Not So Fast! Some Cases That Might Fool You...

Eric E. Schmidt, O.D., FAAOOmni Eye Specialists

Wilmington, NCschmidtyvision@msn.com

As Many Disease As She Pleases

• 77 WF• Macular hole repair OS 8 yrs prior• Subsequent SRNVM w/ large macular

scar• VA OD 20/20, OS HM@6’ – stable for 5

yrs• Recently complained of HA “alot” over OS• Says her vision OS is worsening, “it will go

black at times!”

Exam

• VA OD 20/25- OS – LP• SLE – OD no change, OS – 2+ PCO• DFE –OD - D,M,V,P wnl OS small

macular bleed adjacent to macular scar• ONH - .1/.1 OD pink, .15/.15 OS large

area of PPA• What now?• Did we forget something?

Ancillary Tests

• IVFA – no evidence of new SRNVM• OCT – Plush NFL, no SRNVM• ESR – 20mm/Hr• C-RP – 0.8

• What now? Is she just crazy?• Are you sure we haven’t overlooked

anything?

Explain the VF result

• NOW what would you do?

MRI

• Suprasellar mass with impingement on ON• Probable glioma• Underwent resection

• Craniopharyngioma!

Deja Vu All Over Again

• 60 y/o WF• Meds: Zetia, Plavix• CC: 3 days prior px lost vision in OD for

~30 min. Things were “black” but cleared up perfectly. No associated pain.

• Yesterday things appeared “dusty” , the “cloud” is moving. Slight ache OD

• POH: CE OD 2 yrs prior, staph lid infection

Deja Vu

• Clinical exam– VA 20/30 OD, 20/25OS– PERRL mg(-)– AC – clear– PCL centered and “in bag”, 1+ NS OS– IOP 18 OD, 15 OS– DFE – wnl OU– Carotid auscultation – “no bruit”

Deja Vu

• Diagnosis???

• Next step???

Deja Vu part deux

• 6 wks later px referred to me• CC: Similar episode of blurry VA OD. Very

blurred 3 days prior and gradually improving. Still seeing “little worms” moving OD. Denies pain or dizziness

• Carotid doppler and Echocardiogram last month – “OK”

• MD says poor blood flow R

My Exam

• VA – OD 20/25 (slow), OS 20/30• PERRL mg (-)• SLE-

– K- cl OU– AC 3+ cell/(-) flare OD, d & q OS– PCL centered, (-) phacodenesis

• IOP -13OD, 11OS• Retina – A/V ½ OU, mild tortuosity• Diffuse Vit Heme Inf OD

So Now what Do You Think?What Do You Want to Do?

• AF???

• OIS???

• Retinal Hypoperfusion/Ischemia???

• GCA???

• Something Else???

Lab Tests

• Carotid doppler – normal, (mild Occlusion R & L)

• ESR – 23 mm/hr• C-RP normal• CBC – mildly decreased RBC• Cholesterol- 212

SOOOO......

• What’s your diagnosis?• Is there more testing required?• Do you need to prescribe drops?• Do you need to prescribe pills?

• BTW- She had 3 add’l recurrences of vitreous hemorrhage OD over next 4 mths

• What is the etiology?

A Diagnostic Quandary

• 76 y/o WM cc: OD hurts, “like a toothache”• Pain is worse at night, lasts for 3-6 hrs.• 3 occurrences over past 2 weeks• VA has decreased since 1st episode• Type I DM – BS 130 today, sliding scale• MD says BP is “way hi recently”• BP med

Quandary Exam

• VA – OD 20/100 ph 20/80-2OS 20/40 ph NI

EOM – no rest.PERRL mg (-)SLE – K – cl OU

Conj – cl OULens – 2+/2+/1+ OD, 2+NS, 1+PSC OSAC – quiet OU, Gr 2 VH OU

IOP – 18 OD, 18 OS

Quandary cont

• Gonio – OD 3,2,2,1 OS 2,2,2,2

• DFE – Should you dilate these eyes?

Quandary Retina

• NPDR OU (OS > OD)• No CSME• No NVD, NVE• C/D - .3/.3 OU

• Anything else?

What is your differential diagnosis?

• How you treat this depends upon your diagnosis!!!>>>@@@@****

Quandary options

• Cataract extraction• PI OU• Glaucoma drops• Blood work• Refer to Internist• Refer to Retina• SLT OU• Retinal/ONH Imaging

I Rx’d Lumigan OU QHS

• Ordered labs– CBC – low RBC– ESR – 80mm/Hr– A1c – 5.3– C-RP – normal

• 2 wk f/up

2 week exam

• Pain had returned even w/ Lumigan• VA worsening• AC- mild cell OD, d & q OS• Angles – unchanged OU• IOP – 17mm OU• Retina – scattered h/MA OU, disk heme

OS• Does this change your mind?

TA biopsy vs PI

• Pros and cons for each

• How did our man end up?

Case Of The Sudden Vision Loss

• 17 y/o BM awoke that AM; “couldn’t see” out of OS.

• “somewhat painful”• Looked in mirror, noticed eye was totally

white• Denies trauma• No precursors

Exam

• VA s Rx - OD 20/30, OS LP• Pupils - OD Round, reactive no inverse

APD, OS - not visible• SLE - OD prominent K nerves, no edema,

no bulb inj, OS as shown

• IOP 15 OD, 32 OS

Sudden Loss Question 1What other tests would you perform?• 1. Gonioscopy• 2. Keratometry/Topography• 3. DFE• 4. Corneal pachometry• 5. VF• 6. Gonio & K Topo• 7. DFE & Gonio• 8. Pachometry & Keratometry

Sudden Loss Question 2What Is Your Diagnosis?

• 1. Angle Closure Glaucoma• 2. Corneal Edema• 3. Corneal Hydrops• 4. Corneal Perforation• 5. Pupillary block glaucoma• 6. Fuch’s dystrophy

Sudden Loss Question 3How would you treat it?

• 1. Adsorbonac 5% QID, TXE 0.5OS• 2. Penetrating Keratoplasty• 3. Betimol 1/2% OS BID, Eflone QID• 4. Pressure patch, Atropine OS• 5. BCL, Quixin OS QID• 6. BCL, Lotemax OS QID• 7. Eflone OS QID, Adsorbonac 5% OS

QID

A Strange Cup Of Tea

• 68 y/o African –American• Treated for NTG x 12 yrs• Seidel’s scotomas OU• Notch at 2:00 OS• NTG well controlled w/ Lumigan OU QHS

– (IOP ~ 11mm Hg)• VF and rims now stable• VA stable at 20/20 OU

Routine Follow-Up?

• No subjective complaints• VA OD 20/30, OS 20/20• NI w/ refraction• When asked again – OD did feel “kind of

funny.”• PERRL mg (-), EOM- no restrictions• SLE – OS normal

- OD as shown

Oh Yeah...

• IOP 42mm Hg OD, 14mm Hg OS

• What’s your next step?

• What is your differential diagnosis?

Glaucomatocyclitic Crisis

• Unilateral increased IOP w/ accompanying iritis

• No predispositioning, no precursors• Absence of all other findings• Mildly symptomatic• Diagnosis of exclusion• R/O ACG, NVG, Inflammatory G, PDS

Treatment

• Gonio is the key to the diagnosis• Lower IOP

– Aqueous suppressors• Quiet the anterior chamber reaction

– PF QID– Taper quickly

• IOP sequelae?