presentasi jurnal

7/18/2019 presentasi jurnal

http://slidepdf.com/reader/full/presentasi-jurnal-56d4d9da81373 1/87

Department of Ophthalmology

Moch Hoesin Hospital

Palembang 2015

Case report

Wednestday June 14 2015

Neuro-ophthalmic Presentations and

Treatment of Cryptococcal Meninitis-related

!ncreased !ntracranial Pressure

"ndrian #uner$

Consultantdr% &'% (e)i "*ri Wahyuni+ #pM,.



INTRODUCTION

CM is the most common manifestationof extra pulmonary cryptococcosis.

Intracranial hypertension occurs in upto 75% of patients ith CM an! isassociate! ith increase! mortality.



INTRODUCTION

CM can present to the ophthalmolo"istas #ision loss$ papille!ema$ a!ucens

palsy$ an!&or other cranialneuropathies.



'UR'O()

To illustrate three !i*erentophthalmic presentations ofcryptococcal menin"itis +CM,



C-() R)'ORT +C-() ,

- /01year1ol! male as referre! to theneuro1 ophthalmolo"y clinic fore#aluation of ilateral optic atrophy. 2eha! een ell until 3 months prior henhe experience! #ision loss$ hea!ache$nausea$ an! fe#er. 2e presente! to hisprimary me!ical !octor an! his local

hospital emer"ency !epartment se#eraltimes an! as !ia"nose! ith an!treate! presumpti#ely for sinusitis.



on hospitali4ationforma"neticresonanceima"in"+MRI, an!lumarpuncture+',.Contrast1enhance!MRIofthe rainasunremar6ale.'shoe!anele#ate!openin"pressure+O',of3/cm2O. Cererospinal 8ui! +C(9, ha!

:hiteloo!cells+;<C,&m +75%lymphocytes$ 5%monocytes$=%neutrophils,.CryptococcalC(9 anti"enaspositi#eatmorethan>:$an!culture"re C.neoformans. Cytolo"yan! 8o cytometryerene"ati#e formali"nancy.2I?1testin"aspositi#eithaCD/ count

of0cells&m an!a#iralloa!of3@$===copies&m. Thepatientasstarte!onamphotericin<an! 8ucytosine forCM.Repeat'sereperforme!torelie#eIC'an!monitoranti"entiters.



On examination$ acuity as =&5OD an!=&== O(. -utomate! #isual Ael!s shoe!a ri"ht !ense superior arcuate an! inferior

altitu!inal Ael! !efect an! a left centralscotoma. Ishihara plates ere &/ on theri"ht an! =&/ on the left. There as a leftrelati#e a*erent pupillary !efect +R-'D,.

Ophthalmoscopy shoe! !i*use opticatrophy ilaterally. -ntifun"al treatmentas continue!.



C-() R)'ORT

Case - /31year1ol!femalepresente!ith3ee6sofhea!1ache$ hori4ontal!iplopia$an!ilateral#isionloss.Me!icalhistory assi"niAcant forrenaltransplantationforcon1"enital 6i!ney!iseasein==5an!repeattransplantationfor

focal"lomerulosclerosisreBuirin"immunosuppressionfor @years.'ost1transplant6i!neyfunctionasstale.(heha! chronic$utstalesecon!aryreno#ascularhyper1tension$

hyperlipi!emia$anemiaofchronic!isease$an!prior !eep#enous thromosis e#ents in ==5 treate! itharfarin until her most recent transplant 0 monthsa"o.





C-() R)'ORT

'hysical )xamination eneral (tatus > Normal

Ophthalmolo"y (tatus>

RE LE

VA N/P 100

IOP PN30 5 mm&

Eye ballPosititon

#ymetric

Eye BallMovement

ood to "ll a*e ood to "ll a*e

Palpebra Normal Normal



C-() R)'ORTConjunctiva Normal Normal

Cornea Cicatri all o)er corneasurface

Clear

Anterior Chamber Moderate Moderate

Iris Posterior synechia ,3. Normal

Pupil 6)al+ /7 ,-. N 7ound+ Central+/7,3. +8 5 mm

Lens Can9t :e assessed Clear

Fundus e!le" Neati)e Positi)e

Papil Can9t :e assessed 7ound+ :lurred marin+ Normal 7edColour+ C(; Can9t :e assessed "<;2

Macula =o)eal refle,-.

etina 4 >uadrants detachment ,3.+ iant

retinal tear ,3. temporal reion%





C-() R)'ORTLEF E!E F"#D"$ PHOO%R&PH



C-() R)'ORTRE'#&L DR&('#%

RE



)9T )E) U(



RI2T )E) U(



C-() R)'ORT

#ia$nosis %

7hematoenous 7etinal (etachment /? 3 Cornea

/eu@oma 7? 3 7etinal (etachment /?

Mana$ement% !nformed Consent

&ospitali*ed

/a:oratorium ?amination 3 Chest A-7ay

Pro consult "nesthesioloy (epartment Pro #cleral Buc@le 3 Pars Plana <itrectomy 3 ?ndolaser 3

#ilicone 6il /? ith eneral "nesthesia



Pro$nosis %

Duo ad <itam ; Bonam

Duo ad =unctionam ; (u:ia ad :onam



C-() R)'ORT

&ur$ical eport% '()*+*(,)-.1% Patient in supine position ith "

2% "septic E antiseptic performed+ surical field as narroed

% F00 con'uncti)al peritomy E etraocular muscle isolated

4% #ilicone :and inserted under rectus muscle+ #lee)e installed at

nasal inferior E :and sutured to sclera at 4 ith mersilene 5%0

5% #clerotomy site mar@ed at mm from lim:al and at G o9cloc@ filled

infusion cannula+ 10 o9cloc@-)itrector E 2 o9cloc@-endoilluminator

F% (etached retina and tear as identified+ proceed to performin

)itrectomy until optimal clearance



C-() R)'ORT

H% &ea)y fluid in'ected to sta:ili*e retina and to do the endodrainaeG% fluid-air echane performed+ endolaser applied around tear and

F00 peripheral retina

I% #ilicone 6il in'ected to )itreal ca)ity

10% !nfusion cannula+endoilluminator E )itrector ere remo)ed fromca)ity E sclera sutured ith G%0 )ycril

11% (eamethason-entamycin in'ected su:con'uncti)al and eye

as closed ith sterile patch



Post operti)e therapy CeAxime x == m" 'aracetamol 3 x 5= m" Metil pre!nisolon 3x / m" Toramycine F !exametason )D 0 x

"tt OD



C-() R)'ORT +=6//6W P.

Right Eye 1st *ay post op +th *ay post op

?- 4F0 P&,-. FF0 ph ,-.

IO' 1+1 mm& 15+F mm&

9R +F, +F,

'apil 7ound+ =irm marin+ Normal 7ed Colour+C(;0+ "<;2

7ound+ =irm marin+ Normal 7edColour+ C(;0+ "<;2

Macula =o)eal refle ,3. =o)eal refle,3.

Retina Tiroid appearance+ /attice deeneration,3. + scar laser ,3.+ su:retinal hemorrhaic,3.

Tiroid appearance+ /atticedeeneration ,3.+ scar laser ,3.+su:retinal hemorrhaic ,3.



C-() R)'ORT

1st *ay post op ,th *ay post op

Dia"nosis

'ost Buckle (6lera F parsplana #itrectomyF )n!olaser F(ilicon oil /?F corneal leucomaR) F Retinal !etachment R)

'ost Buckle (6lera F parsplana #itrectomyF )n!olaserF (ilicon oil /?F cornealleucoma R) F Retinal

!etachment R)

Therapy KCeAxime x == m"K'aracetamol 3 x 5= m"KMetil pre!nisolon 3x / m"K Toramycine F !exametason)D 0 x "tt OD

K Toramycine F !exametason)D 0 x "tt OD



IT)R-TUR) R)?I);

It exten!s almost as far anteriorlyas the ciliary o!y

)n!in" point

The ora serrata The outer surface of the sensory

retina is appose! to the retinal

pi"ment epithelium an! thusrelate! to <ruchGs memrane$ thechoroi!$ an! the sclera.

RE'#

&



Thic6ness =. mm at the ora

serrata an! =.50 mm at theposterior pole The macula lutea is !eAne!

anatomically as the 3 mm !iameterarea containin" the yello lutealpi"ment xanthophyll

RE'#&



FO-E&

The retinal a)ascular *one of

fluorescein anioraphy% L 1%5 mm



- !epression that creates a

particular re8ection hen #iee!ophthalmoscopically.

In the center of the macula /mm lateral to the optic !is6

H =.5 mm

FO-EOL&



K In the mi!!le of K The thinnest part of area of the

retina =.5 mmK Only cone photoreceptors.K 'ro#i!in" optimal #isual acuity.

FO-EOL&





IT)R-TUR) R)?I);

Retinal !etachment> separation of thesensory retina from the pi"ment epithelium

hich occur at potential space.



IT)R-TUR) R)?I);

Normally$ sensoryneural attach to R') maintaine!y alance hy!rostatic. R') preser#e the potentialspace free from 8ui! y osmotic "ra!ient an!acti#e1pump mechanism.

3 maJor factor of RD> full1thic6ness retinal !efect +rea6, Traction of retina

(uretinal 8ui!



IT)R-TUR) R)?I);

'otential space in RD Alle! ithsuretinal 8ui!. 9lui! came from

syneretic #itreous throu"h retinal rea6an! separate the sensory retina fromR')



IT)R-TUR) R)?I);

7is@ factor; Myopic eye

Trauma

/attice deeneration

&istory of surery =amily history

“Lattice degeneration is a predisposing factor of RRD. 8 % of

population have lattice and 40% case of RD associated withlattice”



(EM'TOM( Metamorphopsia 'hotopsia

(ha!o or curtain o#er a portion of#isual Ael!

<lur in #ision



IT)R-TUR) R)?I);Management of RRD. An! an! close the rea6 Reattachment retina

Post operati)e o/tcome *epen* on. Macular in#ol#ement !uration of separation until sur"ical mana"ementapply



IT)R-TUR) R)?I);

$/rgical echni/e1 $cleral /c3ling

Retinope4y

(90 C39:

5 h o r i o r e t i n a l a * h e s i o n

Cryo aser

$ c l e r a l i n * e n t a t i o n(ilicone

an!

Tyre

Performed ; sinle :rea@ E peripheral

ood )isuali*ation

only in 1 >uadrant I0 ood result

(rainae



IT)R-TUR) R)?I);

#C/?7"/ BC/!N C6MP/!C"T!6N



IT)R-TUR) R)?I);

2 -itrectomyRationally$ #itrectomy is a proce!ure too#ercome traction an! a#oi!

complication of scleral uc6lin".

VI/EC/OM0clean up hyaloid corte" o! vitreous avoid vitreoretinal traction

# associated vitreous mobility 'li1ue!action 2 PV#.

$cleral/c3le

ela"ation vitreal

traction



IT)R-TUR) R)?I);

VI/EC/OM0 POCE#3E



'#D'&'O#

#isease%

(ia:etic 7etinopathy

P<7

Macular in)ol)ement

Trauma

Malinancy case

Condition%

iant tears

<itreous hemorrhae

Multiple :rea@

?>uatorial tear



IT)R-TUR) R)?I);

<itrectomy Complication

Intra operati#e

Iatro"enic rea6

Iatro"enic to lens

'ost operati#eIncrease IO'

+silicone$uc6lin",

Cataract form

2yphema +hea#y

8ui! to -C,

CM)

'?R



iant retinal tears circumferentialretinal rea6s of @= !e"rees or more



The "eneral principles of mana"ement> Unfol! the posterior 8ap of the tear 9latten it a"ainst the eye all (eal the tear ith a A rm a!hesion.



DI(CU((ION

-namnesis (u!!en lur #ision

No re!!ish eye 'hotopsia 9loaters

Curtain1li6e #ision

#eein flash liht

,photopsia. and =lyin

matter, floaters. are 50

of 77( early symptoms%



DI(CU((ION

9un!us )xamination>K Retinal !etachment +un!ulation

ulae,K 9o#eal in#ol#ementK iant retinal tearK attice !e"eneration



DI(CU((ION

2istory of earin" spectacles +F, 1@D hi"hmiopia lattice !e"eneration

Lattice *egeneration.

-normal con!ition of retina cause! y thinnin"of inner limittin" memrane ith athropic process

of neurosensory$ hich is lea! retinal rea6formation mi"ration of #itreous 8ui! suretinal the sensory retinaKR') separation



Mana"ement for this patient is (clerauc6le F 'ars 'lana ?itrectomy F)n!olaser F InJection (ilicone OilIntra#itreal

iant retinal tear

4H



Reason .

Retinal !etachment shallo oo! i!entiAcation of retinal tear

Post operati)e o/tcome.

Complication not foun!

Retinal 8at +F, ?isual acuity impro#ement at follo up



'ro"nosis > Luo a! #itam > onam

Luo a! fun"sional > !uia a! onam

9ollo Up > etter #isual acBuity$

attache! retina$ no complication



Its ha#e een reporte! a case of Rhe"mato"enretinal !etachment ith "iant retinal tear mana"e!y (clera uc6le F 'ars 'lana ?itrectomy F)n!olaser F InJection silicone oil intra#itreal.

RRD cause! y lattice !e"eneration history ofhi"h miopia.

'ro"nosis !uia a! onam for this patient etter#isual acBuity$ attache! retina$ no complication

O#L"$'O#



H&#6 !O"



R--T

'ro"nosis > !uia a! onam

(etelah tin!a6an operasi !i!apat6anretina yan" attach dan perai6an taJam

pen"lihatan pa!a follow up$ serta ti!a6!i!apat6an 6ompli6asi tin!a6an e!ah.











-()R TI((U) )99)CT

'hotocoa"ulation e*ects. Thermal e*ects$ those most commonly

encountere! ith retinal photocoa"ulation #isile or infrare! li"ht is asore! y tissue

pi"ment asorption of laser ener"y results in a= to = C temperature rise 111 protein!enaturation is seen clinically as tissue hitenin"



-()R TI((U) )99)CT

Thermal e*ects.



(EM'TOM( 8oaters 1 its of !eris in Ael! of

#ision that loo6 li6e spots$ hairs orstrin"s





















IT)R-TUR) R)?I);



IT)R-TUR) R)?I);

Vitrectomy 4 &cleral Buc5le



De"enerasi lattice merupa6an6elainan !ari permu6aan#itreoretinal$ !apat !itemu6an 01=% !ari populasi umum !anilateral pa!a &3 sampai

Jumlah6asus!e"enerasi lattice.De"enerasi lattice serin" munculpa!a pasien !en"an miopia$ tapiti!a6 hanya teratas pa!a pasien

?ITR)CTOME CUTT)R <-U(2 -ND



?ITR)CTOME CUTT)R <-U(2 -NDOM<



Retinal breaks

a - Large U-tear with‘ subclinical RD ’

- treatb - Large symptomatic U-tear

- treat

c - Operculated tear bridgedby blood vessel

- treatd - Asymptomatic operculated

tear- do not treat



Retinal breaks not reuiring treatment

e - Asymptomatic dialysissurrounded by pigment

! - "reaks in both layers o! retinoschisis

g - #mall asymptomatic holesnear ora serrata

h - #mall inner layer holes inretinoschisis

$ypical lattice degeneration



$ypical lattice degeneration• %resent in about &' o! general population• %resent in about ()' o! eyes with RD

• #pindle-shaped islands o! retinal thinning• *etwork o! white lines within islands• +ariable associated R%, changes• #mall round holes within lesions are common

• Overlying vitreous liue!action• ,aggerated attachments

around margin o! lesion

Retina +itreous

. li ti ! l tti d ti



.omplications o! lattice degeneration

/ndications !or prophylais

• *o complications - in most cases• RD associated with atropic holes0 particularly in young myopes• RD associated with tractional tears in eyes with acute %+D

• RD in !ellow eye• ,tensive lattice in high myopia



C-((I9IC-TION O9 '?R



C-((I9IC-TION O9 '?R

The term Pproliferati#e #itreoretinopathyP as coine! in@:3 y the Retina (ociety Terminolo"y Committee.

In @:@$ the classiAcation as amen!e! y the (ilicone(tu!y roup efore ein" most recently mo!iAe! in @@ toits current classiAcation.

Currently$ '?R is !i#i!e! into "ra!es -$ <$ an! C. ra!e - is limite! to the presence of #itreous cells or ha4e. ra!e < is !eAne! y the presence of rolle! or irre"ular

e!"es of a tear or inner retinal surface rin6lin"$ !enotin"suclinical contraction.

ra!e C is reco"ni4e! y the presence of preretinal orsuretinal memranes. ra!e C is further !elineate! asein" anterior to the eBuator +"ra!e Ca, or posterior to theeBuator +"ra!e Cp, an! y the numer of cloc6 hoursin#ol#e! + to ,.

i! i i i



%roli!erative vitreoretinopathy

• +itreous ha1e and

tobacco dust

2rade A 3minimal4

• Rigid retinal !olds

• +itreous condensationsand strands

2rade . 3severe4

• Retinal wrinkling and

sti!!ness• Rolled edges o! tears

2rade " 3moderate4

%R/*./%L,# O5 R,$/*AL D,$A.67,*$ #UR2,R8



%R/*./%L,# O5 R,$/*AL D,$A.67,*$ #UR2,R8

9: #cleral buckling

;: %neumatic retinopey

• .on!iguration o! buckles• %reliminary steps• Locali1ation o! breaks• /nsertion o! local eplant• ,ncircling procedure• Drainage o! subretinal !luid

<: +itrectomy

• 2iant tears• %roli!erative vitreoretinopathy 3%+R4• Diabetic tractional RD



+itrectomy !or Retinal Detachment

Release o! circum!erentialtraction

Release o! antero-posterior traction ,ndophotocoagulation

+itrectomy !or %+R



+itrectomy !or %+R

• Dissection o! star !olds and peeling o! membranes• /n=ection o! epanding gas or silicone oil



'ntraoc/lar gases

(ulfur hexa8uori!e +(90,per8uoropropane +C39:, are the "ases

most freBuently use!.(uccess also has een reporte! ithsterile room air.



%reliminary steps



%reliminary steps

%eritomy /nsertion o! suint hook underrectus muscle

/nsertion o! bridle suture /nspection o! sclera !or thinningor anomalous vorte veins

,ncircling procedure



,ncircling procedure

#trap !ed under !our recti ,nds secured with >at1ke sleeve

#trap slid posteriorly and securedin each uadrant

#trap tightened to produce reuiredamount o! internal indentation



Date post:	01-Mar-2016
Category:	Documents
Upload:	andrian-suner
View:	2 times
Download:	0 times

presentasi jurnal

Documents