Download Anterior Segment Video Rounds

Anterior Segment Video Rounds
Jeffrey S. Nyman, O.D., F.A.A.O.
•
•
•
•
•
•
54 y.o. white female with red, painful photophobic OS x 1 wk.
Treated by G.P.with sulfacetamide 10% but condition worsened
Now notices blurred vision and a “curtain” in her superior field
Hx of moderate/high myopia OU; systemic Hx positive for hypertension
BVA: 20/20 OD, 20/40—OS
Ant. Seg: 3+ conj. hyperemia (superficial and deep) with 3+ flare and 2+ cells;
• some post. synechiae
• Conf. Field reveals superior cut OS
• IOP: 16mmhg OD, 8 mmhg OS
Case #1: Examination
• Lens: mild cortical and nuclear changes OU
• IOP (applanation):
OD: 11mmHg, OS: 4mmHg
• Vitreous: Gr. 3+ cells
• Fundus: Myopic stretching OD, Bullous RD OS with shifting fluid on position change
-Underlying choroidal detachment OS
Case #1: Diagnosis and Management
• Dx: Anterior and posterior scleritis with secondary ciliochoroidal effusion and exudative
detachment OS
• Plan: Refer for immediate vitreoretinal evaluation and treatment
• Refer to primary physician (pt. had no physician) for appropriate medical workup
Case #1: Diagnostic Workup
• Ultrasonography is the most helpful ancillary test in Dx of post. scleritis
• CT also has good yield, but is much more expensive to perform
• Ultrasonography should be first test used
– CT with contrast infusion is first test after ultrasound
– MRI only in cases of normal ultrasound and CT findings
MRI vs. CT
• Didsadvantages of MRI include:
– Insensitivity to calcification
– lack of depiction of fine cortical bone details
– Degradation caused by motion
– Risk of dislodging ferromagnetic implants and foreign bodies
• Advantages of CT over MRI
– Lower cost
– More rapid scanning time
– Thinner sections
– Higher spatial resolution
– Positive imaging of bone
1
Case #1: Laboratory W/U
R/O rheumatoid arthritis
CBC, RF, Westergren sed. rate
R/O systemic lupus
erythematosus
ANA
R/O polyarteritis nodosa
Sed rate, CBC
R/O Wegener’s granulomatosis
Biopsy, serum testing for CANCA (antineutrophil
cytoplasmic antibodies)
R/O sarcoidosis
Chest X-ray, ACE, Gallium Scan
R/O infectious disease:
TB,syphilis
Chest X-ray, PPD,FTA-ABS, RPR
Case #1: Management and Follow-up
•
•
•
•
Rx: topical steroids and cycloplegics
Consider NSAID (such as indomethacin)
– Contraindicated in patients with Hx of ulcer disease, CHF, renal disease, diabetes,
and >70 years old
– Dose: 50mg tid or bid with food as tolerated
Systemic steroids after medical clearance
F/U (6 weeks):
– Severe inflammation OS resolved
– Choroidal detachments resolved
– RD persisted with evidence of PVR
Case #1: Management and Follow-up
• Rx (recommended but refused): Vitrectomy, scleral buckle, possible lensectomy, and gas
tamponade
• Prognosis: Poor
– Vision poor before onset of severe inflammation
– RD associated with myopic degeneration
• Pt.lost to follow/up
Case #1: Challenges and Clinical Pearls
• Importance of thorough external and internal ocular examination of patients presenting with
2
red eyes
• Need for coordination of care in a patient presenting in this fashion
• Need for appropriate laboratory workup
• Sequelae of scleritis
Sequelae of Scleritis
• Severe, destructive disease which can cause decreased vision due to one or more ocular
complications
– Anterior uveitis
– Keratitis
– Glaucoma
– Secondary cataract
– Fundus changes (RD, ciliochoroidal effusion)
Ciliochoroidal Effusion
• A collection of fluid in the potential space pf the suprachoroid which is external to the main
structural and functional layers of the choroid and the ciliary body
• The terms choroidal detachment and choroidal edema have been used interchangeably in the
literature
Case # 1:
Differential Diagnosis
• Conjunctivitis
• Corneal ulcer
• Anterior uveitis
• Episcleritis
• Angle closure glaucoma
• Endophthalmitis
• Panuveitis
• Acute Retinal Necrosis
• Toxicity




Case 2: Clinical Presentation
46 y.o. Caucasian male
Swollen lids (OD>OS), redness, itching, tearing, and a “pressure sensation x 1 wk.
Treated by a G.P. With chloramphenicol ung.
Recent U.R.I.
Examination findings:






BVA: OD: 20/25- OS: 20/20EOMs: full and smooth OU
Perrl – no RAPD
Confrontation VF: Full OU
TA: OD, OS: 22 mmHg
+ Preauricular lymphadenopathy
3
External tissue evaluation:




Edematous, hyperemic lids OU
Folliculosis OU
Pseudomembrane formation OD
Coarse superficial punctate keratopathy with early subepithelial infiltrates OD
Internal tissue evaluation:
o
o
o
o
A-C: deep and clear OU
Lens: clear OU
Vitreous: clear OU with syneresis
DFE: .2/.2 physiologic cupping OU; vessels and maculae normal OU; periphery
unremarkable OU
Case 2: Diagnosis and Management












Dx: Epidemic keratoconjunctivitis (Adenovirus infection) OD>OS
Mgt.: D/C Chloramphenicol ASAP
remove pseudomembrane with cotton swab
Pred-G ophth. susp. 1gttOU q2h x 3days, then qid if improved
Homatropine 5% ophth sol’n. 1gttOU BID
Pt. ed. given re: contagious nature, appropriate precautions, etc.
Case 2: Follow-up
One week later; note significant improvement; infiltrates still present
Two weeks later: almost complete resolution
Case 2: Clinical pearls
Highly contagious in early stage
No definitive medical Rx
Supportive, palliative role of steroids, antibiotics
Antivirals ineffective
Case 3 : Clinical Presentation





18 y.o. male presents in may with painful, red eyes, with some “yellowish” discharge
Hx includes seasonal allergies
Hx of “corneal ulcers” treated 1 yr. ago out of state
Further questioning revealed a hx of eczema and seizure disorder
Ocular hx includes strabismus surgery
Examination findings:





VA: OD:20/80, OS: 20/60
MPH: OD:20/40, OS: 20/30
EOMs: full and smooth OU
Perrl – no RAPD
Confrontation VF: Full OU
TA: OD, OS: 18 mmHg
4
Extenal tissue evaluation:
 Upper lid eversion reveals giant “pavement block” papillae OD>OS
 Cornea OD demonstrates sterile “shield” ulcer
Internal tissue evaluation:
 Anterior chamber deep and clear OU
 Lens clear OU
 Vitreous Clear OU
 Fundus unremarkable OU
Case 3: Dx and Management
Dx: Vernal Conjunctivitis OU with Shield Ulcer OD
 Rx:
o pred acetate 1% qid
o erythromycin ung. tid
o lodoxamide qid
o scopolamine 0.25% bid
o art. tears qid and ung hs
o cool compresses qid
Vernal Conjunctivitis: Clinical Course




The condition gradually improved over the next three months
VA: OD: 20/40-, OS:20/50
He still had a bilateral 3+ papillary reaction of the superior palpebral conj
He had a scar on the superior half of the right cornea with some calcium deposits
(band keratopathy)
Diff. Dx: CL induced GPC
 History of CL wear
 Morphologic difference: papillae are smaller in Cl induced GPC
o 3 mm vs 1.0 mm
Case 4: Clinical Presentation









39 y.o Hispanic male auto mechanic
48 hr. Hx of red, irritated O.D. with “cloud” in front of vision in that eye
“cloud” moved “wherever he looked”
Was hammering metal on metal
Was not wearing safety glasses
After the accident, co-worker looked at him and couldn’t see anything in the eye
Previously treated here 3 months ago for removal of superficial metallic corneal F.B. O.D.and
secondary uveitis
Self treated with previously prescribed eye drops with no improvement
OD now photophobic with lacrimation
Examination findings:


VA: OD: 20/30+ (NIMPH), OS: 20/20
PERRL, no APD
5



EOM: full, smooth OU
TA: OD: 12mmHg, OS: 13mmHg
External tissue evaluation


Lids normal OU; Gr. II conj. hyperemia OD
Cornea OD reveals small linear laceration with stromal channel
Internal tissue evaluation:




A-C well formed, deep with trace flare and cells
Lens examination (after dilation) revealed small inferior anterior subcapsular and
cortical opacity
Vitreous hemorrhage OD – note stream of blood in slit lamp beam
Fundus: intraocular foreign body OD, embedded in posterior pole, impinging on retinal
vein
o Blood leaking into vitreous from this site
Diagnostic Workup in Suspected IOFB


Imaging studies (indicated when IOFB suspected but not seen clinically) include:
o Plain radiography
o CT scanning
o Magnetic resonance imaging (MRI)
• Contraindicated when a ferromagnetic FB is suspected due to possible movement of the
FB during imaging
– Echography (ultrasonography)
In most cases IOFBs are easily detected with echography; however, CT scanning and plain
films remain the gold standards
Case #4: Diagnosis

Dx: Self- sealed corneal laceration with intraretinal foreign body, vitreous
hemorrhage, and cataract OD
Case# 4: Management Considerations



Mgt: Immediate referral to vitreoretinal surgeon for pars plana vitrectomy, endolaser
photocoagulation, removal of IOFB, lensectomy, and PCIOL implantation
Speed and trajectory of FB is important because the degree of damage is directly proportional
to velocity and inversely related to size
Metal particles must be removed to prevent reactions (siderosis and chalcosis)
Case #4: Complications Associated With Retained Iron-containing
Intraocular Foreign Bodies

Ocular siderosis
o
Rust colored corneal stroma
o Mydriasis
o Iris heterochromia
o Cataract/subcapsular iron deposits
6
o
o
o
o

Uveitis
Optic disk hyperemia
Retinal degeneration
ERG initially hypernormal, but gradually diminishes with siderotic degeneration
Chalcosis
o Retained copper causes chalcosis, a severe inflammatory reaction often resulting in sterile
endophthalmitis, hypopyon formation, and occasionally phthisis (or atrophy)
o Lead containing pellets can cause lead poisoning
o Organic or vegetable matter have an increased probability of infection
Treatment Options for Ferrous IOFB’s Retained in the Posterior
Segment





Pars plana vitrectomy (PPV) vs. removal with the external (‘giant’ or hand-held)
electromagnet (EM)
Prognoses are significantly better in eyes undergoing PPV compared to eyes with EM use
PPV allows for anatomical and functional rehabilitation of the injured eye
Removal of the FB is only a tactical component
Timely PPV markedly reduces the risk of endophthalmitis development
Case #4: Follow/up





1 month: VA: 20/300 MPH: 20/200
o Posterior capsule opacification
o Secondary vein occlusion with macular edema
3 month: BVA: 20/60+
o PC opacification
o Macular edema resolving
o Traction on fovea from focal scar
4 month: YAG capsulotomy performed
1 year : RGP contact lens fit BVA: 20/50+
3 year: Pt. reports gradual decrease in vision since accident
o BVA: 20/400 (NIMPH)
o Significant macular scarring and distortion (“wrinkling”)
o Surgery not recommended
Case #4: Complications Associated With Retained Iron-containing
Intraocular Foreign Bodies





Cataract
Vitreous hemorrhage
Retinal detachment
Proliferative vitreoretinopathy
Epiretinal membrane
Case #4: Challenges and Clinical Pearls

Reasons for increased index of suspicion:
o
o
Workplace injury
History of previous superficial FB injuries
7
o

o
o

Not wearing safety glasses
o Hammering metal on metal
Confirmatory findings
Stromal channel
Vitreous hemorrhage and IOFB visible on undilated direct ophthalmoscopy
Unusual aspects of case:
o Self sealing if thin laceration caused by high speed missile
o Absence of classical signs of penetrating injury



Seidel’s sign (percolation phenomenon)
Shallow A-C
Low IOP
Case #4: Differential Diagnosis






Linear corneal abrasion
Linear corneal lamellar laceration
Conjunctivitis
Anterior uveitis
Episcleritis
Angle closure glaucoma
Case #5: Clinical Presentation
 38 y.o. female presents with red, blurry photophobic OS x 1 day
 Vision OS was normal when patient went to bed last night, symptoms 1st noticed after
awakening
 Hx of spectacle Rx for myopic astigmatism
Examination Findings:
 VA: cRx: OD: 20/ 30 -, OS: 20/200
 MPH:
OD: 20/30+, OS: 20/80+
 EOM: full and smooth OU
 PERRL -APD
 IOP: OD:12/8mmHg, OS: 16/19mmHg
External tissue evaluation:
Biomicroscopy OD: lids, conjunctiva normal; cornea clear with irregular shape and an area of
thinning near the inferior limbus
OS: lids normal, moderate bulbar conj. hyperemia, significant stromal edema with extreme
inferior thinning and rupture of Descemet’s membrane
Fundus: Physiologic cupping of ONH OU with normal maculae, vessels and peripheral retinae
Case #5: Diagnosis
Dx: Pellucid Marginal Degeneration with Acute Corneal Hydrops




Bilateral disease with narrow band of corneal thinning localized 1-2 mm from limbus
Obscure etiology, usually diagnosed between age 20 - 50 no gender predilection
High irregular astigmatism best corrected with RGP CLs
Acute hydrops secondary to Descemet’s membrane rupture
8
Case #5: Management




Drugs to lower IOP include beta blockers and CAI inhibitors
May take 7 – 10 weeks to achieve goal of quiet eye, resorbed hydrops and improved
transparency
Then fit with RGP fit – may be challenging to achieve stable fit
If poor outcome, PK may be indicated
Case #6: Clinical Presentation
 A 34 y.o. female presents with a 3 day history of sectoral redness and mild discomfort in the
right eye for the past few days
 There is no discharge and vision is not affected
 Ocular history includes a previous condition in the left eye a few years ago which resolved
with no treatment. She also has a spectacle correction for astigmatism OU
 Systemic history is unremarkable except for seasonal allergies for which she takes
OTC
medication
Examination findings:







Habit VA: OD: 20/20-, OS 20/20
EOM: smooth and full OU
PERRLA – no APD
CT: 2 pd esophoria @ dist, 2pd exophoria @ near
Conf. VF: full OU
TA: OD: 12 mmHg, OS: 14 mmHg
BP: 118/74 mmHg, RAS
External tissue evaluation:



Lids: normal OU
Superficial and deep injection of superior nasal conj. and episclera OD; OS normal; no
pain on palpation of affected area of globe OD (through closed lids)
Cornea: clear OU with no NAFl stain
Internal tissue evaluation:




Ant. chamber: clear OD with scant cells OS
Lens: clear OU
Vitreous: clear and reg. OU
Fundus: 0.5 x 0.5 physiologic cupping of ONH OU; vessels, maculae, periphery
unremarkable OU
Case #6: Diagnosis and Management
Dx: Episcleritis OD
Rx:
No Rx
Supportive Rx (art tears)
Oral NSAID (Ibubrofen)
Topical NSAID
Topical steroid
9
Classification:
Simple: sectoral vs. diffuse
Nodular
Localized to discrete areas, each of which consists of an elevated nodule with surrounding
congestion
Nodule is mobile over the sclera
Vision unaffected
Intraocular structures spared
Management
Generally self limiting over 3 weeks
Often recurs, but less frequently over time
May require no Rx or supportive Rx (lubricants)
Nodular episcleritis is more indolent and may require local corticosteroid drops or antiinflammatory agents.
Rx: oral NSAID (e.g. ibuprofen, flurbiprofen., indomethacin), topical vasoconstrictors, topical
NSAID
Topical steroids or nonsteroidals can be used
Work/up:
Most cases are idiopathic; however, up to one third of cases may have an underlying systemic
condition
All patients sho ld undergo a thorough history, including a review of systems. Results of this
review and u exam findings are used to determine the need for specific laboratory studies.
In most patients with mild self-limited disease, laboratory studies are not useful.
Differential Dx:
Viral Conjunctivitis
Superior Limbic Keratoconjunctivitis
Scleritis
Case #6: Follow/up

the patient experienced gradual improvement with diminution of signs and symptoms over
the next week. We then tapered her off the steroid over the following week when the
condition was totally resolved
Case #7: Clinical Presentation





An 8 year old female presented to the Emergency Service accompanied by her father and
10 year old brother.
The father stated that she returned home from school with what appeared to be a foreign
body in the right eye at the inferior limbal region
The girl patient initially stated that she was walking home from school with her older
brother when something flew into her eye as she looked up to the sky.
Later she told us what really happened:
She and her brother had arrived home from school before their father and mother were
10




home and they were tossing a tennis ball around when the ball hit and shattered an
incandescent light bulb, a shard of which floated down and struck her eyeball
They cleaned up the mess did not tell their parents what really happened for fear of getting
punished, so they created their story
When her father did get home, he thought she had a foreign body and he (unsuccessfully)
attempted to remove it with a cotton-tipped applicator, after which they came to TEI
She reported mild discomfort, lacrimation, and slightly blurred vision in that eye
Her ocular and medical histories were otherwise unremarkable
Examination Findings:




VA: 20/20 OD, 20,30 OS
Pupils: OD round, reactive; OS oval shape with sluggish reponse; no RAPD
EOM: full and smooth OU
IOPNCT: OD:14mmHg, OS: 12mmHg
External tissue evaluation:


Unremarkable OD; conjunctival injection OS
OS: Iris prolapse through wound at inferior limbus
Internal tissue evaluation:



Anterior chamber: clear and deep OD; grade 2 flare; grade 1+ flare and cells OS
Lens, Vitreous clear and regular
Fundus: Physiologic posterior pole and periphery OU
Case #7: Diagnosis and Management
 Dx: Penetrating injury OS @ inferior limbus with iris prolapse and incarceration
 Rx: instilled topical antibiotic and applied Fox shield to OS
 Refer patient to ophthalmology for surgical repair: iris was reposited through the
wound and then the wound was sutured closed
 She was cyclopleged with atropine and treated with broad spectrum topical
antibiotic

Case #7: Follow-up
The patient returned three days later with a dilated and slightly oval pupil. The iris
was somewhat distorted inferiorly and there was minimal hyphema
 Her vision was 20/25 and she was comfortable
 We continued the antibiotic and cycloplegic and recommended lihght ambulation
and advised her to sleep with her head elevated
 One week later she saw 20/20- and had no hyphema
Case # 8: Clinical Presentation
•
•
A 43 y.o. male has been a patient at our facility for the past four years
His chief complaint is gradually progressive blurred vision OU, most noticeable upon
11
•
•
•
•
•
•
•
•
•
•
•
•
•
awakening
He has also noticed:
– increased problems with glare while driving at night as well as in bright daylight
– haloes around lights more than in the past
Medical history:
– Hypertension – treated with HCTZ and Lasix
Refraction to BVA:
– OD: +3.25 –0.75 x 035
– OS: +3.00 – 0.50 x 120
20/30¯ add +1.00 0.4/0.6
20/30¯add +1.00 0.4/0.6
Glare testing:
– OD: 20/40 low contrast, 20/150 with glare on
– OS: 20/ 50+ low contrast, 20/150 with glare on
EOM: Smooth and full OU
PERRLA – no APD
IOP: OD: 12mmHg, OS: 10mmHg
External tissue evaluation:
Anterior chamber: moderate depth, clear OU
Lens: clear and reg. OU
Vit: mild syneresis, clear OU
Fundus: 0.4 x 0.4 physiologic ONH cupping OU
Maculae, vesse’s, periphery all normal OU
Case 8: Assessment and Plan
•
•
Dx: Fuchs’ corneal dystrophy
Rx:
– 5% NaCl sol’n (daytime) and ung. (hs) to increase tonicity of tear film
– Warm air gently blown into eyes with hair dryer (low setting) after awakening
increases tear evaporation and removes H20 from epithelium by osmosis
Case 8: Follow-up
•
•
Over the next few years he became increasingly symptomatic, including increased glare and
photophobia in bright lighting
He elected to have PK and has done well with clear grafts and with 20/25+ BVA OU and
improvement on glare testing to 20/30 low contrast and 20/40 with glare on
Fuchs’ Dystrophy
•
•
syn: epithelial-endothelial dystrophy, late herditary endothelial dystrophy
affects older patients
12
•
•
•
bilateral, often asymmetric
frequently of dominant inheritance
fundamental defect is progressive deterioration of the endothelium
I Fuchs’ dystrophy – phase l
•
•
•
patient is asymptomatic
pigment dusting and guttate excrescences appear in posterior cornea
Descemet’s membrane is opaque and thickened
Fuchs’ dystrophy - phase II - early
• patient begins to experience glare, hazy vision, and possibly haloes
• epithelial edema begins as small, clear epithelial cysts with a roughened surface (bedewing)
• stromal edema appears anterior to Descemet’s and posterior to Bowman’s
• as edema progresses, it involves the entire stroma
Fuchs’ dystrophy - phase II - late
•
•
•
large epithelial bullae start to appear
these can rupture, causing severe pain
visual acuity deteriorates and is worse during the morning
Fuchs’ Dystrophy - Phase III
•
•
growth of subepithelial connective tissue is accompanied by decreased epithelial edema and
less rupturing of the bullae
patient is more comfortable but vision can be quite poor
Fuchs’ Dystrophy - Phase III
•
•
corneal sensation reduced or absent
can be accompanied by complications
– elevated IOP
– peripheral neovascularization
– corneal epithelial erosions
Case #9: Clinical Presentation



38 y.o. Caucasian housewife splashed bleach into her OS about 40 minutes ago
Rinsed with tap water for 5 minutes before coming to office, but couldn’t keep
eye open
o Time of contact before lavage: < 1 minute
Patient is moderately agitated with severe blepharospasm and she has her hand over the
eye
13






Fellow eye (OD)is open and appears normal
Medical and family medical history unremarkable
Ocular and family ocular history: cataracts in grandparents
No medications, allergic to penicillin
Topical anesthesia necessary to enable lavage and examination
No significant previous ocular history
Examination findings:






Habit VA: OD: 20/20- , OS: cannot open eye; proparacaine 0.5% instilled and lavage
performed with slow, steady stream of sterile irrigating solution
After topical anesthesia VA OS: 20/70 after 5 mins. lavage, pH: 6.0
VA OS: 20/80 (MPH: 20/40) after 20 mins. lavage, pH: 7.4
Pupils: 4mm OU , RRL (2+ OU), no APD
EOMs: full OD; difficult to view OS, but slight restriction
IOP: (difficult to obtain) OD: 20mmHg; OS: 24mmHg
Case #9: Clinical Appearance OS
External tissue evauation:

•
•
•
•
OD: all tissues normal; OS as seen on video
Note: degree of conjunctival blanching, including limbus
degree of conjunctival chemosis
large corneal abrasion with overlying patch of necrotic epithelium
some stromal haze, but iris details visible
Internal tissue evaluation:
• A-C difficult to assess, but some cells and flare



Vitreous: physiologic OU
Fundus: .25/.25 physiologic cupping of ONH OU
Maculae, vessels normal OU
Case #9: Diagnosis

Dx: Caustic chemical burn OS with resultant keratoconjunctivitis and corneal
necrosis and erosion
Case# 9: Management


Immediate: copious irrigation
Choice of irrigation fluid:

Water – hypotonic to the cornea and interior eye (corneal stromal osmolarity:
420 mosml/L)
o Corneal tissue diluted by water and accompanying uptake of additional H2O and
diffusion of the corrosive deeper into the cornea

Normal saline (NS) - (NaCl)
o
has a lower osmolarity than tears (290 mosml/L)
o
fails to normalize the pH of the anterior chamber even after prolonged irrigation

Sterile, lactated Ringer’s solution (LR) – a buffered sol’n. which may be more
effective than normal saline
14
Osmolarity: 280 – 309 mosml/L - similar to that of aqueous humor (304
mosml/L)
Balanced saline sol’n. (BSS)
o

o
o
o
o
o

Osmolarity: (310 mosml/L) pH is neutral (7.2)
It contains sodium acetate and citrate
Has an enhanced buffering capacity
Prevents cornea from swelling
Preserves normal corneal endothelium
Preferred irrigating solution:
Diphoterine (Previn®): an amphoteric sol’n. that is able to bind both alkalis and acids
– pH: 7.4
– osmolarity: 820 mosml/L
o Amphoteric or buffered solutions can normalize pH in 15 minutes time
o At least 500 – 1000 mL of irrigation fluid necessary
Effectiveness of irrigation can be evaluated by using universal indicator paper (pH strips)
Irrigation should be continued as long as the pH remains outside normal range
If prolonged irrigation fails to normalize pH, be suspicious that there are still particles in inf.
or sup. cul-de-sac
o



Case #9: Management: Immediate Phase (after copious irrigation)





Debridement to remove necrotic tissue and source of inflammation
Remove particulate matter, especially from fornices
After debridement, instilled:
o 1gtt 0.25% scopolamine ophth sol’n. OS
o 1gtt 1% pred. acetate susp. OS
o 1 rib tetracycline ophth. ung.
Applied firm pressure patch OS
o Could not apply bandage contact lens due to extreme bulbar chemosis
Recommend maximum strength OTC analgesia v. codeine containing compound
Case #9: Follow/up












24 hr. follow/up:
able to sleep for 5 – 6 hours last night
VA: OD: 20/20 OS: 20/80 MPH: 20/30External exam: OD: all tissues normal
OS: lids still closed, swollen and hyperemic
conj.: resolving chemosis with grade 2 bulbar hyperemia and better limbal vascularization
360°
Cornea: 90% of surface still abraded with a 5 mm band of intact epithelium from 10 – 2
o’clock; no infiltration; diffuse ant. stromal edema
IOP (tonopen): OD: 17mmHg, OS: 18mmHg
Anterior chamber: trace flare with 8 – 10 cells
Iris, lens, vitreous, fundus normal
We again instilled 1gtt scopolamine 0.25%, 1 gtt pred. acetate , and 1 rib tetracycline ung OS
and continued oral analgesia
One week follow/up: she has been to see us daily and wore the patch through the fifth day
post-burn
15








Now taking the meds herself: 1 gtt scopolamine qd, 1 gtt pred. acetate tid, and 1 rib
tetracycline ung bid
Still in discomfort but using less oral analgesia
VA OS: 20/40+
External eval. reveals diminution in size of abrasion and edema
Note centripetal healing pattern with well vascularized limbal region
No fornix disruption
Assessment: Resolving chemical burn OS
Plan:
o d/c scopolamine, taper off steroid over next week, continue tetracycline ung bid
OS
o Consider topical NSAID (diclofenac)
o Sweep fornix OS with smooth glass rod covered with tetracycline ung.
Case #9: Long-term Outcome




Persistent SPK OS (+ NaFl stain), primarily in lower third of cornea, denser near limbus
Area of temporal bulbar conjunctival scarring and persistent redness and adjacent pannus
good maintenance of fornix with no symblepharon
persistent dry eye OS due to loss of goblet cells


Case #10: Clinical Presentation
A 10 year old boy presented to the emergency service with a laceration of his right lower
eyelid
He was playing at the family dinner table – he was shooting peas at his older sister using
his fork as a launching device – the fork flew into his eyelid after one of his launchings
Examination findings:





VA: OD: 20/20, OS: 20/20
Refraction: low degree AR astigmatism OU
EOM: full vergences, normal saccades
Pupils: 5mm OU, RRL (3+ OU), (-)APD
TA: OD: 13mmHg, OS: 12mmHg
External tissue evauation:


External tissue examination: Lids, OD (as pictured), OS: normal appearance
Cornea: clear and regular OU, no stain with NaFl
Internal tissue evaluation:




A-C: clear and deep OU
Lens: clear OU
Vitreous: clear OU
Fundus (dilated): no abnormalities OU
Case# 10: Assessment and Plan


Dx: Lower eyelid laceration OD
Management: Cleansed wound , applied antibiotic ointment, applied dressing
16

Referred for consideration of surgical repair
Lid Lacerations: Considerations

Smaller wounds with little or no separation of skin can be treated by:
o
o
o


Cleansing the wound
Application of antibiotic ointment
Dressing the wound
Tetanus toxoid injection indicated
More severe wounds require referral for suturing
Case 11: Clinical Presentation
A 37 y.o. male Caucasian soft contact lens wearer is known to be noncompliant.
Wears lenses for 72 hrs. or more without removing, cleaning or disinfecting them.
He presents with a red, tender, watery, photophobic right eye
Case 11: Clinical findings:
BVA: OD: 20/70, OS: 20/20
External exam: painful (OD) but full motilities OU
PERRL – RAPD
Conf. VF: Full OU (FC)
Case 11: Clinical Presentation
Biomicroscopy: as pictured
Ant. Chamber:
Grade 2 cells
Grade 1 flare
Ant. vit. spillover
IOP (tonopen):
OD: 10mmHg
OS: 17 mmHg
Lens: clear OU
Fundus: unremarkable OU
Case 11: Management
Dx-w/u: + or – culture, cytology study
Rx:
Cycloplegia
Antibiosis
Monotherapy with fluoroquinolone vs. fortified combination therapy
? Steroid (controversial)
Analgesia
topical vs. oral
Follow-up and referral
Case 11: Differential Diagnosis
17
Dx: Infectious Keratitis OU
Diff Dx: Fungal
Gray or dirty white surface with a dry, rough texture
More frequently on peripheral cornea
Serpiginous (“creeping) ulcer
Areas within surface or at margin may be elevated
Satellites common
Case 11: Differential Diagnosis
Diff Dx: Acanthamoeba
A ring-shaped stromal infiltrate signifies adavanced infection and is nearly
pathognomonic for Acanthamoeba keratitis
Annular infiltrate may be segmental or circumferential, progressive, and often
involves stromal thinning or furrowing
Dendritic ulcer vs. geographic ulcer
Neurotrophic ulcer vs. disciform keratitis vs. interstitial keratitis
18