Lamellar Macular Hole

165


Not full thickness

Atypical borders

“Inverted Anvil”

166


Acuity typically better

Difficult to treat

May be more selective on when to treat

167

Patient 10

65 Y/O WM

Progressive blurring

Affecting golf, reading

168

07/2014

20/20 OD, 20/25 OS

Anterior segment: Mild NS OU

Mild ERM OU

169

11/2014

20/20 OD, 20/50 OS

Mild ERM OD

Moderate ERM OS

170

02/2015

20/30 OD, 20/50 OS

Moderate ERM/VMT OD

Moderate ERM OS

171

08/2015

20/50 OD, 20/200 OS

Moderate ERM/VMT OD

Moderate ERM OS

172

173

174

Refer to Retinal Specialist

Vitrectomy and ERM Peel OS (20/200)

175

01/2016

20/30 OD (Stable)

20/40 OS (Was 20/200)

States vision still distorted

Mild Cataract OU

176

177

178

179

180

01/2018

20/25 OD (Stable)

20/25 OS (Was 20/200)

S/P PCIOL OU

181

ERM

Macular Pucker

Creates traction of retina

Can induce edema (typically cystic)

182

183

184

185

186

ERM

Blur

Distortion

Metamorphosis

Range of acuity (20/20 - 20/400)

How many progress?

187

ERM

Typically asymptomatic

If acuity reduced to < 20/40, treat

ILM peel

ERM peel

Vitrectomy

**Cataract Surgery

188

Patient 11

75 Y/O WM

CC: Blur OU

S/P PCIOL OU

COPD, DM, HTN

Anterior segment unremarkable

189

BCVA: 20/50 OD, 20/100 OS

190

191

192

Bilateral macular hole

Patient elected to not have treatment

COPD

193

Macular Hole

Full thickness retinal break

Acuity typically 20/100-20/200**

194

Acuity?195

196

197

Macular Hole

Treatment

Vitrectomy

Broad ILM peel

Fluid gas exchange

198

Macular Hole

Complications

Cataract

Face down position

Lack of closure

199

Macular Hole

ILM Peel with No Face-Down Positioning

Ophthalmology 2013;120:1998-2003

200

Macular Hole

68 patients with idiopathic full thickness macular hole

Vitrectomy, ERM/ILM peel, SF6

Reading position post-op (3-5 days)

201

Macular Hole

100% closure

Mean pre-op 20/100

Mean post-op 20/40

No complications

202

OCT

Historically macular problems diagnosed by

Fundus Appearance

Visual Acuity

203

OCT

OCT changed accuracy of diagnosis

Better able to give prognosis

Better guidance for treatment

Better post-op monitor

204

Patient 12

92 YO WM

CC: “Needs Driver’s Form Filled Out”

205

Ocular History

Cataract Surgery

Glaucoma Suspect

206

Medical History

Hypertension

Colon Cancer

Lung Metastasis?

207

VAcc 20/20, 20/25

Anterior Segment healthy except

208

209

210

~2MM amelanotic cystic growth

Pushing iris back

Gonio: 2 Feeder vessels

211

Posterior segment normal - no tumor

Large C/D ~ 0.6 OU

IOP 16/18

212

Diagnosis: Invasive Carcinoadenoma

Metastasis from Colon

Likely Metastasis to lung

213

Treatment: Hospice

214

Returned to clinic 2 months

New Hyphema

Stabilized

Goal is no pain

215

If eye tumor

Need to consider ophthalmic prognosis

Need to evaluate for metastasis

216

Patient 13

54 YO WM

Blur

Diplopia

217

BCVA 20/25, 20/20

EOM: Poor abduction OS

Not comitant


No APD

218

219

220

Bilateral Optic Nerve Edema

MRI

Lumbar Puncture

Blood Pressure

221

MRI - Inconclusive

Blood Pressure - 145/80

LP - Opening pressure Day 1 = 43

Day 2 = 36

+WBC

222

LP Cytology - cancer cells

Diagnosis = Leptomeningeal Carcinomatosis

223

Metastasis from esophageal cancer (rare)

More common from breast, lymphoma, leukemia

224

Patient treated with systemic chemotherapy

Died 6 months later

225

Patient 14

72 year old male

C/O Red Eye x 1 day

226

227

VAsc 20/20

SLEX Normal - except conjunctiva OS

IOP 32/32

Gonio Narrow - no PAS

228

229

230

231

232

233

234

Patient 14

Glaucoma is usually ASYMPTOMATIC

Don’t brush off sub-conjunctival heme

235

Patient 15

58 year old African American Male

C/O blur at near

236

Myopic

20/20 OD, 20/25 OS


No APD

IOP 17/17

237

238

239

240

241

Diagnosis?

242

Solar Maculopathy

243

Solar Maculopathy

Thermal Burn

Pscyh Diagnosis

Eclipse

Drugs

244

Solar Maculopathy

Adjustment Disorder

Alcohol Abuse

Inadequate Housing

Depressive Disorder

Tobacco Dependence

245

246

247

248

Solar Maculopathy

No ocular treatment - non progressive

Mental health referral?

249

Patient 16

42 y/o white male

CC: Spots in vision OS for 7 days. Spots don’t move

No pain or discomfort

No family history

No ocular history

250

BCVA

20/30

20/400

EOM - Full

Confrontation - Full

P + RXN - No APD

251

IOP 15/15


Retina:

White lesions throughout retina OS>OD

252

253

254

255

256

257

258

Purtscher’s Retinopathy (or Purtscher’s Like Retinopathy)

In a patient with Severe Alcoholism

Recent Acute Pancreatitis

259

Refer to:

Retina

Rehab

260

Purtscher’s Retinopathy

Purtscher’s Retinopathy is rare

Often associated with trauma

60% bilateral

261


Can be associated with other conditions:

Acute pancreatitis (100% bilateral)

Connective tissue disorder

Childbirth

Renal disease

262


Purtscher flecken are pathognomonic findings

Polygonal areas of retinal whitening with a clear demarcating line

263

264


No known successful treatment

Often try IV steroids

265


Patient unlikely to recover visual acuity

Especially if nonperfusion

266

Patient 17

72 year old White Male

History of “burst blood vessel” OS

OD normal

Establishing care at VA

267

VA: 20/20 OD, 20/400 OS


ACIOL OD

PCIOL OS

268

EOM, IOP, Confrontation normal

269

270

271

Differential

BRVO

HRVO

AMD

Macroaneurysm

272

We called it wet AMD

Were we right?

273

274

Macroaneurysm

Usually asymptomatic

Threats to vision: heme at macula, macular edema

275

Macroaneurysm

Can be monitored if no threat to vision

Treated with laser photocoagulation

Anti-VEGF

276

Patient 18

55 YO WF

C/O Blur OS

Pain on eye movement

Headache OS

277

History

Strabismic Amblyopia OD

Normal health

278

Came to KCVA - transfer

Labs normal except Lyme

Normal MRI

279

20/200 OD

20/60 OS

280

EOM normal

+APD OS

IOP 16/19

Gonio: normal


281

282

283

284

285

286

287

Plan

Consult Neurology

Lumbar Puncture

Consider second round of corticosteroid

288

2 months later...

Untreated

20/200

20/25

289

290

291

292

Diagnosis - Atypical Optic Neuritis

Normal LP, MRI, no confirmation of Lyme

Treatment - help photophobia

293

What about Multiple Sclerosis?

294

15 year data from ONTT

Normal MRI -> risk around 25%

>1 lesions on MRI -> risk around 75%

295

Patient 19

46 year old black female

Routine checkup

Blur at distance

Headache

296

Patient

-3.00 sphere 20/20

Balance CF

"I've never seen good out of my left eye"

297

Patient

Anterior segment normal

Posterior segment normal OD

Myopic degeneration OS

Tilted, myopic nerve OS - ? Pallor OS

298

Patient

Unsure why vision bad

Attributed to old injury

Nothing appears treatable

Refer to Neurology for headache

299

Patient300

301

Follow-up

KERATOMETRY

46.5/47 OD AND OS

AXIAL LENGTH

23.5 MM OD

31.0 MM OS

302

Follow-upAUTOREFRACTION

-2.75 SPHERE

-21.00 SPHERE

REFRACTION

-2.75 SPHERE 20/20

-20.00 SPHERE 20/800-

303

Follow-up

Myopic Degeneration and Amblyopia

Posterior Staphyloma

304

Staphyloma

In womb or at birth

Thinning of scleral wall

Protrusion of uvea

305

Staphyloma

No treatment

No known systemic cause

306

[email protected]

307

Documents

Grand Rounds - Amazon S3 · 2019-10-14 · Grand Rounds Anthony DeWilde, OD 1 Patient 1 72 year old African American male Blur OD x 3 months Last eye exam 10 years ago 2 Ocular History