Download Andrew Lloyd Webber`s Phantom of the Retina

Joel Pearlman, MD, PhD
Retinal Consultants Medical Group
SVOS 2016 Lake Tahoe, CA
The Phantom of the Retina
In Gaston Leroux’s gothic novel and Andrew Lloyd Webber’s masterful musical interpretation, a mysterious
phantom haunts an opera house in 1880. He lives in the shadows in a lair in the subterranean space beneath the
theater. He is most difficult to detect, showing up unexpectedly, while cloaking his visage and body. He sends
ominous notes and threats. The phantom generally wreaks havoc on the beautiful work of the opera singers and
their theater. He destroys the grand chandelier that lights the opera house. In the end, he is rooted out by a
complicated series of events and sacrifices.
Like the opera house of Leroux, the retina sometimes harbors its own phantoms. Difficult to detect, cloaked as
other ailments, sometimes hiding in the subretinal space or in the retinal vasculature, these phantoms wreak
havoc on the beautiful photoreceptors and their theater, the retina, wrecking the chandelier of the brain. Some of
these phantoms lie deeper still and require a high index of suspicion and specialized imaging to find. This
“interpretation” of phantom cases will match Richard Stilgoe’s and Charles Hart’s beautiful lyrics with the
phantoms we might encounter in our practices.
Think of me
63 year old guy comes into the clinic with blurry vision OS for 3 months
Has been healthy all his life despite smoking for many years
20/20 OU
Think of Serous Detachment of the Retina
CSR
Harada’s
Posterior Scleritis
Infectious
Infiltrative/Neoplastic/Paraneoplastic
New Drugs - Ipilimumab (Revs Up Immune System)
The Phantom of the Retina
58 year old African American guy comes into the clinic with blurry vision OS for 2 weeks
Uses and inhaler occasionally
20/20 OD
20/60 OS
Think of:
•
Cystoid Macular Edema
•
ICD10 “Cystoid Macular Degeneration”
•
Post-cataract/Post-retinal surgery
•
Inflammatory - Uveitis
•
Vascular - Vein occlusions and diabetes
•
Drugs - prostaglandins, epinephrine, Actos, Avandia
•
Vitamins - Niacin
•
Dystrophies - RP
The music of the sight
A 61 year old otherwise healthy woman
Mild blurry vision for 3 years, on and off
20/25 OU on presentation
Think of:
•
Diabetic Retinopathy
•
Vein Occlusions
•
Radiation Retinopathy
•
Drug Retinopathy - e.g., Interferon
•
Venous Stasis Retinopathy
•
Carotid/Ophthalmic Artery Stenosis
•
Hypertensive Retinopathy
•
Idiopathic Retinal Telangiectasia...that’s a weird one.
All I ask of you…is that you get an MRI
•
55 yo man referred for CSR
•
Blurry vision OS for several years
•
Saw an eye doctor for something years ago, couldn’t remember who or why
•
20/20 OD, LP OS
Masquerade
•
53 yo fellow came in with blurry vision OS for a few weeks
•
No significant medical history
•
20/20 OD and 20/30 OS
•
Occam’s Razor fails again
•
Syphilis and Sarcoid
•
IV PCN for 2 weeks
•
Tested his wife - negative
•
•
She was not so happy, initially
Oral steroids
The Point of No Return
•
75 yo woman came in with amaurosis symptoms
•
Had some coronary artery disease and atrial fib
•
Vision would go black for a minute two or three times a day for the past few weeks
•
Associated with a persistent headache
•
No angina, MI, TIA, or stroke
•
20/25 OU
Think of:
Diffuse Ischemia
Severe Cardiac Disease
Carotid stenosis/dissection/vasculitis
Ophthalmic Artery stenosis/dissection/vasculitis
Questions