Tests Include Differential Diagnosisshelleyeyecenter.com/files/202-B_Louise_Sciafani.pdf · ð›Post-op effects of YAG laser – PVD secondary to Pilocarpine use – PVD or rapid

SCLAFANI-GRAND ROUNDS SAMPLE

GRAND ROUNDS:Guess what I saw today!

Louise A. Sclafani, OD, FAAOCOPE#24602-SD

Cases will be presented in a grand rounds mannerwith audience participation determining

management.Classic and unusual conditions will be discussed in

detail from diagnosis to treatment.Examples are included

Patient History and ClinicalFindings are Presented

Age, Race, Gender POHX: Patient Ocular History PMHX: Patient Medical History FO/MHX: Family Ocular and Social History CC: Chief Complaint Are there any other questions Always look at the fellow eye Survey the family history More is revealed when someone else asks

Tests IncludeBasic Tests BVA: Best

corrected vision Pupils/Motility SLX: Slit Lamp

evaluation IOPs DFE: Dilated

fundus evaluation

Additional Tests Office procedures

– Color, Vital Dye Lab tests Imaging VF, OCT, FANG

Differential Diagnosis What are the most likely causes of

your findings based on the patientspresentation and history.

Include the most common and thosethat are rare.

What are the trends and include yourpast experience

TREATMENT PLAN Include medical and surgical options What is your scope of practice What is standard of care Is there consent When is the follow-up

If you would like the backgroundinformation for the cases presented today,

please email me:

[email protected]



Age, Race, Gender POHX: PMHX: FO/MHX: CC: BVA: SLX: IOPs DFE:

Other tests:

What is your DDX? What are the ClinicalFindings of this condition?

How would you treatthis condition? NOTES

mailto:[email protected]


PATIENT HISTORY 67 yo WF c/o reduced vision and sees a white floating

line in center of vision OS PoHx: cataracts, LPI OS, floaters, DES PmHx: Capillary Leak Syndrome, HTN,

cholesterol, asthma, allergy, fibromyalgia Meds: Darvocet, Effexor, Benicar, Seravent,

fosamax, Lipitor, AT FoHx: brother and sister with glaucoma Referred to me by retinal service/ general

ophtho

EXAM FINDINGS VARE 20/60 LE 20/50 mono.dip BVA RE 20/50 -1.00 +.75 x 173

LE 20/30 - .75 + 2.00 170 ** IOPS 23,23 SLX 2-3+ NS/CS OU OS

Patent LPI OTHER TESTS

OTHER TESTS

Trial frame improves symptomsof monocular diplopia but “wavy

line” persists.

Consistent Finding


DIFFERENTIALDIAGNOSIS

Posterior VitreousDetachment

ERM or othermacular condition

TESTS TO R/O– DFE– OCT


Posterior Vitreous Detachment ERM or other macular condition Cortical Cataract Post-op effects of YAG laser

– PVD secondary to Pilocarpine use– PVD or rapid cataract progression due to

shock wave (energy + 5.8 mj)– Visual symptoms due to LPI

Contact Lens TrialCooperVision Prosthetic

Series No. 3, BO ( back tint,

open pupil) Eliminates symptoms

of line and some ofblur when combinedwith trial frame

No longer availablefrom CV: Marietta Lab

PURPOSE:

PURPOSE: Patients experience visual

disturbances after LP 1st study to evaluate them and

determine if there was anassociation of lid position andsize.

172 eyes, 92 controls

J Glaucoma, Volume 14, October2005

CONCLUSION:Visual symptoms related to LPI

occur in 7%

More likely to occur in patientswho have exposure, and mostlikely if it is partial. Fully

Eye (2006)

Glare from PI


RESULTS

full


Post-op effects of YAG laser– PVD secondary to Pilocarpine use– PVD or rapid cataract progression due to shock wave (Nd:YAG =

energy + 5.8 mj– Visual symptoms due to the LPI

Visual symptoms LPI hole vs. Tear Mensicus– Weintraub and Burke, Ophthalmology 1992

Pt reports that when she lifts the lid away (exposing entire PI)the symptoms go away.

Symptoms also relieved when looking down Therefore symptoms not related to aperture, but due to light

rays being refracted by the tear film at the edge of the upperlid and then passing through PI.

TREATMENT Occluder Contact Lens Cataract surgery first

– Cataracts are significant, however patient isanxious

– Eliminate narrow angles– Iris will be repositioned and reduce symptoms– McCannel closure preferred vs. Morcher

segment Corneal Tattoo

– Tattoo should always be done after cataractsurgery so as not to hinder view

Therapeutic Tattoo Coloring: organic, gold dust, india ink etc

– Pfeiffer describes anterior stromal micropuncturetechnique using commercially available dyes

– Risk of full thickness puncture, inflammatory reaction inwhich cells eat up dye, non-uniform results, RCE

– Long term safety unknown: possible toxicity (arsenic,Cl) Use of Intacs channel dissector to distribute dye

– Risk of non-uniform or limited surface area– Awdeh suggests use of Intralase to create flap/paint

stromal cap Chemical reaction involving precipitated pigment

brought about by metallic salts

Filter paper soakedwith sterile platinumchloride solution isinserted into 2 mmstromal pocket anteriorto PI

The reducing agent,hydrazine hydrate wasadded under paperand excess solutionremoved.

Over time, reduced toplatinum black :

20 months later

PATIENT HISTORY c/o wants cataract removed to see if there is vision

potential/ improve cosmesis BVA: OD NLP OS 20/20 sc PoHx: Trauma OD > 20 yrs, strabismus sx OD

>10yrs, cryo sx OS for retinal hole > 5 yrs LEE > 5yrs

PmHx: UTI, +RA Meds: IV AB, d/c pred and methotrexate CLHx: wears SCL opaque lenses purchased at

beauty supply store. Uses Visine weekly. EW.Present lens 3 months old. Pays $25 per pair.

Social: “gypsy”




Other Tests:




PATIENT HISTORY 30 YO WM H/O sudden RE eye pain, redness, blur CLHx: Ciba N/D, OptiFree Express OMD: 3 days after RE symptoms he began

Vigamox TID -OD. Some improvement soresumed CL wear. One day later, severeeye pain OU.

PmHX and FoHX: negative Social: cleans portable toilets, cleans CLS

at work

LE 5 circular epithelial defects in acurva-linear pattern across cornearanging in size .1 to 2.1 mm withsurrounding infiltrate. RE had one

Feathery appearance: DDX?/ Tests?


Corneal Abrasion or Trauma Sterile Infiltrate Microbial Keratitis

– Bacterial– Fungal– Viral– Protozoan

SterileInfection

Mild pain Small Multiple or arcuate Peripheral No discharge Epithelium intact* Elevated AC quiet Focal Accumulation

of inflammatory cells

Moderate to extreme Large Individual lesions Central Discharge Epithelial staining Flat or excavated AC reaction Localized edema

Stein RM, Clinch TE, Cohen EJ,Genvert GI, Arentsen JJ, Laibson PR:

Infected vs. sterile corneal infiltrates in contact lenswearers.

Am J Ophthalmol 1988, 105(6);632-636

Infiltrative KeratitisDifferential diagnosis is critical

LAS

Most Likely Organismsin CL Wearers

Pseudomonas aeruginosa: gram -– 50% of CL related ulcers, also post sx or trauma– Can penetrate an intact cornea & perforate in 24 h

Staphylococcus aureus (gram + non mobile)– Colonizes eyes, nose axillae

Serratia marcesens (gram - bacteria)– Develops over time and requires a break in epithelium

Acanthamoeba (protozoa)– A minor corneal break allows it to enter from

contaminated CL solutions, cases, or tap water. Ring


TREATMENT PLAN Vigamox increased to q 2h OU ( seemed to

improve symptoms previously) Natamycin q 4 hours ( high suspicion FK) Cultures Taken

– Cornea: no growth– CLS/Case/Solution: -gram colonies of

Alcaligenes xylosoxidans. Later confirmed withPCR

– Case series showed a 92% sensitivity alcaligensto systemic trimethaprim-sulmethoxazole

– Started Polytrim (polymyxin B/trimethoprin) qhand continue Natamycin. D/C Vigamox

Improvement over Time Symptoms improved

after 2 days: Polytrimtapered q 4 x 5 days,then QID x 10 days

d/c Natamycin 1 week BVA 20/25 at 10 days Residual scar at 3 wks

Achromobacterxylosoxidans

Motile, aerobic,gram-negative,non-fermentativestraight rod with aperitrichousflagella*

DDX: PA Urine, blood, ears,

respiratory tract,and spinal fluid

Opportunisticpathogen tocompromised tissue

Water pathogen foundin pools, chlorhexidine

Reports: post-PKP,EKC, steroid use,NVGTherapeutic BCL

Resistant to many AB Sensitive to Polytrim

Patel, Saidel, UC ARVO 2008

SIGNIFICANCE OFCASE

There are only 15 reports of ocular infectionfrom Achromobacter xylosoxidans and thisis the first to be confirmed with PCRtechnique

VITEK 2 rapid panel assays which can ddxfrom PA and determine specificities

Recent study showed (excluding PA) a highconcordance rate of gram negative rodsbetween +CL cultures and – cornealscrapings

Our patient Extensive daily wear use (15 – 20 hours) A.xylosoxidans isolated from sewage sludge His case and solution was exposed at work

making colonization possible, and uponexposure under stress infection can result.

Cultures revealed A.xylosoxidans to beresistance to aminoglycosides,cephalosporins and first-generation FQ.Perhaps the low dose Vigamox was enoughto render cornea culture negative, butenough to eliminate infection.




Other Tests:




Patient M.C.

HPI: 34 year old female with: Red swollen left eye Purulent discharge Central corneal opacity Suicidal ideation

Additional HPI: History severely limited by patient

agitation/intoxication Last used crack cocaine today Seen at OSH 4 days ago for “corneal

abrasion.” Prescribed abx butnoncompliant.

Varied patient response regardinglength of problem OS - 4 days, 2months or 2 years???

Medical History PMH: Bipolar disorder, hepatitis B and C Ocular History: Unknown Meds: Depakote, Trazadone (non-

compliant) Allergies: NKDA SHx: +EtOH, +crack cocaine, +tobacco FHx: Non-contributory

Visual Examination VASC: CF@ 2ft OD; LP OS Pupils: 6mm unreactive to light OD; hazy

view OS, ~4mm unreactive to light; ?Reactive to near

Motility and CVF: Unable to cooperate External exam: Photo Anterior segment: Photo DFE: Normal OD; no view OS; Bscan –

retina flat

Differential Diagnosis Corneal ulcer

– Bacterial– Fungal– Parasitic– Neurotrophic

Corneal melt Corneal burn Self-induced trauma Toxic exposure

Clinical Course Admitted to hospital for psychiatric

observation Lid and corneal cultures sent in ER Tobramycin q1h; Vancomycin q1h –

alternating q30min Eye culture: One colony coagulase (-)

Staph; one colony Corynebacterium,(normal flora)

Fungal/AK cx negative


Additional LaboratoryStudies

Utox: +cocaine Head CT: normal RPR: non-reactive HIV: negative

Additional historyobtained

Uses $100/day of crack cocaine(smokes)

Works as prostitute Unable to see out of left eye for >2

years Non-compliant with follow-up Denies history of contact lens wear,

surgery, head trauma OS

Clinical Course f/u VA 20/100 OD; LP OS IOP 20 OD; 21 OS Denies any symptomatic improvement No clinical improvement in corneal

defect, size of infiltrate Seidel negative; no evidence of

perforation Started Doxycycline and Vitamin C Recommended FTA-ABS

Future TreatmentStrategies

Prevention of corneal melt– Doxycycline– Vitamin C– Topical medroxyprogesterone– 10% sodium citrate

Tarsorrhaphy Amniotic membrane graft Corneal transplant Substance abuse counseling

Eye Complications ofCocaine Abuse

Angle closure glaucoma Retinal hemorrhages Optic neuropathy Ocular motility disturbances Nasolacrimal duct obstruction Orbital cellulitis Corneal epithelial defects SPK Corneal ulcers Corneal perforation

If you would like the backgroundinformation for the cases presented today,

please email me:

[email protected]

Documents

Tests Include Differential Diagnosisshelleyeyecenter.com/files/202-B_Louise_Sciafani.pdf · ð›Post-op effects of YAG laser – PVD secondary to Pilocarpine use – PVD or rapid