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Grand Rounds in Eye Care FROM THE LIDS TO THE MESHWORK Lee W. Carr, O.D. Jeff D. Miller, O.D. 28 y.o. White female C/O: “I had a big stye on my lid, and now it’s really swollen up, and it hurts really bad.” No known health problems No medications, currently Allergic to penicillin No other known allergies Relevant History First noted “sty” one week ago Initially: small, non-tender “lump” “Looked ugly. Made me look ugly.” Patient squeezed it, “Like a zit.” Patient tried to “pop it” using a sewing needle. DID sterilize the needle in a flame Did not disinfect skin first Did manage to draw blood from the site Worked on lesion “…for about 20 minutes.” Worked on lesion “…till it started to swell pretty good and it really started to hurt.” Currently… “Swelling is spreading” Lesion is becoming increasingly painful “It really hurts now.” “I’m afraid I’ve got an infection in my eye.” The Exam VA’s (sc): OD: 20/20 OS: 20/20 Pupils: PERRLA, brisk OU Motilities: full, unrestricted OD + OS Conf Fields: full, OD + OS SLE: quiet and clear cornea and anterior chamber EXTERNAL: OD: quiet, WNL OS: extensive lid swelling Assessment: Preseptal vs Postseptal Cellulitis Re-checked EOM’s. Full, unrestricted Took patient’s temperature: 97.5 degrees Pulse & BP: 74 bpm; 122/78 Questioned patient regarding current or recent sinusitis Evaluated nasal passages with transilluminator light Attempted sinus transillumination Attempted combined scan ultrasound Discussed monitor/empiric therapy or CT evaluation options with patient Management Rx: azithromycin (z-pack x 2) Take 2 (250mg) tablets twice per day for two days; Then reduce to 1 tablet per day until all tablets are gone Rx: tramadol Take 1 (50mg) tablet qid x 2 days Requested tetanus booster via Adult Med RTC: 24 hours to re evaluate motilities, other findings DILATED FUNDUS EXAM All findings considered benign and WNL for OD and for OS 54 year old male Yearly eye exam C/O OD blurry for the last 3-4 weeks Has happened before but intermittent Refr. Hx: hyperopic/astigmat/presbyope Medical Hx: Type II DM, HTN, elevated cholesterol Meds:Metformin,HCTZ,Toprol-XL, Zetia,Vitamins The Exam VA’s sc OD 20/40 OS 20/30 Pupils, motility, CVF all normal BVA OD:+1.25-0.25x100 20/30 OS:+1.25-1.00x097 20/20 Ant Seg: trace SPK OD > OS Quick TBUT OU NS 1+ OU IOP: 21/23 @3:25pm Retina and ONH appear normal OU .3 c/d OU No BDR noted Additional Testing Lissamine Green Cirrus OCT of Macula OU Topography Pachymetry OD 530 OS 509 Additional History: always sleeps with ceiling fan on high ##### Cirrus SD OCT Topography OU Working Diagnosis Irregular topography OD secondary to Dry Eye Suspect corneal thickness OS > OD (Ocular HTN/Glaucoma suspect?) REC: D/C ceiling fan if possible, AT’s upon waking and throughout day, various samples given, consider “gel” HS RTC 3-4 weeks progress evaluation F/U Exam Patient states mild improvement some days better than others Using Soothe XP with some success C/O of Mild itching VA cc OD 20/25- OS 20/20 Cornea eval trace SPK OD, clear OS Everted Lids: clear however, lids very “flaccid” Lids everted w/o any particular effort or technique Additional History At this point the spouse offered some information through a question “We’ve stopped the ceiling fan however, he has just recently started using a CPAP for sleep apnea. Will that dry his eyes out more?” Working Diagnosis Changed FES, Sleep Apnea, and Glaucoma Several ocular disorders have been found in association with Obstructive Sleep Apnea or OSA: FES, optic neuropathy, glaucoma, NAION, and papilledema. 5-15% of OSA pts. have FES 96% of FES pts. have OSA (collagen in esophagus / pharynx similar to tarsal plate – results in esophageal collapse) 57% of NTG pts. Have sleep apnea symptoms Glaucoma – 2% of general population, 7+% of OSA patients Multiple studies have shown over 70% of NAION pts. have OSA Trigger: failure of AUTOREGULATION (all NAION pts. Should be advised to be evaluated for OSA) www.slideshare.net/rhodopsin/sleep-apnea-and-the-eye Rick Trevino, O.D. GDX Evidence of Ischemia’s Role in Glaucoma Overwhelming evidence indicates high IOP contributes to the development of glaucoma As many as 80% of Ocular HTN’s don’t develop glaucoma What about NTG? – about 30% of glaucoma patients appear to have normal IOP yet go on to have their nerves collapse and deteriorate The Key? – AUTOREGULATION Management Continue to treat Ocular surface disease Continue to monitor for Glaucoma Encourage patient to have continued f/u care with PCP discussed OSA and potential neurovascular, cardiovascular sequela as well as glaucoma and ION 66 y.o. White female Referred in from Low Vision Service and Rural Eye Program clinic for evaluation for ectropion repair—right lower lid History of longstanding Bell’s Palsy, right side (“at least 14 years ago”) Hx: Type 2 diabetes, on insulin Hypertension Ocular History General Ophthalmologist Pan retinal photocoagulation OU (2002) Retinal Specialist PRP and grid (2002) Vitrectomy, OD, (2003) Low Vision Service (2003) VA: OD: 10/400 OS: 20/150 Hx (continued): Corneal Specialist Exposure keratitis management (2005) Cataract surgery, OD, (2005) Lateral tarsorrhaphy, OD, (2005) Recommendation: Cataract surgery OS Retinal Specialist More PRP (2006) Cataract surgery, OS, (2006) Low Vision Service VA: OD: 10/100 OS: 10/350 Hx (continued): Retinal Specialist PRP, OU, (2007) Anti-VEGF, OU (2007) Vitrectomy and Retinal Detachment Repair, OS, (2007) Low Vision Service VA: OD: 6/80 OS: HM at 2 feet Specialty Care Exam (4/22/08) “I was advised to get my eye lid fixed again.” “No pain; I’ve gotten used to it.” “Sometimes I forget to use my artificial tears, but not often.” Mx: insulin, Fosthopace, Systane, Theratears, Erythromycin ophthalmic ointment (prn use) VA: OD: 20/400 at 4 feet OS: Light Projection Ext: Severe right face droop—full facial palsy Significant edema below right lower lid. Mild ectropion, right lower lid Grossly incomplete lid closure, OD. Mild red eye reaction OD—watery Blue tinge to right lower lid Solid nodule palpable within edematous right lower lid Assessment: Atypical for ectropion Consult with our clinical ophthalmologist Additional Hx obtained: Patient last seen by her primary care physician in January, 2008. He recommended eye lid evaluation. In late November, 2007, the PCP had removed a “skin lump” from outer canthus, right lower lid. Pathology report identified basal cell carcinoma. At March, 2008 exam, PCP expressed concern to patient that residual tumor may exist, and again recommended eye lid surgery. Lesson Learned PATIENT EDUCATION IS CRITICAL This patient thought that the recommendation for ectropion repair and the recommendation for evaluation of the right lower lid for residual basal cell carcinoma were “one-and-the-same” Management Assessment: Probably deep basal cell carcinoma spread—potentially orbital invasion. Plan: Made immediate referral to oculoplastic surgeon--Tulsa 22 y/o male college student Presented with c/o mild decreased vision OD associated with scratchy FB sensation and photophobia Reports is being treated for a “stye” on his OD upper lid with lid scrubs and tobradex drops for 1 week – no improvement – in fact, getting worse OD red, questions allergy to drops? The Exam Healthy young male no systemic conditions, no meds p.o. VA sc OD 20/30 OS 20/20 All entrance visual skills normal SLE: Assessment / Treatment Herpetic lid lesion and HSK D/C Tobradex Begin Viroptic q1h OD Begin 400mg Acyclovir p.o. 5 x day Herpes Simplex Keratitis The Leading Cause of Corneal Blindness in the US Ocular Herpes Simplex Each year in the U.S. 25 million people have flare-ups of facial Herpes (95% of population exposed by age 6yrs) 1/3 of the population worldwide has had HSV infection 700,000 have developed HSV-related ocular disease in the US 20,000 – 50,000 new cases/yr 28,000 reactivations/yr Rarely is this bilateral however, has been seen bilaterally in children After the first corneal infection, 25% re-occur with in 2 years It is the most common cause of infectious blindness in the Western World Ocular Herpes Simplex After the second infection odds of further recurrences greatly increases 40% of these patients have more than one recurrence Infectious Epithelial keratitis Neurotrophic Keratopathy Necrotizing Stromal Keratitis Immune Stromal Keratitis (ISK) Endotheliitis (Keratouveitis or trabeculitis) One of the leading indications for PK in the US Diagnostic Pearls Evaluate lid margin and lash follicles closely Look for a follicular vs. papillary response Look for more of a serous vs. mucous discharge Don’t forget decreased corneal sensitivity Cotton wisp test (check before staining!) Multiple raised epithelial defects vs. medium to large classic dendrites Be careful with steroids on garden variety eye inflammation Oasis Medical Inc. 909-305-5400 Treatment - Oral Antivirals Valacyclovir hydrochloride Trade name – Valtrex Acyclovir Trade name – Zovirax Both inhibit viral DNA replication by interfering with viral DNA polymerase Acute Phase Dosages and Precautions Valtrex 500mg 1 p.o. bid x 7 days ($88) Zovirax 400mg 1 p.o. 5 x a day for 10-14 days (14 days $20) Contraindicated in patients with kidney disease, liver disease, and immunosuppressed patients (HIV) Acute Phase Treatment - Topical Antivirals Trifluridine ophthalmic drops Trade name – Viroptic ($125, generic $95) 1 drop q1h (8 times a day) Vidarabine ophthalmic ointment (UNAVAILABLE EXCEPT BY SPECIALORDER) Trade name – Vira-A ung (5 times a day) Effective against strains unresponsive to Viroptic and Acyclovir What about steroids to decrease scarring? Treatment of Ocular Herpes Simplex HEDS –Herpes Eye Disease Study (Archives of Ophthalmology,121,Dec.03’) Longterm use of oral Acyclovir greatly reduces the recurrence of HSK 400mg daily, compliance is mandatory Patients who stopped early – re-infected 12 months vs. 18 months vs. Indefinitely Diagnosis We’ve all heard “Herpes Zoster the Great Imposter” however, Ocular Herpes Simplex can be cunning as well Pearls Consider superficial wipe with weck cell sponge or cotton tip applicator with HSK Remember subsequent epithelial infections are not as irritating or painful Family and friends watch for “red eye” Do not miss multiple doses of oral Acyclovir can lead to reactivation Think of it as BC or a daily Vitamin If nonresponsive try Vira-A ung LeiterRX.com – 800-292-6773 Be cautious with steroids!! 60 y.o. white male POAG diagnosed 3 years previously IOP Disks 24-2’s GDX (+) Family History Mother Significant field loss Managed with Timoptic .5% Baseline IOP consistently around 21mmHg C.E.O. of major academic institution Engaged in major capital fundraising campaign Anticipating program’s 100 year anniversary celebration week Prominent lecturer on CME circuit Professionally, very active Personally, Physically, very active Initial Treatment Timoptic .25% Rx: 1gt OD + OS, once per day, a.m. IOP OD: 20 and OS: 19 Rx: 1gt OD + OS, twice daily, a.m. + p.m. IOP OD: 19 and OS: 19 Patient complains of difficulty with daily early-morning jogging Timoptic discontinued Xalatan treatment initiated Rx 1 gt OD + OS at night, prior to sleep IOP OD: 16 OS: 15 Complaint of “red eye reaction” Daily dosing schedule altered Rx 1 gt OD + OS at dinner time “Red eye reaction” complaint persists Xalatan discontinued Travatan initiated “Red eye reaction” complaint intensifies Argon Laser Trabeculoplasty discussed with patient Selective Wavelength Laser Trabeculoplasty mentioned to patient S.L.T. performed OD + OS Inferior 180-degrees IOP at 2 months: OD 21 OS 21 Second S.L.T. performed Superior 180-degrees IOP at 1 month: OD: 16 OS: 15 IOP stable at 15 – 18 at this time 52 y/o Female “I want to have LASIK” Previous CL wearer (monovision) started to have comfort issues and previous doc told her to go to glasses – “hates them!” Med Hx: menapausal, mild controlled HTN C/O VA is blurry with glasses in distance OD > OS The Exam VA cc OD 20/40 OS 20/25 Pupils, EOM’s, CVF normal OU BVA OD -3.00-75 x 040, 20/30OS -4.00-1.00 x 025, 20/25 SLE: Lids and lashes clear, A/C deep and quiet, 1+NS OU, See corneal photos Internal: .25 C/D OU, Macula and periphery clear OU Corneal photo Corneal photo ?? LASIK Candidate ?? Is a patient with Fuch’s Dystrophy a candidate for LASIK? Is a patient with Cogan’s (MDF) Dystrophy a candidate for LASIK? Fuch’s Endothelial Dystrophy Females 3:1 Autosomal Dominant Slowly progressive formation of guttate lesions between the corneal endothelium and Descemet’s membrane Guttate are thought to be abnormal elaborations of basement membrane and fibrillar collagen from distressed or dystrophic endothelial cells So does performing laser on the corneal stroma effect this condition in any way? Refractive Surgery and Fuch’s Incisional refractive surgery, AK, RK, LASIK and ALL-LASER LASIK, is contraindicated in Fuch’s patients (?) Surface Ablation, PRK, LASEK, Epi-LASIK are relative contraindications It is estimated that there is 3-8% of endothelial cell loss during laser ablation DSEK or DSAEK Descemet’s Stripping Endothelial Keratoplasty Descemet’s Stripping Automated Endothelial Keratoplasty Impressively mild post-op Minimal corneal edema or anterior corneal compromise Rapid rehab with minimal to no astig. DSAEK VIDEO Cogan’s Dystrophy MDF, ABMD, EBMD, Microcystic Epithelial Dystrophy Nonprogressive but fluctuating in course F>M 1/3 of patients have RCE Irregular Astigmatism common cause of VA loss VA loss does not match clinical picture via slit lamp exam Cogan’s Dystrophy Pathophysiology: Corneal epi adheres to underlying BM Faulty BM – thickened, multilaminar, misdirected into epi: “maps & fingerprints” Deeper epi cells don’t migrate to the surface: “dots, intraepithelial microcysts” Epi cells ant. To the BM difficulty forming hemidesmosomes results in RCE Cogan’s Dystrophy Treatments: AT’s, Muro 128 gtts and ung 2005 only prospective study to date no difference between AT”s and NaCl Irregular Astig. CL fix? RGP vs. Soft Superficial Keratectomy Polish BM w/ diamond burr or alger brush ASP for erosions or post Keratectomy, consider donut approach and spare visual axis PTK or PRK if going for refractive correction Not great LASIK candidates Cogans Dystrophy For decreased VA w/ suspect irregular astigmatism look at placedo disc vs. topography Consider Silicone Hydrogels however, beware most of these patients have some degree of dry eye and are more likely to have torsion marks / RCE Daily vs. EW? Poor dexterity in elderly