Download Grand Rounds - University of Louisville Ophthalmology

Grand Rounds Conference
Brett Mueller, D.O., Ph.D.
6/17/2016
University of Louisville
Department of Ophthalmology and Visual Sciences
Patient Presentation

CC: From Neurology attending: “My patient has blood
in her eye.”

HPI: 87 yo WF presented to the hospital with 2 hrs of
L sided facial droop and L sided weakness. Received
tissue plasminogen activator (tPA), and a repeat head CT
demonstrated a 1.61 cm by 0.68 cm intraochemorrhage
History
POHx: Cataract surgery OU
PMHx: Dementia, HTN, CAD, cerebral aneurysm s/p coiling, and an old
stroke with residual L sided weakness
FAMHx: none
ROS: none
MEDS: Lisinopril, statin, ASA, memantine
ALLERGIES: none
Head CT w/o Contrast
Pre-tPA
A
Post-tPA
B
Hyperdense area in OD measuring 1.61 cm by 0.68 cm
Exam
VA
Blink to light
Blink to light
EOM: Unable to obtain
CVF: Unable to obtain
3--2
P
13
T
3--2
No APD
14
Exam
OD
OS
LIDS/LASHES
WNL
WNL
CONJ
WNL
WNL
CORNEA
WNL
WNL
IRIS
WNL
WNL
LENS
PCIOL
PCIOL
OD
Fundus Photos
OS
Color fundus photos:
OD: a large inferior suprachoroidal hemorrhage, subretinal hemorrhages and temporal
hemorrhagic retinal detachment
OS: nasal subretinal and suprachoroidal hemorrhage and multiple small intra-retinal
hemorrhages, and a hemorrhagic retinal detachment
Summary
87 y/o WF w/ bilateral suprachoroidal hemorrhages with
hemorrhagic retinal detachments OD>OS, 2ndary to the
administration of tPA for a nonhemorrhagic stroke
PLAN: Observe
Choroidal Effusion
• Abnormal accumulation of fluid in the suprachoroidal
space (between the sclera and choroid)
• Common complications of glaucoma surgery, other
intraocular surgeries, inflammatory and infectious
diseases, trauma, neoplasms, and drug rxns,
• Can be either serous (painless and can by asymptomatic)
or hemorrhagic (painful and marked reduction in VA)
Treatment of Choroidal
Effusion
• After glaucoma surgery choroidals are generally treated
conservatively
• If bleb is overfiltrating can taper steroids quickly to
promote bleb scarring, and cycloplegic agents can be
used to deepen the anterior chamber
• Surgical drainage indications: flat anterior chamber,
decreased vision, long-lasting choroidal effusions,
appositional choroidals, and suprachoroidal hemorrhages
Treatment of Choroidal
Effusion
• Surgical drainage is accomplished by performing a conj
peritomy, a 2- to 3-mm radial incision is made in the sclera
3-4 mm posterior to the limbus
• The incision is deepened until the suprachoroidal space is
entered and fluid is released
• The sclerotomy site is left open with closure of overlying
conj
Tissue Plasminogen Activator
•
Implicated in the treatment for blood clots: pulmonary
embolism, MI, and stroke
• Stroke: Guidelines recommend tx w/ tPA for all pts
presenting with stroke like symptoms w/in a 3-4.5 hr
window
• PE: heparin commonly used, but if PE causes severe
instability, then tPA is recommended
• MI: tPA can be administered w/in 12 hrs of symptoms if pt
cant get a cath
tPA Causing Suprachoroidal
Hemorrhages
• Only reported in 5 case reports where patients were
getting tPA for a MI
• First reported case of a pt having a stroke who developed
bilateral suprachoroidal hemorrhages after the
administration of tPA
• Neurologist need to be aware of this rare complication
associated with tPA administration, as it may be more
common than we think
THANK YOU
References
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