Home / Past Meeting Abstract Archives
"Rad" Retinopathy: A Misdiagnosed Case of Hypertensive Retinopathy
Published 2023 by Andrea Yiasemis
Co-Author(s): Xiao (Shawn) X. Yu
Program Number: 235309
Article Type: Scientific Program
Board: 24
PURPOSE:
Radiation retinopathy is typically described as a delayed, gradually progressive retinopathy in patients with a history of radiation to the orbit, head and neck. Retinal vasculature damage from radiation therapy initially causes occlusive microangiopathy which manifests clinically as retinal hemorrhages, microanuerysms, cotton wool spots (CWS), exudates and macular edema. As the retinopathy progresses, anterior and posterior segment neovascularization may develop. The clinical findings of radiation retinopathy are not unlike those seen in diabetes, hypertension, and anemia. We present a case of radiation retinopathy that was misdiagnosed for 2 years as hypertensive retinopathy in order to highlight the similarities between the retinopathies and the importance of a thorough systemic history review.
CASE REPORT:
A 66 yo AA male presented for a dilated eye exam. He had no visual complaints with his current glasses and his BCVA was 20/20 in each eye. The pt had been diagnosed with hypertensive retinopathy at his previous eye exam 7 mos ago. His medical history was remarkable for HTN which was well controlled on medication. His previous BP reading was 123/78mmHg one month prior. In office BP measurement at this visit was 131/81mmHg. Medical hx also included small cell lung cancer for which the patient received chemotherapy and 60Gy of radiation followed by prophylactic cranial irradiation of 50 Gy to prevent brain metastasis 4yrs earlier. Dilated fundus examination revealed suspicious optic nerve cupping OD>OS. Cotton wool spots and blot hemes were noted OU. Very mild AV nicking was also observed. A review of the pt's latest blood work ruled out diabetes, anemia and HIV. Chart review of previous exams revealed a h/o of CWS that resolved and reappeared over the past 2 years that had been attributed to HTN. The pt's BP readings over the past few years ranged from 111-131mmHg systolic and 62-83mmHg diastolic. Given the pt's HTN was fairly well controlled with no obvious hypertensive vasculature changes, in addition to the pt's h/o of high dose cranial radiation, it was concluded that the retinopathy was secondary to radiation retinopathy.
CONCLUSION:
Radiation retinopathy, particularly it in its early presentation, may be easily misdiagnosed as it presents clinically similar to other, more common etiologies. A thorough case history and review of systemic history, vitals, and lab work can direct the provider to the proper diagnosis and management. Pts with radiation retinopathy require close monitoring for progression and development of neovascularization which requires prompt referral to ophthalmology for treatment. As life expectancy continues to increase, incidence of cancer and radiation treatment is likely to increase. It is important for eye care professionals to make the correct diagnosis to avoid mismanagement.
PURPOSE:
Radiation retinopathy is typically described as a delayed, gradually progressive retinopathy in patients with a history of radiation to the orbit, head and neck. Retinal vasculature damage from radiation therapy initially causes occlusive microangiopathy which manifests clinically as retinal hemorrhages, microanuerysms, cotton wool spots (CWS), exudates and macular edema. As the retinopathy progresses, anterior and posterior segment neovascularization may develop. The clinical findings of radiation retinopathy are not unlike those seen in diabetes, hypertension, and anemia. We present a case of radiation retinopathy that was misdiagnosed for 2 years as hypertensive retinopathy in order to highlight the similarities between the retinopathies and the importance of a thorough systemic history review.
CASE REPORT:
A 66 yo AA male presented for a dilated eye exam. He had no visual complaints with his current glasses and his BCVA was 20/20 in each eye. The pt had been diagnosed with hypertensive retinopathy at his previous eye exam 7 mos ago. His medical history was remarkable for HTN which was well controlled on medication. His previous BP reading was 123/78mmHg one month prior. In office BP measurement at this visit was 131/81mmHg. Medical hx also included small cell lung cancer for which the patient received chemotherapy and 60Gy of radiation followed by prophylactic cranial irradiation of 50 Gy to prevent brain metastasis 4yrs earlier. Dilated fundus examination revealed suspicious optic nerve cupping OD>OS. Cotton wool spots and blot hemes were noted OU. Very mild AV nicking was also observed. A review of the pt's latest blood work ruled out diabetes, anemia and HIV. Chart review of previous exams revealed a h/o of CWS that resolved and reappeared over the past 2 years that had been attributed to HTN. The pt's BP readings over the past few years ranged from 111-131mmHg systolic and 62-83mmHg diastolic. Given the pt's HTN was fairly well controlled with no obvious hypertensive vasculature changes, in addition to the pt's h/o of high dose cranial radiation, it was concluded that the retinopathy was secondary to radiation retinopathy.
CONCLUSION:
Radiation retinopathy, particularly it in its early presentation, may be easily misdiagnosed as it presents clinically similar to other, more common etiologies. A thorough case history and review of systemic history, vitals, and lab work can direct the provider to the proper diagnosis and management. Pts with radiation retinopathy require close monitoring for progression and development of neovascularization which requires prompt referral to ophthalmology for treatment. As life expectancy continues to increase, incidence of cancer and radiation treatment is likely to increase. It is important for eye care professionals to make the correct diagnosis to avoid mismanagement.
12 Common Errors in Amblyopia Diagnosis and Management
Published 2023 by Yi Pang
Co-Author(s): Kelly Frantz
Article Type: Lectures & Workshops
COPE ID: 85848-FV
This course will describe and discuss the common errors in amblyopia diagnosis and treatment, including proper testing, differential diagnosis, and prescribing lenses and atropine. Clinical cases and evidence-based amblyopia management will be presented.
This course will describe and discuss the common errors in amblyopia diagnosis and treatment, including proper testing, differential diagnosis, and prescribing lenses and atropine. Clinical cases and evidence-based amblyopia management will be presented.
2023 Updates in Retinal & Clinical Manifestations of Neurodegenerative Disorders (PHEV Section and ViA SIG Symposium)
Published 2023 by Barbara Cohn
Co-Author(s): Robert Rissman, Amir Kashani, Kelly Malloy
Article Type: Lectures & Workshops
COPE ID: 87159-NO
Invited back are our panel of nationally known researchers in the field of Biomedical Engineering and Neuroscience to update us on the advances in identifying potential retinal biomarkers for neurodegenerative disease and bring the audience up to date on the current clinical studies. Imaging of the eye has the potential to provide a more patient-friendly biomarker tool compared to the currently established biomarkers that are either costly (MRI/PET imaging) or invasive (CSF through lumbar puncture). Although the full potential of eye imaging is still unknown at this state, research in this field is increasing and involves collaboration among disparate backgrounds of researchers (ophthalmology, neurology, pathology, technology etc.). Lastly the panel will then provide a summary of current care and suggested approaches from a provider in Neuro-Ophthalmic and rehabilitative care.
Invited back are our panel of nationally known researchers in the field of Biomedical Engineering and Neuroscience to update us on the advances in identifying potential retinal biomarkers for neurodegenerative disease and bring the audience up to date on the current clinical studies. Imaging of the eye has the potential to provide a more patient-friendly biomarker tool compared to the currently established biomarkers that are either costly (MRI/PET imaging) or invasive (CSF through lumbar puncture). Although the full potential of eye imaging is still unknown at this state, research in this field is increasing and involves collaboration among disparate backgrounds of researchers (ophthalmology, neurology, pathology, technology etc.). Lastly the panel will then provide a summary of current care and suggested approaches from a provider in Neuro-Ophthalmic and rehabilitative care.
A Case Report of Venous Stasis Retinopathy
Published 2023 by Oanh Duong
Program Number: R2023226
Article Type: Residents Day
Board: R-210
Purpose:
A 79-year-old Caucasian male with diabetes mellitus type 2, anemia, hypertension, and hyperlipidemia presents with asymmetric retinopathy and Hollenhorst plaques. This case will discuss the diagnosis and management of patients with venous stasis retinopathy.
Case History:
79 y/o Caucasian male presents for a new comprehensive eye examination CC: blurred vision at distance without correction POH: cataract extraction OU ~ 5 years ago PMH: Diabetes Mellitus Type 2, Hypertension, Hyperlipidemia, Anemia, Intermittent Arrhythmia Pertinent Meds: insulin novolin, amlodipine, lisinopril, hydralazine, atenolol, atorvastatin, ferrous sulfate, aspirin 81mg Last laboratory work (2 months prior): Controlled A1C (6.1%), high glucose, low RBC/HGB/HCT
Pertinent Findings:
Initial Visit -VA: 20/20 OD/OS -Pupils: ERRL, (-)APD OU -EOMS: Full OU -VF (gross): FTFC OU -Anterior segment findings are unremarkable -IOP (GAT): 13/13 mmHg -DFE: many scattered mid-peripheral dot-blot hemes superior, inferior, and temporal with one hollenhorst plaque (HHP) along the IT arcade and another HHP superior to the ONH in the right eye; <5 dot-blot hemes in the posterior pole with no mid-peripheral dot/blot hemes in the left eye -OCT-Macula: WNL OD/OS Additional Testing -Carotid doppler: no flow in the right internal carotid artery, compatible with occlusion -Optos FA: (-)neovascularization OD
Differential Diagnosis:
Primary: Venous Stasis Retinopathy (VSR)/Ocular Ischemic Syndrome (OIS) Other: CRVO, Diabetic Retinopathy, Hypertensive Retinopathy, Anemic Retinopathy
Diagnosis & Discussion:
VSR occurs due to ocular hypoperfusion, typically from severe stenosis or occlusion of the carotid artery (1). Systemic associations often include HTN, DM, and peripheral vascular disease (2). VSR shares similar features to CRVO and diabetic retinopathy, which often masks the diagnosis. Common retinal findings include unilateral mid-peripheral dot-blot hemorrhages, dilated non-tortuous retinal veins, and narrow retinal arteries (3). When associated with anterior segment findings, the condition is classified as OIS. Serious complications such as maculopathy and neovascular glaucoma may cause severe vision loss (3). Patients often present with gradual vision loss, eye pain, and TIA symptoms (3). In this case, the patient was asymptomatic but the presence of HHP in the right eye and asymmetric retinopathy (OD>OS) is highly suspicious for VSR. A carotid doppler was ordered and confirmed the presence of severe occlusion of the proximal right ICA.
Treatment, Management:
The 5-year mortality rate in patients with OIS is 40%, with the most common causes of death being cardiac disease and stroke (4). Addressing the underlying cause is imperative to minimize systemic morbidities. Thus, the patient was referred to the vascular clinic for further management. In patients with less than 99% obstruction of the ICA, carotid endarterectomy and carotid artery stenting are common treatments (5). However, this patient has a full occlusion and medical management with ASA, control of systemic associations, and yearly surveillance with carotid duplex are recommended instead. Patients also need to be monitored frequently for serious ocular sequelae. Imaging techniques such as fluorescein angiography are useful in evaluating retinal and choroidal circulatory functions. Laser photocoagulation is recommended to treat neovascularization of the anterior and posterior segment. Intravitreal anti-vegF has been shown to be useful in treating NVG and macular edema (7).
Conclusion:
Patients with VSR/OIS often complain of gradual vision loss and/or eye pain. In asymptomatic patients who present with asymmetric retinopathy, it is imperative to rule out ICA occlusion with diagnostic radiology studies such as carotid doppler and CT angiogram. The patient's healthcare team should also be promptly notified for early management to help reduce mortality.
Purpose:
A 79-year-old Caucasian male with diabetes mellitus type 2, anemia, hypertension, and hyperlipidemia presents with asymmetric retinopathy and Hollenhorst plaques. This case will discuss the diagnosis and management of patients with venous stasis retinopathy.
Case History:
79 y/o Caucasian male presents for a new comprehensive eye examination CC: blurred vision at distance without correction POH: cataract extraction OU ~ 5 years ago PMH: Diabetes Mellitus Type 2, Hypertension, Hyperlipidemia, Anemia, Intermittent Arrhythmia Pertinent Meds: insulin novolin, amlodipine, lisinopril, hydralazine, atenolol, atorvastatin, ferrous sulfate, aspirin 81mg Last laboratory work (2 months prior): Controlled A1C (6.1%), high glucose, low RBC/HGB/HCT
Pertinent Findings:
Initial Visit -VA: 20/20 OD/OS -Pupils: ERRL, (-)APD OU -EOMS: Full OU -VF (gross): FTFC OU -Anterior segment findings are unremarkable -IOP (GAT): 13/13 mmHg -DFE: many scattered mid-peripheral dot-blot hemes superior, inferior, and temporal with one hollenhorst plaque (HHP) along the IT arcade and another HHP superior to the ONH in the right eye; <5 dot-blot hemes in the posterior pole with no mid-peripheral dot/blot hemes in the left eye -OCT-Macula: WNL OD/OS Additional Testing -Carotid doppler: no flow in the right internal carotid artery, compatible with occlusion -Optos FA: (-)neovascularization OD
Differential Diagnosis:
Primary: Venous Stasis Retinopathy (VSR)/Ocular Ischemic Syndrome (OIS) Other: CRVO, Diabetic Retinopathy, Hypertensive Retinopathy, Anemic Retinopathy
Diagnosis & Discussion:
VSR occurs due to ocular hypoperfusion, typically from severe stenosis or occlusion of the carotid artery (1). Systemic associations often include HTN, DM, and peripheral vascular disease (2). VSR shares similar features to CRVO and diabetic retinopathy, which often masks the diagnosis. Common retinal findings include unilateral mid-peripheral dot-blot hemorrhages, dilated non-tortuous retinal veins, and narrow retinal arteries (3). When associated with anterior segment findings, the condition is classified as OIS. Serious complications such as maculopathy and neovascular glaucoma may cause severe vision loss (3). Patients often present with gradual vision loss, eye pain, and TIA symptoms (3). In this case, the patient was asymptomatic but the presence of HHP in the right eye and asymmetric retinopathy (OD>OS) is highly suspicious for VSR. A carotid doppler was ordered and confirmed the presence of severe occlusion of the proximal right ICA.
Treatment, Management:
The 5-year mortality rate in patients with OIS is 40%, with the most common causes of death being cardiac disease and stroke (4). Addressing the underlying cause is imperative to minimize systemic morbidities. Thus, the patient was referred to the vascular clinic for further management. In patients with less than 99% obstruction of the ICA, carotid endarterectomy and carotid artery stenting are common treatments (5). However, this patient has a full occlusion and medical management with ASA, control of systemic associations, and yearly surveillance with carotid duplex are recommended instead. Patients also need to be monitored frequently for serious ocular sequelae. Imaging techniques such as fluorescein angiography are useful in evaluating retinal and choroidal circulatory functions. Laser photocoagulation is recommended to treat neovascularization of the anterior and posterior segment. Intravitreal anti-vegF has been shown to be useful in treating NVG and macular edema (7).
Conclusion:
Patients with VSR/OIS often complain of gradual vision loss and/or eye pain. In asymptomatic patients who present with asymmetric retinopathy, it is imperative to rule out ICA occlusion with diagnostic radiology studies such as carotid doppler and CT angiogram. The patient's healthcare team should also be promptly notified for early management to help reduce mortality.
A Case Report on Milkweed Corneal Toxicity from Asclepias Curassavica
Published 2023 by Joseph Trinh
Program Number: R2023028
Article Type: Residents Day
Board: R-12
Purpose:
A 57-year old Hispanic male with corneal toxicity after handling Asclepias curassavica, commonly known as tropical milkweed. Clinical examination revealed stellate epithelial defects, stromal edema, and endothelial folds resolved with moxifloxacin and prednisolone acetate.
Case History:
`- 57-year-old Hispanic male - CC: Constant decreased vision since rubbing eyes after cutting a plant in the morning. Constant moderate pain, burning, irritation, redness, and watery discharge. - POH: None, (-)Contact Lens - PMH: hypertension, hypercholesterolemia - Meds: lisinopril
Pertinent Findings:
Clinical Findings - BCVA OD 20/100, OS 20/100 - IOP OD 12, OS 12 Goldmann - PERRL - SLE: Diffuse conjunctival injection OU, moderate corneal endothelial folds OU, severe pinpoint staining OU, stromal edema OU - A/C deep and quiet without cells or flare
Differential Diagnosis:
Primary: milkweed toxicity Others: corneal abrasion, corneal ulcer, keratoconjunctivitis sicca, chemical keratitis, allergic/bacterial/viral conjunctivitis, uveitis, contact lens associated red eye
Diagnosis & Discussion:
The patient revealed the plant from his pocket during the examination and reported contacting his eyes shortly after handling it this morning. Tropical milkweed, Mexican butterfly weed, or Asclepias curassavica is a flowering plant belonging to the milkweed family which is known to contain cardiac glycosides, toxic compounds harmful to humans when contacting the eyes. Toxicity occurs due to their inhibitory effects on Na+/K+-ATPase enzymes in the corneal endothelium. Following contact with the plant, patients with milkweed corneal toxicity will present with pain, injection, serous discharge, foreign body sensation, and decreased vision. Clinical examination reveals conjunctival injection, corneal edema, punctate keratitis, and corneal epithelial defects. This presentation aligns with an array of differential diagnoses therefore it is imperative to obtain a detailed history of outdoor activities.
Treatment, Management:
Given the presentation of the Asclepias curassavica plant by the patient and a detailed history, he was treated for milkweed corneal toxicity. Milkweed toxicity has been documented to elicit corneal signs consistent with the clinical findings. Topical moxifloxacin 0.05% antibiotic eyedrop and prednisolone acetate 1.0% eyedrop were prescribed QID OU.� Preliminary clinical studies have shown that topical antibiotics and steroids are effective in treating Milkweed toxicity. Antibiotic prophylactically prevents infection in the presence of epithelial defects, and steroids reduce the inflammatory response. Recently studies demonstrated that steroidal treatment may increase the function of the Na+/K+-ATPase pump that was inhibited by the toxin. Three days later, BCVA improved to OD 20/25, and OS 20/30. IOP were stable at 14/16. There was trace SPK with resolution of injection and corneal edema. Moxifloxacin was discontinued and prednisolone acetate was tapered weekly until discontinued.
Conclusion:
Milkweed corneal toxicity is an important differential to consider in cases of acute ocular irritation, pain, and discomfort following exposure to milkweed family plants. It is imperative to obtain a thorough history of outdoor activities, espcially in patients that are frequently exposed to vegetation. With timely diagnosis, appropriate treatment and management can begin to ensure optimal prognosis and visual outcome.
Purpose:
A 57-year old Hispanic male with corneal toxicity after handling Asclepias curassavica, commonly known as tropical milkweed. Clinical examination revealed stellate epithelial defects, stromal edema, and endothelial folds resolved with moxifloxacin and prednisolone acetate.
Case History:
`- 57-year-old Hispanic male - CC: Constant decreased vision since rubbing eyes after cutting a plant in the morning. Constant moderate pain, burning, irritation, redness, and watery discharge. - POH: None, (-)Contact Lens - PMH: hypertension, hypercholesterolemia - Meds: lisinopril
Pertinent Findings:
Clinical Findings - BCVA OD 20/100, OS 20/100 - IOP OD 12, OS 12 Goldmann - PERRL - SLE: Diffuse conjunctival injection OU, moderate corneal endothelial folds OU, severe pinpoint staining OU, stromal edema OU - A/C deep and quiet without cells or flare
Differential Diagnosis:
Primary: milkweed toxicity Others: corneal abrasion, corneal ulcer, keratoconjunctivitis sicca, chemical keratitis, allergic/bacterial/viral conjunctivitis, uveitis, contact lens associated red eye
Diagnosis & Discussion:
The patient revealed the plant from his pocket during the examination and reported contacting his eyes shortly after handling it this morning. Tropical milkweed, Mexican butterfly weed, or Asclepias curassavica is a flowering plant belonging to the milkweed family which is known to contain cardiac glycosides, toxic compounds harmful to humans when contacting the eyes. Toxicity occurs due to their inhibitory effects on Na+/K+-ATPase enzymes in the corneal endothelium. Following contact with the plant, patients with milkweed corneal toxicity will present with pain, injection, serous discharge, foreign body sensation, and decreased vision. Clinical examination reveals conjunctival injection, corneal edema, punctate keratitis, and corneal epithelial defects. This presentation aligns with an array of differential diagnoses therefore it is imperative to obtain a detailed history of outdoor activities.
Treatment, Management:
Given the presentation of the Asclepias curassavica plant by the patient and a detailed history, he was treated for milkweed corneal toxicity. Milkweed toxicity has been documented to elicit corneal signs consistent with the clinical findings. Topical moxifloxacin 0.05% antibiotic eyedrop and prednisolone acetate 1.0% eyedrop were prescribed QID OU.� Preliminary clinical studies have shown that topical antibiotics and steroids are effective in treating Milkweed toxicity. Antibiotic prophylactically prevents infection in the presence of epithelial defects, and steroids reduce the inflammatory response. Recently studies demonstrated that steroidal treatment may increase the function of the Na+/K+-ATPase pump that was inhibited by the toxin. Three days later, BCVA improved to OD 20/25, and OS 20/30. IOP were stable at 14/16. There was trace SPK with resolution of injection and corneal edema. Moxifloxacin was discontinued and prednisolone acetate was tapered weekly until discontinued.
Conclusion:
Milkweed corneal toxicity is an important differential to consider in cases of acute ocular irritation, pain, and discomfort following exposure to milkweed family plants. It is imperative to obtain a thorough history of outdoor activities, espcially in patients that are frequently exposed to vegetation. With timely diagnosis, appropriate treatment and management can begin to ensure optimal prognosis and visual outcome.
A Case Series of Occult Macular Dystrophy
Published 2023 by Stephen Dellostritto
Co-Author(s): Sarah Gleason, Sherry Bass
Program Number: 235314
Article Type: Scientific Program
Board: 29
PURPOSE:
This case series describes three University Eye Center (UEC) patients with mild variations in phenotypic presentation of Occult Macular Dystrophy (OMD). All patients have confirmed mutations in the Retinitis Pigmentosa 1-Like 1 (RP1L1) gene. This inherited retinal disease (IRD) typically displays no fundoscopic or fundus auto-fluorescence (FAF) abnormalities and is often identified using optical coherence tomography (OCT); however, these cases display a range of fundus findings and visual acuity.
CASE REPORT:
Case 1: 62-year-old female presented for electrodiagnostic testing to rule out Stargardt's Disease. Her BCVA was 20/125 OD and 20/80 OS. External testing and anterior segment exam were unremarkable. DFE showed unremarkable optic nerve, flat and in-tact macula, and attached peripheral retina 360-degrees OU. FAF showed trace hyper-autofluorescence (AF) surrounding the macula. Macular OCT had diffuse thinning and mild photoreceptor integrity line (PIL) attenuation and disruption OU. Octopus M-Top visual field revealed central scotoma OD>OS with inferotemporal eccentric fixation. Multifocal (mf)-ERG was diffusely depressed OS>OD and worse centrally OU. Case 2: 35-year-old male presented to the UEC with a history of OMD OU. His BCVA is 20/80 OD/OS. External testing and anterior segment exam were unremarkable OU. DFE showed unremarkable optic nerves with a mild myopic tilt, flat and in-tact macula with a positive foveal reflex and attached peripheral retina 360-degrees with mild white-without-pressure OU. FAF was unremarkable. Macular OCT had mild photoreceptor PIL attenuation and disruption OU. Octopus M-Top visual field revealed small central inferonasal depression OD and moderate central scotoma OS. mfERG showed reduced responses centrally. Case 3: 65-year-old male presented to the UEC with a history of OMD and glaucoma suspicion. His BCVA is 20/200 OD/OS. External testing was unremarkable and anterior segment was positive for dry eye, arcus, and significant mixed cataracts OU. DFE displayed temporal optic nerve pallor with large cupping (0.80 OD/0.85 OS). His macula had mottling OS>OD and peripheral retina was unremarkable. FAF displayed central hyper-AF OD with central hypo-AF and surrounding hyper-AF OS. Macular OCT had mild PIL attenuation and disruption OD and central outer retinal atrophy OS. Octopus M-Top visual field revealed moderate superior paracentral depression OD and a moderate central scotoma and inferior depression OS. Full-field ERG displayed a normal cone response OU.
CONCLUSION:
Occult Macular Dystrophy is an uncommon autosomal-dominant disease associated with a mutation in the RP1L1 gene. Although individuals with this IRD typically funduscopically appear normal, there may be a phenotypic spectrum impacting visual potential. Diagnosis of this condition is heavily dependent on macular OCT, electrophysiological testing, and genetic testing.
PURPOSE:
This case series describes three University Eye Center (UEC) patients with mild variations in phenotypic presentation of Occult Macular Dystrophy (OMD). All patients have confirmed mutations in the Retinitis Pigmentosa 1-Like 1 (RP1L1) gene. This inherited retinal disease (IRD) typically displays no fundoscopic or fundus auto-fluorescence (FAF) abnormalities and is often identified using optical coherence tomography (OCT); however, these cases display a range of fundus findings and visual acuity.
CASE REPORT:
Case 1: 62-year-old female presented for electrodiagnostic testing to rule out Stargardt's Disease. Her BCVA was 20/125 OD and 20/80 OS. External testing and anterior segment exam were unremarkable. DFE showed unremarkable optic nerve, flat and in-tact macula, and attached peripheral retina 360-degrees OU. FAF showed trace hyper-autofluorescence (AF) surrounding the macula. Macular OCT had diffuse thinning and mild photoreceptor integrity line (PIL) attenuation and disruption OU. Octopus M-Top visual field revealed central scotoma OD>OS with inferotemporal eccentric fixation. Multifocal (mf)-ERG was diffusely depressed OS>OD and worse centrally OU. Case 2: 35-year-old male presented to the UEC with a history of OMD OU. His BCVA is 20/80 OD/OS. External testing and anterior segment exam were unremarkable OU. DFE showed unremarkable optic nerves with a mild myopic tilt, flat and in-tact macula with a positive foveal reflex and attached peripheral retina 360-degrees with mild white-without-pressure OU. FAF was unremarkable. Macular OCT had mild photoreceptor PIL attenuation and disruption OU. Octopus M-Top visual field revealed small central inferonasal depression OD and moderate central scotoma OS. mfERG showed reduced responses centrally. Case 3: 65-year-old male presented to the UEC with a history of OMD and glaucoma suspicion. His BCVA is 20/200 OD/OS. External testing was unremarkable and anterior segment was positive for dry eye, arcus, and significant mixed cataracts OU. DFE displayed temporal optic nerve pallor with large cupping (0.80 OD/0.85 OS). His macula had mottling OS>OD and peripheral retina was unremarkable. FAF displayed central hyper-AF OD with central hypo-AF and surrounding hyper-AF OS. Macular OCT had mild PIL attenuation and disruption OD and central outer retinal atrophy OS. Octopus M-Top visual field revealed moderate superior paracentral depression OD and a moderate central scotoma and inferior depression OS. Full-field ERG displayed a normal cone response OU.
CONCLUSION:
Occult Macular Dystrophy is an uncommon autosomal-dominant disease associated with a mutation in the RP1L1 gene. Although individuals with this IRD typically funduscopically appear normal, there may be a phenotypic spectrum impacting visual potential. Diagnosis of this condition is heavily dependent on macular OCT, electrophysiological testing, and genetic testing.
A Case Study on Non-surgical Management of Consecutive Esotropia Following Congenital Trochlear Nerve Palsy and Consecutive Exotropia
Published 2023 by Rebecca Hung
Program Number: R2023081
Article Type: Residents Day
Board: R-65
Purpose:
A child with a history of multiple strabismus surgeries for congenital right trochlear nerve palsy and consecutive exotropia underwent vision therapy for consecutive esotropia. A multifaceted approach should be considered to address binocular instability.
Case History:
`- 10-year-old Caucasian female - CC: Inward eye turn increasing in frequency. Worsens with fatigue. Reports eye strain, headache, poor depth perception, and intermittent diplopia - POH: History of strabismus surgery for congenital right trochlear nerve palsy at 9 months old, resulting in consecutive exotropia. Second strabismus surgery for exotropia at 7 years old, resulting in consecutive esotropia - History of patching with good compliance - Motivated to pursue non-surgical management
Pertinent Findings:
`- BCVA (sc): 20/20 OD, OS - Cover test (sc): 16pd IAET (OS preferred) with 2pd right hypertropia at distance; 11pd IAET (OS preferred) with 2pd right hypertropia at near - Synoptophore: Harmonious anomalous retinal correspondence (ARC) with 1st degree target. Unsteady harmonious ARC with different 2nd degree targets - Harmonious ARC on Bagolini - Bifocal spectacle rx: OD: +1.00 -0.50 x092. 5pd BO, 1pd BD OS: +0.50sph 6pd BO Add: +1.00 - Cycloplegic refraction: OD: +2.25 -0.50 x100 OS: +1.75sph - RANDOT Global Stereo: 900' - Worth-4-dot: fusion at near, intermittent OD suppression at distance - Full EOM. Concomitant on 9 positions of gaze - Eccentric fixation: unsteady central OD; steady central OS - NPC: 12cm (OD in)
Differential Diagnosis:
EOM paresis/restriction, dry eye, corneal irregularities, irregular or uncorrected astigmatism, uncorrected hyperopia, cataract
Diagnosis & Discussion:
Consecutive esotropia is defined as resulting esotropia following strabismus surgery for exotropia. Due to the tendency for exo-drift following surgery, some studies have suggested that initial overcorrection resulting in consecutive esotropia is desirable. It is unclear why some cases of consecutive esotropia are able to resolve spontaneously, or with passive treatment with prism that is tapered, to orthophoria while others persist. Cases that do persist are not favorable due to risk of cosmetic concerns or binocular vision dysfunction, such as diplopia, suppression, or amblyopia. There are few reports in the literature that have investigated the clinical course of non-surgical management of consecutive esotropia. Non-surgical management typically includes occlusion, base out ground-in or fresnel prism, vision therapy, or close monitoring. To date, the binocular system of patients with consecutive esotropia following multiple strabismus surgeries is not well understood.
Treatment, Management:
Our non-surgical treatment protocol involved a combination of vision therapy, compensatory base out and base-down prism, as well as binasal occlusion. The goals were to develop fusion with increased fusional amplitudes, eliminate anomalous sensory fusion, improve cosmesis, and avoid another strabismus surgery if possible. Clinical studies have found that vision therapy has a beneficial impact on enhancing normal sensory processing and post-surgical outcomes in patients with consecutive esotropia. However, the prognosis when complicated by a congenital trochlear nerve palsy is unclear. On initial presentation, she showed harmonious anomalous retinal correspondence (ARC), which changed to unstable unharmonious ARC (varied by target) and then normal correspondence as therapy progressed. During this transitional phase, stable binocular vision was a challenge. A mixed approach was required to treat intermittent binocular diplopia and triplopia, as well as monocular diplopia.
Conclusion:
As there are few published cases examining the prognosis of persistent consecutive esotropia following a congenital trochlear nerve palsy and multiple surgeries, there is much that remains unknown about this condition. Despite seeking vision therapy several years after her strabismus surgeries, her binocular system remained amenable to change. A combination of prism, binasal occlusion, and vision therapy should be considered to enhance binocular function.
Purpose:
A child with a history of multiple strabismus surgeries for congenital right trochlear nerve palsy and consecutive exotropia underwent vision therapy for consecutive esotropia. A multifaceted approach should be considered to address binocular instability.
Case History:
`- 10-year-old Caucasian female - CC: Inward eye turn increasing in frequency. Worsens with fatigue. Reports eye strain, headache, poor depth perception, and intermittent diplopia - POH: History of strabismus surgery for congenital right trochlear nerve palsy at 9 months old, resulting in consecutive exotropia. Second strabismus surgery for exotropia at 7 years old, resulting in consecutive esotropia - History of patching with good compliance - Motivated to pursue non-surgical management
Pertinent Findings:
`- BCVA (sc): 20/20 OD, OS - Cover test (sc): 16pd IAET (OS preferred) with 2pd right hypertropia at distance; 11pd IAET (OS preferred) with 2pd right hypertropia at near - Synoptophore: Harmonious anomalous retinal correspondence (ARC) with 1st degree target. Unsteady harmonious ARC with different 2nd degree targets - Harmonious ARC on Bagolini - Bifocal spectacle rx: OD: +1.00 -0.50 x092. 5pd BO, 1pd BD OS: +0.50sph 6pd BO Add: +1.00 - Cycloplegic refraction: OD: +2.25 -0.50 x100 OS: +1.75sph - RANDOT Global Stereo: 900' - Worth-4-dot: fusion at near, intermittent OD suppression at distance - Full EOM. Concomitant on 9 positions of gaze - Eccentric fixation: unsteady central OD; steady central OS - NPC: 12cm (OD in)
Differential Diagnosis:
EOM paresis/restriction, dry eye, corneal irregularities, irregular or uncorrected astigmatism, uncorrected hyperopia, cataract
Diagnosis & Discussion:
Consecutive esotropia is defined as resulting esotropia following strabismus surgery for exotropia. Due to the tendency for exo-drift following surgery, some studies have suggested that initial overcorrection resulting in consecutive esotropia is desirable. It is unclear why some cases of consecutive esotropia are able to resolve spontaneously, or with passive treatment with prism that is tapered, to orthophoria while others persist. Cases that do persist are not favorable due to risk of cosmetic concerns or binocular vision dysfunction, such as diplopia, suppression, or amblyopia. There are few reports in the literature that have investigated the clinical course of non-surgical management of consecutive esotropia. Non-surgical management typically includes occlusion, base out ground-in or fresnel prism, vision therapy, or close monitoring. To date, the binocular system of patients with consecutive esotropia following multiple strabismus surgeries is not well understood.
Treatment, Management:
Our non-surgical treatment protocol involved a combination of vision therapy, compensatory base out and base-down prism, as well as binasal occlusion. The goals were to develop fusion with increased fusional amplitudes, eliminate anomalous sensory fusion, improve cosmesis, and avoid another strabismus surgery if possible. Clinical studies have found that vision therapy has a beneficial impact on enhancing normal sensory processing and post-surgical outcomes in patients with consecutive esotropia. However, the prognosis when complicated by a congenital trochlear nerve palsy is unclear. On initial presentation, she showed harmonious anomalous retinal correspondence (ARC), which changed to unstable unharmonious ARC (varied by target) and then normal correspondence as therapy progressed. During this transitional phase, stable binocular vision was a challenge. A mixed approach was required to treat intermittent binocular diplopia and triplopia, as well as monocular diplopia.
Conclusion:
As there are few published cases examining the prognosis of persistent consecutive esotropia following a congenital trochlear nerve palsy and multiple surgeries, there is much that remains unknown about this condition. Despite seeking vision therapy several years after her strabismus surgeries, her binocular system remained amenable to change. A combination of prism, binasal occlusion, and vision therapy should be considered to enhance binocular function.
A Case of Bilateral Panuveitis and Papillitis Due to Sarcoidosis
Published 2023 by Melissa Joy
Program Number: 235327
Article Type: Scientific Program
Board: 42
PURPOSE:
Ocular manifestations of sarcoidosis can present inside the eye as anterior, intermediate, posterior, or panuveitis. Rarely, optic nerve involvement can be a finding. The purpose of this poster is to remind clinicians why sarcoidosis is traditionally included in a uveitis work-up and that uveitis does not always manifest with painful, red eyes.
CASE REPORT:
A 69 year-old Caucasian male presented for a routine exam with a complaint of seeing floaters for 2-3 weeks. He also noticed that his vision was not as clear shortly after his 2nd COVID-19 vaccination. His ocular history includes bilateral optic nerve drusen which have been routinely monitored for years with normal visual acuities, color vision, OCT RNFL, and visual field testing. Upon presentation, he denied any eye pain, redness, or photosensitivity. His best corrected vision was 20/25+2 in the right eye and 20/25-2 in the left eye along with reduced color vision. Slit lamp examination revealed 2+ diffuse keratic precipitates and 1+ cells in the anterior chamber in both eyes. Dilated fundus examination showed elevated, hyperemic optic nerves with adjacent hemorrhages and indistinct disc margins in both eyes and subretinal deposits in the right eye. There were vitreous cells and vitreous balls with scattered peripheral retinal hemorrhages in both eyes. The patient was evaluated by a retina and uveitis provider on the same day for further work-up. He was diagnosed with bilateral panuveitis with papillitis. An extensive lab and imaging work-up have since been performed. Fluorescein angiography showed some small vessel leakage consistent with an inflammatory process. HVF testing showed bilateral defects. A CT scan of the head had evidence of elevated intracranial elevation. Opening pressure was unable to be obtained on lumbar puncture due to sluggish flow of CSF but some WBCs were detected. MRI of the brain, spine and orbits were unremarkable. While quantiferon gold was negative, a CT scan of the chest showed pulmonary nodules concerning for sarcoidosis. The Pulmonary Department was consulted and has a working diagnosis of presumed sarcoidosis. The patient's presenting panuveitis and subsequent multiple anterior uveitis flare-ups were treated with topical steroids. New subretinal fluid in the left eye was treated with oral steroids.
CONCLUSION:
It is important for eye care providers to understand that sarcoidosis can affect any part of the eye and its manifestations in the eye may not present with the typical eye pain associated with uveitis. A careful and thorough evaluation of the eye, followed by a prompt referral to specialists is important to help not only the eye health but systemic health as well. Proper diagnosis requires a thorough work-up to rule out infectious and inflammatory etiologies.
PURPOSE:
Ocular manifestations of sarcoidosis can present inside the eye as anterior, intermediate, posterior, or panuveitis. Rarely, optic nerve involvement can be a finding. The purpose of this poster is to remind clinicians why sarcoidosis is traditionally included in a uveitis work-up and that uveitis does not always manifest with painful, red eyes.
CASE REPORT:
A 69 year-old Caucasian male presented for a routine exam with a complaint of seeing floaters for 2-3 weeks. He also noticed that his vision was not as clear shortly after his 2nd COVID-19 vaccination. His ocular history includes bilateral optic nerve drusen which have been routinely monitored for years with normal visual acuities, color vision, OCT RNFL, and visual field testing. Upon presentation, he denied any eye pain, redness, or photosensitivity. His best corrected vision was 20/25+2 in the right eye and 20/25-2 in the left eye along with reduced color vision. Slit lamp examination revealed 2+ diffuse keratic precipitates and 1+ cells in the anterior chamber in both eyes. Dilated fundus examination showed elevated, hyperemic optic nerves with adjacent hemorrhages and indistinct disc margins in both eyes and subretinal deposits in the right eye. There were vitreous cells and vitreous balls with scattered peripheral retinal hemorrhages in both eyes. The patient was evaluated by a retina and uveitis provider on the same day for further work-up. He was diagnosed with bilateral panuveitis with papillitis. An extensive lab and imaging work-up have since been performed. Fluorescein angiography showed some small vessel leakage consistent with an inflammatory process. HVF testing showed bilateral defects. A CT scan of the head had evidence of elevated intracranial elevation. Opening pressure was unable to be obtained on lumbar puncture due to sluggish flow of CSF but some WBCs were detected. MRI of the brain, spine and orbits were unremarkable. While quantiferon gold was negative, a CT scan of the chest showed pulmonary nodules concerning for sarcoidosis. The Pulmonary Department was consulted and has a working diagnosis of presumed sarcoidosis. The patient's presenting panuveitis and subsequent multiple anterior uveitis flare-ups were treated with topical steroids. New subretinal fluid in the left eye was treated with oral steroids.
CONCLUSION:
It is important for eye care providers to understand that sarcoidosis can affect any part of the eye and its manifestations in the eye may not present with the typical eye pain associated with uveitis. A careful and thorough evaluation of the eye, followed by a prompt referral to specialists is important to help not only the eye health but systemic health as well. Proper diagnosis requires a thorough work-up to rule out infectious and inflammatory etiologies.
A Case of Bullous Keratopathy due to Phakic Implantable Contact Lenses
Published 2023 by Alyssa Calta
Program Number: R2023022
Article Type: Residents Day
Board: R-6
Purpose:
A patient with bilateral iris-clipped anterior chamber implantable contact lenses (ICL) develops unilateral corneal bullae years after surgery. Acute symptoms improve with topical therapy, but future surgery will likely be required.
Case History:
•A 48-year-old Caucasian female •CC: Referred by a local optometrist for a corneal evaluation. Symptoms include redness and scratchiness of the left eye for 2 weeks •POH: Soft contact lenses wearer, refractive surgery- ICL implantation OU in 2006, ICL repositioning OD in 2006, ICL repositioned OS 2011, high myopia (-14 D) prior to lens implantation. •PMH: classic migraines •Meds: propranolol ER, sumatriptan
Pertinent Findings:
Clinical • BCVA OD: 20/30+2; PH 20/25+2 BCVA OS: 20/30-1; PH 20/25+1 • IOP: 20 OD, unable OS due to patient anxiety • Anterior segment findings: o Cornea: OD: clear OS: nasal microcystic edema with early bullae sparing the visual axis o Anterior Chamber OD: Iris-clipped ICL OS: Iris-clipped ICL displaced anteriorly and inferonasal Ancillary Testing • Specular Microscopy OD: Normal morphology (1870 cells/mm2) OS: low cell density (unable to quantitate) •Anterior segment OCT OS: Bullous keratopathy with ICL in the anterior chamber
Differential Diagnosis:
• Bullous keratopathy due to ICL dislocation • Bullous keratopathy due to trauma during ICL procedure • Fuch's endothelial dystrophy • Posterior polymorphous dystrophy • ICE syndrome
Diagnosis & Discussion:
For patients whose refractive error cannot be fully corrected by laser procedures, phakic intraocular lens (pIOL) implants have been utilized for a few decades to provide exceptional vision.1 The iris-clipped Verisyse or posterior chamber placed Visian are both examples of pIOLs.2 A common complication of pIOL implantation is endothelial cell loss.1 There may be a higher risk for cell loss with the Verisyse lens over the Visian, though most studies present conflicting data.2 Different hypotheses for endothelial cell loss in patients with pIOLs include the proximity of the implanted lens to the endothelium or excessive trauma during surgery.2 The asymmetric loss of cells in the patient suggests that the left lens displacement may be the cause of bullae. Data on Verisyse dislocation rates is limited. Regardless of the cause of cell loss, endothelial density should be closely monitored in patients with pIOLs, especially when decades of functional cells and corneal clarity are needed.
Treatment, Management:
The patient started Muro 128 ointment at night and prednisolone acetate 1% drops four times a day in the left eye to reduce corneal swelling and inflammation. The patient responded well and presented with minimal microcystic edema at the follow-up appointment. Additional treatment options discussed included continuing the current regimen, starting Muro drops 4 times a day, a sub-tenon's Kenalog injection, off-label use of Rho-kinase inhibitors, and a future need for an endothelial corneal transplant with possible extraction of the pIOL. Sub-tenon's Kenalog injection was performed for effective edema control and longer duration of action. The patient will consider Rho-kinase inhibitor (ripudasil, Kowa pharmaceuticals, Japan) via FDA compassionate use exemption. Ripudasil has been shown to promote endothelial cell proliferation and wound healing.3,4 An endothelial keratoplasty may be indicated in the future if corneal decompensation and a significant decrease in vision occur.
Conclusion:
The possibility of endothelial cell loss should be considered prior to any intraocular surgery, especially with implantable lenses. Patients should be fully informed of any risks associated with pIOLs. Endothelial cell density must be monitored to avoid corneal edema, bullous keratopathy, or decompensation. If endothelium is compromised, treatment options are available including topical medications to reduce signs and symptoms, and endothelial keratoplasty with great optical outcomes.
Purpose:
A patient with bilateral iris-clipped anterior chamber implantable contact lenses (ICL) develops unilateral corneal bullae years after surgery. Acute symptoms improve with topical therapy, but future surgery will likely be required.
Case History:
•A 48-year-old Caucasian female •CC: Referred by a local optometrist for a corneal evaluation. Symptoms include redness and scratchiness of the left eye for 2 weeks •POH: Soft contact lenses wearer, refractive surgery- ICL implantation OU in 2006, ICL repositioning OD in 2006, ICL repositioned OS 2011, high myopia (-14 D) prior to lens implantation. •PMH: classic migraines •Meds: propranolol ER, sumatriptan
Pertinent Findings:
Clinical • BCVA OD: 20/30+2; PH 20/25+2 BCVA OS: 20/30-1; PH 20/25+1 • IOP: 20 OD, unable OS due to patient anxiety • Anterior segment findings: o Cornea: OD: clear OS: nasal microcystic edema with early bullae sparing the visual axis o Anterior Chamber OD: Iris-clipped ICL OS: Iris-clipped ICL displaced anteriorly and inferonasal Ancillary Testing • Specular Microscopy OD: Normal morphology (1870 cells/mm2) OS: low cell density (unable to quantitate) •Anterior segment OCT OS: Bullous keratopathy with ICL in the anterior chamber
Differential Diagnosis:
• Bullous keratopathy due to ICL dislocation • Bullous keratopathy due to trauma during ICL procedure • Fuch's endothelial dystrophy • Posterior polymorphous dystrophy • ICE syndrome
Diagnosis & Discussion:
For patients whose refractive error cannot be fully corrected by laser procedures, phakic intraocular lens (pIOL) implants have been utilized for a few decades to provide exceptional vision.1 The iris-clipped Verisyse or posterior chamber placed Visian are both examples of pIOLs.2 A common complication of pIOL implantation is endothelial cell loss.1 There may be a higher risk for cell loss with the Verisyse lens over the Visian, though most studies present conflicting data.2 Different hypotheses for endothelial cell loss in patients with pIOLs include the proximity of the implanted lens to the endothelium or excessive trauma during surgery.2 The asymmetric loss of cells in the patient suggests that the left lens displacement may be the cause of bullae. Data on Verisyse dislocation rates is limited. Regardless of the cause of cell loss, endothelial density should be closely monitored in patients with pIOLs, especially when decades of functional cells and corneal clarity are needed.
Treatment, Management:
The patient started Muro 128 ointment at night and prednisolone acetate 1% drops four times a day in the left eye to reduce corneal swelling and inflammation. The patient responded well and presented with minimal microcystic edema at the follow-up appointment. Additional treatment options discussed included continuing the current regimen, starting Muro drops 4 times a day, a sub-tenon's Kenalog injection, off-label use of Rho-kinase inhibitors, and a future need for an endothelial corneal transplant with possible extraction of the pIOL. Sub-tenon's Kenalog injection was performed for effective edema control and longer duration of action. The patient will consider Rho-kinase inhibitor (ripudasil, Kowa pharmaceuticals, Japan) via FDA compassionate use exemption. Ripudasil has been shown to promote endothelial cell proliferation and wound healing.3,4 An endothelial keratoplasty may be indicated in the future if corneal decompensation and a significant decrease in vision occur.
Conclusion:
The possibility of endothelial cell loss should be considered prior to any intraocular surgery, especially with implantable lenses. Patients should be fully informed of any risks associated with pIOLs. Endothelial cell density must be monitored to avoid corneal edema, bullous keratopathy, or decompensation. If endothelium is compromised, treatment options are available including topical medications to reduce signs and symptoms, and endothelial keratoplasty with great optical outcomes.
A Case of Diffuse Corneal Endotheliitis Secondary to Suspected HSV in a 14-Year-Old, Complicated by Concurrent Peripheral Infiltrate
Published 2023 by Heidi Volos
Program Number: R2023089
Article Type: Residents Day
Board: R-73
Purpose:
A 14-year-old with diffuse corneal endotheliitis linked to suspected HSV, compounded by a concurrent peripheral infiltrate. Rare subtype presents distinct challenges in diagnosis and management, emphasizing prompt intervention to prevent scarring.
Case History:
● Patient demographics: 14-year-old Asian female ● Chief complaint: Pain, redness, photophobia, and blur OS ● Ocular history: Previously diagnosed as corneal abrasion in Urgent Care, given Tobramycin ointment without improvement. Uses daily disposable contact lenses, denies poor CL hygiene and ocular trauma. ● Medical history: None ● Medications: Erythromycin ointment QID OS ● Other salient information: Patient denies upper respiratory infections, fever, malaise. No cutaneous lesions visible.
Pertinent Findings:
VAcc: OD: 20/25-2 OS: 20/200 Pupils: PERRL OU (-) APD IOP: OD:23 OS: 18 by ICare 4:30pm Anterior Segment: OD unremarkable. OS findings as follows: ● Adnexa: No lesions present ● Lids/Lashes: mild thickening ● Conjunctiva: 3+ bulbar injection 360 degrees. 2+ mixed papillary reaction. ● Cornea: 2mm peripheral infiltrate at 10:00 with trace epithelial defect overlying. 2-3+ diffuse pancorneal stromal edema with marked endothelial folds. Small to moderate sized keratic precipitates on inferior endothelium. ● Anterior Chamber: Unable to assess given marked corneal edema. Cell and flare likely present. ● Iris: Round and sluggish ● Lens: Clear to extent seen ● Vitreous: Clear to extent seen ● Fundus: Normal to extent seen
Differential Diagnosis:
● Diffuse Corneal Endotheliitis, secondary to HSV ● Corneal Interstitial Keratitis, secondary to HSV ● Multiple Parallel-Line Endotheliitis (MPLE) ● Contact Lens related Corneal Infiltrate
Diagnosis & Discussion:
Corneal Endotheliitis presents with edema, keratic precipitates(KP), and anterior chamber reaction often triggered by HSV1. Categorized into linear, sectorial, disciform, and diffuse, classified by inflammation distribution and pattern of KP. Disciform, the most common, has round stromal shaped edema. Linear has peripheral edema with linear KP, while sectorial has focal edema. Diffuse, the rarest subtype, has pancorneal edema with suspected viral shedding in the anterior chamber2. Marginal Parallel Linear Endotheliitis may be a mild HSV infection with limited inflammation and Interstitial Keratitis typically has stromal neovascularization3. Anterior chamber-associated immune deviation (ACAID) is the proposed mechanism of progression by suppressing cell-mediated immunity's delayed-type hypersensitivity, enabling latent virus proliferation and shedding. Peripheral infiltrate absence in HSV-mediated endotheliitis suggests an unrelated finding, likely linked to daily contact lens use.
Treatment, Management:
Patient was treated with Vigamox 0.5% TID OS x 7 days, PredForte 1% QID OS x 14 days, and Valacyclovir 500mg tablet 1 tab po BID x 14 days. Corneal scarring and opacity can arise due to stromal collagen remodeling, underscoring the urgency of early diagnosis and management for favorable long-term visual outcomes. Findings from the Herpetic Eye Disease Study(HEDS) highlight the significance of topical corticosteroids in addressing stromal or endothelial edema. Additionally, oral antivirals contribute to a 50% reduction in stromal recurrence by decreasing systemic viral load when used for prophylactic care.5 Concurrent epithelial defects, whether associated with HSV keratitis or other comorbidities, necessitate treatment with topical antibiotics, pseudomonas coverage should be used in Individuals who wear contact lenses. Furthermore, when selecting antiviral treatment, Valacyclovir may offer advantages over acyclovir, with enhanced bioavailability and reduced dosing frequency.5
Conclusion:
Characterizing edema and KP distribution patterns aid in subtype identification of corneal endotheliitis. Treatment involves antivirals and corticosteroids for stromal/endothelial involvement. Prompt therapy is crucial to prevent stromal scarring. Blood HSV titers might not aid in diagnosis given ubiquitous nature, however, aqueous humor testing6 and In vivo confocal microscopy (IVCM) may allow for early detection of endothelial alterations and presence of intraocular viral proliferation7.
Purpose:
A 14-year-old with diffuse corneal endotheliitis linked to suspected HSV, compounded by a concurrent peripheral infiltrate. Rare subtype presents distinct challenges in diagnosis and management, emphasizing prompt intervention to prevent scarring.
Case History:
● Patient demographics: 14-year-old Asian female ● Chief complaint: Pain, redness, photophobia, and blur OS ● Ocular history: Previously diagnosed as corneal abrasion in Urgent Care, given Tobramycin ointment without improvement. Uses daily disposable contact lenses, denies poor CL hygiene and ocular trauma. ● Medical history: None ● Medications: Erythromycin ointment QID OS ● Other salient information: Patient denies upper respiratory infections, fever, malaise. No cutaneous lesions visible.
Pertinent Findings:
VAcc: OD: 20/25-2 OS: 20/200 Pupils: PERRL OU (-) APD IOP: OD:23 OS: 18 by ICare 4:30pm Anterior Segment: OD unremarkable. OS findings as follows: ● Adnexa: No lesions present ● Lids/Lashes: mild thickening ● Conjunctiva: 3+ bulbar injection 360 degrees. 2+ mixed papillary reaction. ● Cornea: 2mm peripheral infiltrate at 10:00 with trace epithelial defect overlying. 2-3+ diffuse pancorneal stromal edema with marked endothelial folds. Small to moderate sized keratic precipitates on inferior endothelium. ● Anterior Chamber: Unable to assess given marked corneal edema. Cell and flare likely present. ● Iris: Round and sluggish ● Lens: Clear to extent seen ● Vitreous: Clear to extent seen ● Fundus: Normal to extent seen
Differential Diagnosis:
● Diffuse Corneal Endotheliitis, secondary to HSV ● Corneal Interstitial Keratitis, secondary to HSV ● Multiple Parallel-Line Endotheliitis (MPLE) ● Contact Lens related Corneal Infiltrate
Diagnosis & Discussion:
Corneal Endotheliitis presents with edema, keratic precipitates(KP), and anterior chamber reaction often triggered by HSV1. Categorized into linear, sectorial, disciform, and diffuse, classified by inflammation distribution and pattern of KP. Disciform, the most common, has round stromal shaped edema. Linear has peripheral edema with linear KP, while sectorial has focal edema. Diffuse, the rarest subtype, has pancorneal edema with suspected viral shedding in the anterior chamber2. Marginal Parallel Linear Endotheliitis may be a mild HSV infection with limited inflammation and Interstitial Keratitis typically has stromal neovascularization3. Anterior chamber-associated immune deviation (ACAID) is the proposed mechanism of progression by suppressing cell-mediated immunity's delayed-type hypersensitivity, enabling latent virus proliferation and shedding. Peripheral infiltrate absence in HSV-mediated endotheliitis suggests an unrelated finding, likely linked to daily contact lens use.
Treatment, Management:
Patient was treated with Vigamox 0.5% TID OS x 7 days, PredForte 1% QID OS x 14 days, and Valacyclovir 500mg tablet 1 tab po BID x 14 days. Corneal scarring and opacity can arise due to stromal collagen remodeling, underscoring the urgency of early diagnosis and management for favorable long-term visual outcomes. Findings from the Herpetic Eye Disease Study(HEDS) highlight the significance of topical corticosteroids in addressing stromal or endothelial edema. Additionally, oral antivirals contribute to a 50% reduction in stromal recurrence by decreasing systemic viral load when used for prophylactic care.5 Concurrent epithelial defects, whether associated with HSV keratitis or other comorbidities, necessitate treatment with topical antibiotics, pseudomonas coverage should be used in Individuals who wear contact lenses. Furthermore, when selecting antiviral treatment, Valacyclovir may offer advantages over acyclovir, with enhanced bioavailability and reduced dosing frequency.5
Conclusion:
Characterizing edema and KP distribution patterns aid in subtype identification of corneal endotheliitis. Treatment involves antivirals and corticosteroids for stromal/endothelial involvement. Prompt therapy is crucial to prevent stromal scarring. Blood HSV titers might not aid in diagnosis given ubiquitous nature, however, aqueous humor testing6 and In vivo confocal microscopy (IVCM) may allow for early detection of endothelial alterations and presence of intraocular viral proliferation7.
page 1 from 2303 next page →