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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