Uncommon Cases with Common Lessons - MAOOmaoo.org/wp-content/uploads/2009/08/uncommon-cases.pdf ·...

Uncommon Cases with

Common Lessons

John A. McGreal Jr., O.D.

Missouri Eye Associates

St. Louis, MO

Case of The “Lost My

Monovision!”

77yowf CC: “Can’t read!”

HPI: 1 D duration / intermittent loss, altitudinal,

preceded episode / painless / OD

Meds: Amiodarone, ASA, Coumadin, Cartia, Zoloft,

Advil, Singulair, Cozaar, Norvasc

ROS: 190 lbs, recent Spinal surgery (L3-5),

planned shoulder (rotator cuff) surgery, Monovision

BVA: 20/60 OD 20/20 OS PERRL + APD

EOM: Full EXT: NL

SLE: ACIOL OD, PCIOL OS Blurred optic disc

margin OD, otherwise NL

What is the likely diagnosis?

1. Idiopathic optic neuritis

2. Ischemic optic neuropathy

3. Burried drusen

4. Papilledema

5. Cerebral vascular accident

What eye test would you order

1. Pachymetry

2. Visual fields

3. SCODI

4. ERG

5. IVFA / Photo

What other testing is

indicated?

1. CBC with differential

2. Brain MRI

3. C-reactive protein

4. ESR

Tests results

1. Visual field = Mild central defect OD,

normal OS

2. ESR = 17mm/Hr

Reference 0-20mm/Hr

3. C-reactive protein = 0.899mg/L

Reference 0.000-3.0mg/L

What should you do now?

1. Start Prednisone

2. Order biopsy of superficial temporal artery

3. Retina consult

4. Follow conservatively for NAION

Case of The “Graduation”

83yowf from Memphis, TN CC: “Skim on my eye,

then it went black!”

HPI: 1 D duration / intermittent loss, altitudinal,

preceded episode / painless / OD

Meds: HCTZ, meclizine, centrum, naproxen

ROS: 115lbs, HA, stiffness

BVA: NLP OD 20/30 OS PERRL + APD

EOM: Full EXT: NL

SLE: PCIOL OD NS 2 OS Fundi: OD

Blurred optic disc margin, otherwise NL

What is the likely

diagnosis?

1. Idiopathic optic neuritis

2. Ischemic optic neuropathy

3. Burried drusen

4. Papilledema

5. Cerbral vascular accident

1. Pachymetry

2. Visual fields

3. SCODI

4. ERG

What other testing is

indicated?

2. Brain MRI

3. C-reactive protein

4. ESR

Tests results

1. Visual field = absolute defect OD, normal

2. ESR = 44mm/Hr

Reference 0-20mm/Hr

1. Start Prednisone

2. Order biopsy of superficial temporal artery

3. Retina consult

4. Relocate to Memphis

Tests results

Corrected C-reactive protein test delivered

by mail five days later!

1. Quit !

2. Ask the lawyer who sues you to sue the

lab too!

3. Be certain all doctors know the results

4. Relocate to another country

You Make The Call

Differential Diagnosis – Anterior ischemic

optic neuropathy, Giant cell arteritis, CVA,

Additional Testing – STAT ESR, CRP, STA

Biopsy +/-

Diagnosis – AION, GCA

Treatment Plan – Prednisone 60mg PO qd,

chronic care with internist or neurologist

Case of “I Want Chalazion

Removed”

55yowf CC: “OD dx chalazion”

Pupils: PERRLA-MG

Meds: Premarin, Zocor, HCTZ

VA 20/30 OU

IOP: 16/17

SLE: Lid lesion E2 OS Fundus : NL

What is the best option now?

1. Remove chalazion with I&D

2. Intralesional kenalog injection

3. Biopsy

4. Oral antiobiosis and hot packs

Case of “I Have A Peculiar

Nerve”

45yowm CC: “OD wants R/O Papilledema”, Indistinct optic discs, IOP 20-25 range,pach 637

PH: Hodgkin’s disease, R hip replacement, 3 vessel CABG, HTN, Hyperlipidemia

FH: + POAG paternal aunt

Meds: Darvocet, Amitryptilline, nitrate, isosorbide, norvasc,toprol, plavix, lipitor, ASA

VA 20/20 OU PERRL-APD

IOP: 26/23 Pach: 639

SLE: Nl OU Fundus : As shown

What is the diagnosis?

1. Normal optic nerves

2. Papilledema

3. Optic nerve drusen

4. Ocular histoplasmosis

5. Choroidal nevus

What is tests are indicated?

1. VF / Pach / SCODI / Stereo disc photos

2. MRI

3. MRI / VF

4. Histoplasmosis titres

5. IVFA / VF

Case of “I Have A Peculiar

Nerve”

45yowm CC: “OD wants R/O Papilledema”,

DCT OD: 24.9 / OPA 4.4 / Q3

DCT OS: 23.1 / OPA 3.8 / Q3

SLE: Nl OU Fundus : As prev

VF OD: Superior and inferior nasal defects

VF OS: minor changes

SCODI: Confirms disc elevation limited to

disc itself

Case of “I Lost Vision Last

Night!”

35yowm CC: “Lost vision last night”

Pupils: PERRLA+MG

Meds: Glucophage for 3 years

VA 20/20 OD, HM OS

IOP: 17/18

1. Macular twig venous occlusion

2. Birdshot retinochoroidopathy

3. Hypercholesterolemia (retinal lipidemia)

4. CRAO

What is the best test to order?

1. IVFA

2. Carotid artery ultrasound

3. Total cholesterol, LDL, HDL, TG

4. Blood pressure

What is the best option now?

1. Breathe into a bag, massage globe

2. Anterior chamber paracentesis

3. Topical antiglaucoma agents

4. Thrombolytic therapy

Case of “Black Outs”

35yobm CC: “Lost vision last night”

Pupils: PERRLA-MG

Meds: Glucophage for 2 years

VA 20/20 OD, 20/25 OS

IOP: 19/19

Papilledema

Drusen of optic nerve

Bilateral optic neuritis

Ischemic optic neuropathy

Assessment / Plan

Order VF

Order Fundus photo

Order RTA

Order BP

Assessment / Plan

Probable pseudotumor cerebri

Must rule out mass lesion

MRI of brain and orbit

Must confirm elevated CSF

Lumbar puncture

Anomalous discs are diagnosis of

exclusion with burried drusen likely

Case of The “Pink” Eye

17yobm CC: “Pink-eyes”

HPI: 3 W duration / getting worse / painful

Meds: Ilotycin Trauma: None NKDA

BVA: 20/30 OU PERRL No APD

EOM: Full EXT: Raised Red Rash-Neck

SLE: Cell & Flare 3+ OU Fundi:WNL

1. Sarcoidosis

2. Tuberculosis

3. Syphilis

4. Idiopathic uveitis

What tests would you order?

1. Chest x-ray

2. RPR/VDRL

3. PPD

4. HLA B-27

You Make The Call

Differential Diagnosis

Additional Testing

Diagnosis

Treatment Plan

You Make The Call

Differential Diagnosis-idiopathic uveitis,

sarcoid, TB, syphilis, Lyme, AS/Reiters, HIV

Additional Testing-ANA, RPR/VDRL, HLAB-

27, PPD, CXR, titers, HIV?

Diagnosis-Syphilis (stage 2), AIDS

Treatment Plan-Ceftriaxone IM, start NRTI

and Protease Inhibitors

Case of “Beat by an Aussie”

14yowf CC: “Eye pain”

HPI: OD / Sudden / Pain / Moderate /

Worsening / MG Jaw-Wink Syndrome /

Frontalis suspension / No Contacts

Meds: None Trauma: None NKDA

BVA: 20/100 OD PERRL No APD EOM:

Full EXT: Inject 2

SLE: Midcentral epi defect, endothelial

ring, peripheral lesion, AC D&Q

1. Disciform keratitis

2. Acanthameba

3. Bacterial keratitis

4. Marginal sterile infiltrate

What additional tests

would you order?

1. Culture and sensitivity

2. Biopsy

3. None; begin topical therapy

4. None: get a consult

What treatment would you

prescribe?

1. Topical fluoroquinolone

2. Tobramycin & cephazolin (fortified)

3. Tobramycin/Dexamethasone

4. Bacitracin ointment

You Make The Call

Additional Testing

Diagnosis

Treatment Plan

You Make The Call

Differential Diagnosis-bacterial keratitis,

infiltrative keratitis, acanthomeba, HSV,

disciform keratitis, interstitial keratitis

Additional Testing-culture/sensitivity

Diagnosis-Kingella kingae keratitis

Treatment Plan-Fortified tobramycin &

cefazolin q1h alternately.

Protection/lubrication of the ocular surface

Case of “Zoster Mystery”

25yobm CC: “HA, Blurred vision”

HPI: Vesicles / 1Wk / V1-R / floaters and

decreased VA X 4D / OD / Worsening

Meds: Acyclovir Trauma: None NKDA

BVA: 20/100 OD 20/20 OS PERRL No

APD EOM: Full EXT: VZV

SLE: Ant uveitis OD Fundi: 360 RD,

retinal vasculitis OD

1. Cytomegalovirus retinitis

2. Acute retinal necrosis

3. Non-rhegmatogenous RD

4. Ocular ischemic syndrome

Who is the appropriate

consultant?

1. Infectious disease

2. Neurologist

3. Retina

4. Dermatologist

You Make The Call

Additional Testing

Diagnosis

Treatment Plan

You Make The Call

Differential Diagnosis-VZV, AIDS/HIV, RD

(rhegm vs non-rhegm), CMV, ARN

Additional Testing-HIV, CBC/Diff, PE

Diagnosis-HIV, VZV dermatitis, ARN

Treatment Plan-Acyclovir IV, PPV, Silicone

oil, low vision support and continued care

with PCP for AIDS

Case of The “Tough” Guy

34yobm CC: “Swollen eye”

HPI: 4 D duration / getting worse / painful

EOM: Full EXT: Erythema-ocular/facial

SLE: WNL Fundi: WNL

1. Allergic blepharitis

2. Preceptal cellulitis

3. Trichinosis

4. Sinusitis

1. MRI of maxillary sinus

2. Temperature

3. Blood cultures

What is the best treatment?

1. Tetracycline 250mg PO qid

2. Augmentin 500mg PO bid

3. Bacitracin ointment qid

4. Prednisone 20mg PO qd

You Make The Call

Additional Testing

Diagnosis

Treatment Plan

You Make The Call

Differential Diagnosis - cellulitis, sinusitis,

allergy, orbital cellulitis

Additional Testing - Temperature, warm to

touch, sore, further history

Diagnosis - preceptal/facial cellulitis

Treatment Plan

Keflex 250mg po qid, loading dose

warm compresses

RTO 24h

Preceptal Cellulitis

Skin/skin structure infection

Staph/strep-adults H.flu-children

Contiguous structure infection

hordeolum, dacryocystitis, trauma, sinusitus

Trauma cases-Tetanus toxoid

Clinical-pain, tenderness, erythema,

fever+/-

Pearl: temperature on first and

second visit!

Antimicrobial Therapy - Oral

Penicillins

Dicloxacillin 500mg qid

Amoxicillin/Clav (Augmentin 500mg, 850mg bid)

Cephalosporins

Cephalexin (Keflex 250mg qid)

Cefaclor (Ceclor 250mg tid)

Cefadroxil (Duracef 1000mg qd)

Cefixime (Suprax 400mg qd)

Ceftriaxone (Rocephin 1g IM)

Antimicrobial Therapy - Oral

Macrolide

Erythromycin Ethylsuccinate (EES 400mg

Erythromycin Particles (PCE 333mg tid)

Erythromycin Delayed (ERYC 250mg qid)

Clarithromycin (Biaxin 250mg bid x 7 D)

Azithromycin (Zithromax Z-Pak, Tri-Pak)

ZPak500mg qd-Day 1, 250mg qd-Day 2-5

TriPak 500mg qd x 3D

12mg / kg / Day X 5 Days (Pediatric)

The “Sick Little Boy”

10yowm CC: “uveitis”

HPI: 10 D duration / OD>OS / getting better

Meds: PF qid, HA qid, vancenase, Zantac

BVA: 20/20 OU EOM: Full EXT: NL

SLE: C&F +1OU Posterior synechia OD

Fundi: Disc edema OD

ROS: Abdominal CT + inguinal adenopathy,

L hip pain, Tick bite scalp 11mos, 25 lb

weight loss in 2 months, cat scratch

1. Papilledema

2. Uveitis

3. Lyme disease

4. Uveitis with systemic etiology

1. PE, RPR, PPD, HIV, Lyme, ANA, ACE

2. PE, Lyme, ESR, CBC/Diff, HLA-B27,

3. MRI of brain

4. Fluorescein angiography

You Make The Call

Additional Testing

Diagnosis

Treatment Plan

You Make The Call

Differential Diagnosis – Lyme, Syphilis, Lupus, JRA, Reiters /AS, Sarcoid, TB, Lymphoma / CA, Cat scratch, Mass lesion of brain, Chrones

Additional Testing –MRI, VF, Bartonella, endoscopy of esophagus, colonoscpy, ESR

Diagnosis - ?????? Probably cat scratch

Treatment Plan – PF & HA, tapered, observation by us and…

Pediatrics

Gastroenterology

Case of “Doc, I See Double”

57yobm CC: “Double vision”

HPI: OU / 3 D duration / Stable / not painful /

Horizontal

Past H: Colon cancer / surgery / radiation /

Chemo Meds: Multiple Trauma: None

NKDA BVA: 20/30 OU PERRL No

EOM: R Adduction deficit, L Jerky

nystagmus

SLE: NS OU Fundus : NL

1. Internuclear Ophthalmoplegia

2. Ocular Myasthenia Gravis

3. Duanes Retraction Syndrome

4. CN 3 Palsy

What is the best next step?

1. ESR

2. Neuro-ophthalmology consult

3. Neurology consult

4. MRI of head

You Make The Call

Additional Testing

Diagnosis

Treatment Plan

You Make The Call

Differential Diagnosis - CN 3P, CN 6P, INO, Decompensating heterophoria

Additional Testing-old photos

Diagnosis-R INO, metastasis of colon CA

Lesion- R MLF

Treatment Plan- MRI, Neurology / Neurosurgery, Oncology, PCP, monocular occlusion

Case of “Exotopia”

Age: 2yowm CC: R/O strabismus

HPI: OD / 4mos / constant / severe

Meds: none

BVA: No Fix or follow Pupils: PERRL-APD

EOM: L XT 45 EXT: NL

SLE: NL

IOP: Soft

Fundi: ON abnormal OS

PFSH & ROS: NL

1. Coloboma optic nerve entrance

2. Morning glory syndrome

3. Retinal detachment

4. Cavernous hemangioma

2. MRA brain and orbits

3. EUA

4. IVFA

You Make The Call

Additional Testing

Diagnosis

Treatment Plan

You Make The Call

Differential Diagnosis – morning glory, retinal hemangioma, ON coloboma

Additional Testing – PE family members, eye examination family members

Diagnosis – cavernous hemangioma retina, strabismus, amblyopia

Treatment Plan – external plaque radiation, EOM surgery, patching treatment

Case of “Retinal Abrasion”

Age: 19yowm CC: Floaters

HPI: OD / 3wks / constant / worsening since corneal abrasion

Meds: none

BVA: 20/20 OU Pupils: PERRL EOM:NL EXT: NL

SLE: small corneal defect / haze at limbus

IOP: 18/16

Fundi: As shown

PFSH & ROS: NL

1. Old CA with residual edema

2. Intraocular foreign body

3. Toxocara canis

4. Vitreous condensation

1. Ultrasound

2. Orbital CT

You Make The Call

Additional Testing

Diagnosis

Treatment Plan

You Make The Call

Differential Diagnosis – Old CA, retinal IOFB, primary retinal pathology

Additional Testing – US, Photograhy, VF

Diagnosis - IOFB

Treatment Plan – pars plana vitrectomy, FB removal, intravitreal antibiotics

Case of “Woke Up Blind!”

Age: 19yobf CC: decrease VA

HPI: OU / rapid / severe / worsening

Meds: plaquenil 400mg, lopressor

BVA: CF OU Pupils:PERRL-APD EOM:NL EXT: NL

SLE: NL

IOP:16/16

Fundi: as shown

PFSH & ROS: SLE x 3yrs, ischemic necrosis of hip secondary to corticodteroids

1. Diabetic retinopathy

2. Hypertensive retinopathy

3. Retinal vaculitis

4. Bilateral CRVO

2. ESR

3. ANA

5. Photo

You Make The Call

Additional Testing

Diagnosis

Treatment Plan

You Make The Call

Differential Diagnosis – SLE with retinal vasculitits, HTN and retinopathy, DM and retinopathy, hyperviscosity states

Additional Testing – IVFA, photos, ESR, ANA, C-reactive protein, VF

Diagnosis – SLE and retinal vasculitis

Treatment Plan – IV corticosteroids, rheumatology consult, retina consult

Case of the “Blue Freckle”

Age: 34yobm CC: blurred vision

HPI: OS / 1 yr / stable / constant

Meds: none

BVA: 20/20 OU Pupils: PERRL-APD EOM:

full EXT: pigmented lesions of face

SLE: pigmented lesions of the sclera

IOP: 19/29

Fundi: deeper retinal/choroidal pigmented

PFSH & ROS: NL

1. Nevus flammeus

2. Nevus of Ota

3. Sturge-Weber

4. POAG

1. Old photos

3. Scanning lasers

4. Gonioscopy

You Make The Call

Additional Testing

Diagnosis

Treatment Plan

You Make The Call

Differential Diagnosis – Sturge-Weber,

Nevus Ota, Nevus flammeus, OAG

Additional Testing – VF, GDx/HRT, Gonio

Diagnosis – Nevus of Ota, OAG OD

Treatment Plan – Photodocument, blue tint

spectacles, Timoptic 0.5%XE qd OS

The “Headache” Lady

45yowf CC: “HA, Blurred vision”

HPI: Sudden / Explosive / Constant HA

Lower Extremity Amputee / Tracheotomy

APD EOM: Full EXT: WNL

SLE: WNL Fundi: Globular Sub-Hyaloid

Hemorrhage OD

1. Valsalva retinopathy

2. Terson’s syndrome

3. Diabetic retinopathy

4. Vitreous hemorrhage

1. MRI of the brain

2. Lumbar puncture

3. Fundus photography

4. Random blood glucose

You Make The Call

Additional Testing

Diagnosis

Treatment Plan

You Make The Call

Differential Diagnosis-Drance hemorrhage,

CNVM, migraine, subarachnoid hemorrhage

Additional Testing-MRI/MRA, lumbar

puncture+/-, pupillary testing, physical

examination (neurology)

Diagnosis

ICA/SAH Terson’s Syndrome

You Make The Call

Treatment

STAT admission/high mortality & morbidity

Oxygenation

Sedatives

Control of blood pressure

Monitor cerebral edema

Surgery +/-

endovascular ballons, “clipping” of aneurisms

ICA / SAH

Neurological/Neurosurgical emergency

Prodromal sentinel signs common

Rapid onset of pain/HA, nuchal rigidity, loss

of consciousness, loss of sight, obtundation,

Survivors-mild /severe cognitive impairment

Case of The “Football” Kid

14yobm CC: ”Loss of Vision”

HPI: OS / Sudden / Painless / Rapid

Growth / Enlarging face & hands

APD EOM: Full EXT:

Moon Face, Buffalo Hump

SLE: WNL Fundi: WNL

1. Acromegaly

2. Pituitary adenoma

3. Optic nerve glioma

4. Optic neuritis

1. Visual fields

2. MRI of the brain

3. VER

4. Cortisol

What is the best treatment?

1. Trans-sphenoidal hypophysectomy

2. IV methylprednisolone

3. Radiation of the chiasm

4. Monitor over time

You Make The Call

Additional Testing

Diagnosis

Treatment Plan

You Make The Call

Differential Diagnosis-Chiasmal tumor, optic

nerve disease, Acromegaly, Cushings

Syndrome, pheochromocytoma

Additional Testing-ACTH/cortisol, MRI, Visual

fields, red cap, growth hormone, BP

Diagnosis-Pituitary adenoma

Treatment Plan-Neurosurgery consultation

Pituitary Adenomas

Macrocytic/microcytic

Hormone secretion varieties

Prolactin, GH, ACTH

Bromocryptine (Parlodel)

Surgical approach -trans-sphenoidal

Case of “Nevus”

34yowf CC: “Freckle in my eye”

HPI: OD / 2 wks duration / Lasik OU 1 wk

Meds: Allopurinol NKDA

EOM: Full EXT: W&Q

SLE: Flaps OU IOP: soft OU

Fundus: as pictured

What is the likely

diagnosis?

1. Epiretinal membrane

2. Congenital hypertrophy of RPE

3. Macular drusen

4. Choroidal osteoma

5. Benign choroidal nevus

6. Malignant melanoma

1. IVFA

2. Visual fields

3. SCODI

4. B scan ultrasound

What is the best course now?

1. Retina consult

2. Ocular Oncology

3. PCP

4. LASIK retreatment

5. Retire; I can’t take another day of this

Case of Wife Made Me Do It”

Age: 67yoWM CC: “discharge” SH: wife just had cat surg and thinks husband needs it too

HPI: OS / few weeks / Mild / worsening

Meds: none Allergy: Codeine

VA: 20/80 OD, 20/100 OS Pupils:PERRL-APD EOM:NL EXT: NL

SLE: NS+2 OU, inject+2 OU, poor tear qual

IOP:14/14

Fundi: as shown

PFSH & ROS: Smoker 2ppd, Spec Rx NVO

What are the diagnostic

problems?

What Is Your Treatment Plan?

You Make The Call

Additional Testing

Diagnosis

Treatment Plan

You Make The Call

Differential Diagnosis – HTN/hypertensive retinopathy, venous stasis, hyperviscosity, Glaucoma, atherosclerosis/hypercholesterolemia

Additional Testing – IVFA, photos, Lipid profiles, BP, Carotid auscultation/US, Nuclear stress test, cardiac catheterization,

Diagnosis – Impending Central Retinal vein Occlusion OS, CAD, PVD, HTN, Hypercholesterolemia, Cataracts, Allergic conjunctivitis, Dry eyes

Treatment Plan – Diovan, Toprol, Cardiac angioplasty, ASA, Plavix and may have lower extremity surgery later. Close observation of retina status, watch for glaucoma. Cataract surgery later.

Case of Wife Made Me Do It”

Age: 67yoWM CC: “Blur”

HPI: OS / few weeks / Mild / improving

Meds: Toprol,Diovan,ASA,Plavix, Patanol, Systane Allergy: Codeine

VA: 20/25 OD, 20/30 OS Pupils:PERRL-APD EOM:NL EXT: NL

SLE: NS+2 OU, improved tear quality

IOP:15/15

Fundi: as shown

PFSH & ROS: Smoker 4 cigs/D

Case of “Light Sensitive”

Age: 15 yowf CC: “Lights hurt”

HPI: OS / 2D / worsening / severe

Meds: none OcHx: Accuvue SCL denies sleeping in lens, Renu

VAsRx: OD 20/100, OS LP Pupils: PERRL-APD EOM: full EXT: injected, ptosis

SLE: as pictured

IOP: not done

Fundi: not viewed

PFSH & ROS: NL

You Make The Call

Additional Testing

Diagnosis

Treatment Plan

You Make The Call

Differential Diagnosis – bacterial keratitis, fungal keratitis, acanthameba keratitis, foreign body, hypopion uveitis

Additional Testing – culture/sensivity

Diagnosis – bacterial keratitis

Treatment Plan – moxifloxacin q2h, close watch

Case of “High pressure”

Age: 55 yowf CC: “High pressure”

HPI: OD / 2mos / worsening / severe

Meds: atenolol, gabapetin OcHx: OD blurry for 4-6mos

VAsRx: OD HM, OS 20/30 Pupils: PERRL+APD EOM: full EXT: Nl

SLE: as pictured

IOP: 37/14

Fundi: as pictured, CDR 0.7/.1

PFSH & ROS: HTN, Post-herpetic neuralgia (chest & back) x 3 yrs

You Make The Call

Additional Testing

Diagnosis

Treatment Plan

You Make The Call

Differential Diagnosis – glaucoma, hyphema, cataract, neovascularization of iris, venous stasis/occlusion

Additional Testing – anterior & posterior segment photography, gonioscopy, scanning laser, carotid artery auscultation, IVFA, BP

Diagnosis – Neovascular glaucoma, vein occlusion

Treatment Plan – Cosopt bid, xalatan qhs, schedule glaucoma tube shunt surgery, retina for photocoagulation and VEGF

Case of the “Bump”

Age: 45 yowf CC: “Bump”

HPI: OD / 5mos / worsening / Mild

Meds: none OcHx: RCE OS/PTK 5yrs ago, Dry eye symptoms OS – artificial tears frequently, inferior punctal plugs 4 years ago

VA: OD 20/15 (SCL), OS 20/20 Pupils: PERRL-APD EOM: full EXT: punctal lesion

SLE: as pictured

IOP: 16/13

Fundi: CDR 0.2/0.2

PFSH & ROS: Zoloft

What Would You Do Next?

You Make The Call

Additional Testing

Diagnosis

Treatment Plan

You Make The Call

Differential Diagnosis – chalazion, molluscum, verruca, sebaceous gland carcinoma, pyogenic granuloma

Additional Testing – anterior segment photodocument

Diagnosis – pyogenic granuloma (punctal plug)

Treatment Plan - excision

Uncommon Cases with Common Lessons - MAOOmaoo.org/wp-content/uploads/2009/08/uncommon-cases.pdf ·...

Documents

Uncommon Flooring Ideas

Uncommon Goods: Cool, Unique & Unusual Gifts | Uncommon Goods

Uncommon Communication Challenges Require Uncommon Sense€¦ · Uncommon Communication Challenges Require Uncommon Sense Re-published with permission from Family Center on Technology

Uncommon Service

Uncommon Community

Uncommon Hernias

Uncommon ancestors

Uncommon gifts for uncommon people

Uncommon Summer 8.02.15

Uncommon Design Patterns

Amazing Uncommon Flowers

An uncommon man

UNCOMMON SAILOR-SONGS

Uncommon Fund Presentation

Uncommon worship 7.26.15

Uncommon Grounds

Uncommon obstetrical procedures

Uncommon Quotes

thyrotoxicosis: uncommon causes

UNCOMMON CANCERS