"Doctor, I See a Spot in my Vision"
Published 2022 by Eun Jung Kim
Program Number: R2022253
Article Type: Residents Day
Board: 235
Abstract:
The purpose of this case report is to increase awareness of subtle or asymptomatic BRAO to properly diagnose, detect and manage patients with BRAO.
Case History:
--A 73 year old female presented for evaluation of new floaters in the right eye since 4 days ago.
--Pt reported seeing a new gray spot in the vision and it has a silver light around to it.
--She also stated that she sees squiggly lines in the right eye.
--Her medical history was remarkable for HTN, cholesterol and previous history of Hollenhorst plaque in the right eye.
Pertinent Findings:
--Unaided VA 20/20 OD 20/25 OS
--External examinations of Pupils, EOMS, CVF were normal in both eyes
--Amsler grid revealed inferior scotoma OD and normal OS
--IOP was WNL OU
--Anterior slit lamp examination revealed temporal pinguecula and 1+ guttatae in both eyes. Iris and anterior chamber were clear; PCIOL was in good position in both eyes.
--Fundus examination revealed PVD in both eyes; optic nerves and macula were normal in both eyes
--Retinal vessels appeared normal in both eyes
--There was no sign of plaque or emboli in both eyes
--However there was a very small and faint whitish area superior to macula in the right eye
Differential Diagnosis:
--BRAO
--CRAO
--AAION
--NAION
Diagnosis & Discussion:
Diagnosis: BRAO
--It was important that in this case, the patient had signs/symptoms that were mostly related to PVD. However the diagnosis was BRAO.
--It was challenging to diagnose BRAO due mild signs and vague symptoms.
--Chief complaint of floaters is not always a vitreous problem.
--Fundus photos were obtained for each eye, and retinal whitening in the right eye was easier to appreciate when compared to the left eye.
Treatment, Management:
--Carotid ultrasound was ordered, which revealed 50% of blockage
--Antiplatelet therapy was initiated
--Stroke work up is appropriate, especially in patient with HTN, DM and cholesterol
--Intravitreal anti-VEGF therapy may be needed for neovasuclar complications
--Close monitoring is needed
--Pt will come back for VF 24-2 OU at the next follow up
Conclusion:
--Patients chief complaint of floaters is not always due to PVD
--BRAO can be subtle but is a worrisome finding due to possibility of stroke or ischemic event. We must be aware of the causes and effects of BRAO. Even though it can be very subtle it can have major health and visual issues when not properly worked up
--Further stroke work up should be done. BRAO often occurs in older age population with predisposing factors of HTN, DM and cholesterol
--Careful retinal exam, case history and ocular findings are necessary to make the diagnosis
--OCT can be used as an alternative investigation tool to aid the diagnosis
Bibliography:
Hayreh, S. S., & Zimmerman, M. B. (2014). Branch retinal vein occlusion. JAMA Ophthalmology, 132(1), 13. https://doi.org/10.1001/jamaophthalmol.2013.5515
10 Common Misconceptions in Myopia Management
Published 2022 by Maria Liu
Article Type: Lectures & Workshops
COPE ID: 79648-GO
1. Be able to understand the intricate association between axial length and refraction‚ the critical influencing factors and its clinical implications.
2. Be able to objectively and systematically interpret the efficacy results from various studies‚ the major factors contributing to the individual variability of treatment efficacy‚ and how to reliably apply the findings in daily practice.
3. Be familiar with the proposed anti-myopia mechanisms of various treatment options‚ the plausibility and the flaw in each hypothesis‚ and the potential implication on treatment customization.
Myopia management is one of the fastest growing specialties in our field, with many studies published in the recent years. However the rigid interpretation and application of some key findings from various studies are concerning. The course will discuss 10 critical findings from myopia studies involving both animal models and human subjects that are commonly mis-presented or mis-interpreted that have significant implications on the clinical management of progressive myopia.
Learning Objectives:1. Be able to understand the intricate association between axial length and refraction‚ the critical influencing factors and its clinical implications.
2. Be able to objectively and systematically interpret the efficacy results from various studies‚ the major factors contributing to the individual variability of treatment efficacy‚ and how to reliably apply the findings in daily practice.
3. Be familiar with the proposed anti-myopia mechanisms of various treatment options‚ the plausibility and the flaw in each hypothesis‚ and the potential implication on treatment customization.
12-year Old Patient with Bilateral Optic Nerve Pallor and Latent Nystagmus in the Presence of a Novel HUWE1 Gene Variant and Cerebral Palsy
Published 2022 by Lakshmisahithi Rani
Program Number: R2022176
Article Type: Residents Day
Board: 158
Abstract:
A patient with Cerebral Palsy (CP) and HUWE1 variant, a rare gene disorder, presents with multiple ocular conditions. Since both conditions have widespread systemic effects, pinpointing the etiology of the ocular manifestations can be difficult.
Case History:
12 y/o Hispanic male with a history of cerebral palsy and a recent diagnosis of HUWE1 variant complaining of:
-Poor ability to visualize his environment and surroundings
-Nystagmus OU, pt’s mother has noticed it since birth
-Eye turned in OD
Medical History:
-Diagnosed with HUWE1 gene variant by clinical geneticist
-Moderate Intellectual disability
-Plagiocephaly
-Seizures
-Cerebral Palsy
-Speech delay, patient is non-verbal
-Short stature, low overall weight, and low muscle tone
Educational History:
-IEP in place with OT, PT, Speech Services
-7:2 classroom setting, has a teacher for the visually impaired, will be learning Braille in September 2022
Pertinent Findings:
-Facial features: Short palpebral fissures, deep set eyes
-Uncorrected VA OU: 20/130 using Teller Acuity Cards at 55cm
-Nystagmus: OU fixation shows latent nystagmus OD worse than OS, left beat
-Pupils: Sluggish constriction OD>OS, unable to assess APD
-CVF: Unable to assess
-Cover Test: Large angle constant right esotropia at distance and near without correction
-Cycloplegic Retinoscopy:
OD: +1.00-2.00x180
OS: +1.00-2.00x180
-Ocular Health: Bilateral temporal pallor with distinct margins
-VEP: Responsive to 4Hz on Flash VEP with 100ms latency (no delays)
Differential Diagnosis:
The leading diagnosis for the patient’s primary ocular findings is Cerebral Palsy. Other causes of optic nerve pallor include hypoxia, ischemia, infections, and toxins affecting the optic nerve. Other differentials for nystagmus include infantile nystagmus syndrome, albinism, aniridia, Leber’s, and ROP.
Facial characteristics such as shortened palpebral fissures and deep set eyes can be associated with HUWE1, as in the case of this patient, or in other genetic variants such as Down’s Syndrome. Systemic findings of the patient, such as the patient’s small stature and low weight can be attributed to conditions such as hypothyroidism or growth hormone deficiencies, but is common in patients with a HUWE1 variant.
Diagnosis & Discussion:
This patient has both Cerebral Palsy and a rare HUWE1 gene variant, both responsible for numerous systemic and ocular findings. Cerebral Palsy, affecting 1-4 per 1000 children, is a group of disorders that affect muscle tone, movement, and posture and is often associated with an intellectual disability. The cause of CP is thought to be due to damage to the developing shortly before, during, or after the birth of a baby. The most common ocular manifestations of CP include nystagmus, strabismus, optic atrophy or pallor, and cortical visual impairment, all except for the CVI are present in this patient.
HUWE1 variants and rearrangements are associated with X-linked intellectual disability, delayed or absent speech, small stature, deep set eyes, and short palpebral fissures. While the exact number of patients affected is unknown, the DECIPHER database has identified 51 open-access patients matching this gene. This patient has an intellectual disability, absent speech, small stature, deep set eyes, and short palpebral fissures.
Treatment, Management:
Management of Cerebral Palsy as well as a genetic condition such as HUWE1 involves managing the ocular manifestations along with co-management with the PCP. For this patient, we will continue to monitor the patient’s temporal optic nerve pallor as well as obtain regular VEPs to observe any changes in visual potential. Given the result from the last VEP as well as OU VA of 20/130, the patient’s mother was educated that the patient has some visual potential, although it is difficult to know the exact extent to his functional vision.
As the patient continues to receive OT, PT, and services from the Teacher for the Visually Impaired, further referrals to the Low Vision clinic can also be made. After visual potential is identified, the patient can also be given spectacle correction to continue to improve visual function. The patient’s mother’s chief complaint of if the patient had the potential to visualize and see his surroundings was discussed and addressed.
Conclusion:
This case illustrates that it is important to consider all comorbidities that are relevant to the patient’s ocular findings. In addition to CP, this patient had HUWE 1 which explained some traits that were not features of CP. Since HUWE1 variants are so rare, more information may be available in the future that may help associate some of the ocular findings in this case with HUWE1 vs CP.
Bibliography:
Moortgat, Stéphanie, et al. 'HUWE1 variants cause dominant X-linked intellectual disability: a clinical study of 21 patients.' European Journal of Human Genetics 26.1 (2018): 64-74.
Penix, Kimberly, Mark W. Swanson, and Dawn K. DeCarlo. 'Nystagmus in pediatric patients: interventions and patient-focused perspectives.' Clinical Ophthalmology (Auckland, NZ) 9 (2015): 1527.
Krigger, Karen W. 'Cerebral palsy: an overview.' American family physician 73.1 (2006): 91-100.
Marasini, Sanjay, et al. 'Ocular manifestations in children with cerebral palsy.' Optometry and Vision Development 42.3 (2011): 178.
2022: The Optometric Year in Review
Published 2022 by Jacob Lang
Co-Author(s): Roya Habibi, Jaclyn Garlich, Mark Buboltz
Article Type: Lectures & Workshops
COPE ID: 79401-GO
• To discuss the new releases and expected releases of new therapeutics and drugs in eyecare.
• To discuss the new surgical options in cataract‚ retina‚ and glaucoma including MIGS
• To discuss new contact lens options available for doctors including myopia control contacts
This presentation is truly a rapid-fire rundown of all the major releases, headlines, and updates to the optometric world in 2022. Discussion will focus on the new innovations and changes in therapeutics and treatment options that effect the ways optometrists’ practice. Topics of focus will include medical and surgical glaucoma therapies, ocular surface disease treatment options, cataract surgery advancements, as well as new drugs, contact lenses, and other optometric advancements.
Learning Objectives:• To discuss the new releases and expected releases of new therapeutics and drugs in eyecare.
• To discuss the new surgical options in cataract‚ retina‚ and glaucoma including MIGS
• To discuss new contact lens options available for doctors including myopia control contacts
6 year-old boy with Bilateral Central Persistent Pupillary Membrane with Concurrent Anterior and Posterior Colobomas
Published 2022 by Evelyne Mechas
Program Number: R2022003
Article Type: Residents Day
Abstract:
A 6-year old Vietnamese boy presents with bilateral dense, central persistent pupillary membrane with concurrent inferonasal iris, lens, and chorioretinal coloboma. Optical iridectomy and pupillary membranectomy is performed for further visual rehabilitation.
Case History:
A 6-year-old Vietnamese boy presented to Bascom Palmer Eye Institute for evaluation of bilateral decreased vision and congenital pupillary anomalies. He was born at 38 weeks with no pregnancy or delivery complications; he had no pertinent medical history, took no medications, and met all developmental milestones. Family ocular history revealed possible similar “iris defects” in his paternal grandmother.
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Pertinent Findings:
Patient presented BCVA OD 20/70 and OS 20/60, minimal reactive pupils, and no APD. Inferior-nasal iris keyhole, dense central persistent pupillary membrane, lens coloboma, cortical changes, anterior capsule pigment, and inferior-nasal chorioretinal coloboma.
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Differential Diagnosis:
The leading diagnosis was bilateral central persistent pupillary membranes with concurrent anterior and posterior coloboma. Differentials for congenital pupillary abnormalities include congenital polycoria or microcoria, Axenfeld-Rieger syndrome, and other anterior segment dysgeneses.
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Diagnosis & Discussion:
A young healthy male with no systemic disease presented with bilateral persistent pupillary membrane and a complete coloboma. Embryologically, this case involves bilateral maldevelopment of both anterior and posterior structures. A population-based study including 33 children with colobomas, only 3 children reported having both anterior and posterior colobomas in both eyes.1 A retrospective study involving 72 patients with uveal colobomas suggested that maldevelopment of neural crest cells appears to be responsible for the association between ocular and systemic anomalies.3
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Treatment, Management:
A 1.5-mm pupil opening is necessary for adequate retinal stimulation and visual cortex development.2 Though able to develop moderate vision through the iris coloboma, surgical intervention with optical iridectomy and pupillary membranectomy was advised for subsequent refractive amblyopia given the irregular retinoscopy reflex through the peripheral iris coloboma and lens equator. Cycloplegic refraction for glasses and subsequent amblyopia therapy was performed at postoperative month one. Genetic testing pending.
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Conclusion:
Concurrent dense bilateral central PPM complete coloboma has not yet been reported. This case highlights the unique feature that the iris colobomas created a visual axis, however irregular, outside the PPM that ultimately allowed for visual development. Comprehensive ocular and systemic examination is necessary to rule out associated syndromes and other comorbidities limiting visual prognosis. A population-based study describing ocular and systemic conditions associated with colobomas diagnosed 2/3 with a non-ocular disorder, including developmental delay in 1/3 and CHARGE syndrome in 12% of patients.1 Early surgical intervention followed by appropriate amblyopia therapy is safe and effective to achieve best visual prognosis for these congenital anomalies.
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Bibliography:
1. BG;, Nakamura KM;Diehl NN;Mohney. Incidence, Ocular Findings, and Systemic Associations of Ocular Coloboma: A Population-Based Study. https://pubmed.ncbi.nlm.nih.gov/21220631/.
2. HJ;, Huang YT;Lin. “Long Term Surgical Outcome for Persistent Pupillary Membranes with Associated Ocular Abnormalities: A Retrospective Case Series Study.” BMC Ophthalmology, U.S. National Library of Medicine, https://pubmed.ncbi.nlm.nih.gov/34034692/.
3. Ozeki, Hironori, et al. Maldevelopment of Neural Crest Cells in Patients with Typical Uveal Coloboma. 1 Nov. 1999, https://journals.healio.com/doi/abs/10.3928/0191
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A CHANGE IN HEALTH CARE POLICY CHANGES ACCESS TO VISION CARE IN SAN MATEO COUNTY, CALIFORNIA
Published 2022 by Doug Major
Program Number: 225155
Article Type: Scientific Program
Board: 155
Purpose:
INTRODUCTION: In January 2020, the California Department of Healthcare Services (DHCS) enacted a policy requiring all eyecare providers in San Mateo County to use the California Prison Industrial Authority (CALPIA) to fill all optical lens prescriptions for all Medi-Cal patients. This change provides a unique opportunity to observe the effect of healthcare policy on usage, access to care, and provider consequences. A survey was completed by each eye care practice in the county and CALPIA provided a usage report. The survey and prescription fulfillment data demonstrate how health care policy can lead to the collapse of access to vision care and healthcare inequality.
PURPOSE: This purpose of this study is to document the results of exclusive control of optical prescription fulfillment as per the CALPIA policy on access to vision care. This paper demonstrates the effects of this policy change on the 130,000 patients under Medi-Cal coverage in San Mateo County.
Methods:
METHODS: Using the online Eye Care Panelist for San Mateo Medi-Cal providers, every doctor/optical site was contacted and asked these questions:
1. Do you currently serve Medi-Cal (San Mateo Health) patients?
2. Do you provide optical service for these patients?
3. How has the change of PIA-only lens fabrication affected your practice?
The survey was conducted on March 19-20, 2020; updated on July 21, 2021. A usage record was obtained from DHCS that included data from every office in the state that ordered optical fabrication from CALPIA from the year 2018 to 2021.
Results:
RESULTS: Fourteen of the fifteen eye care groups contacted responded to the survey.
• The three largest groups, (Stanford, Palo Alto Foundation, and San Mateo Health), representing 22 optometric providers, have no on-site optical. All referred to a storefront optical, Eye-Catcher, which could not afford to use the CALPIA. All eyeglass prescriptions from these groups were either private pay or remained unfulfilled.
• At the Community Health Location (CHC), the optical used the CALPIA but encourage private pay upgrades.
• At the private offices, 2 also referred to Eye-Catcher which has no optical for Medi-Cal; 5 offices planned to discontinue any Medi-Cal patients, and 2 additional offices only accepted existing Medi-Cal patients.
This reduction of access to optical treatment was confirmed by the CALPIA usage report for 2020. This indicated that one private office fulfilled 248 glasses prescriptions of the yearly total of 607, with the remaining fulfilled by CHC. Expected annual eyeglasses prescriptions exceed 10,000 for this population.
Conclusion:
CONCLUSION: The survey and prescription fulfillment data clearly demonstrate how health care policy can have the unintended consequence of collapsing access to vision care, causing healthcare inequality among those who need it the most.
A Case Report of Preseptal Cellulitis Secondary to Methicillin-Resistant Staphylococcus Aureus
Published 2022 by Mai Lee
Program Number: R2022055
Article Type: Residents Day
Board: 37
Abstract:
Preseptal cellulitis is one of the most common infections of the eyelid. Preseptal cellulitis secondary to methicillin-resistant staphylococcus aureus (MRSA) is increasing and it is important to understand how to appropriately treat it.
Case History:
A 51 years old Native American male presented for an acute exam for a painful, swollen, and red left eye on July 14, 2022. The initial onset was the morning of July 12, 2022. His initial symptoms started with an itch on the eyebrow of the left side, then felt a pressure on temporal adnexa, and started developing a sticky discharge along with moderate pain at the end of the day. The patient denied doing anything or getting anything in his eyes when his symptoms first started. He reported the itchy eyebrow and temporal pressure had resolved by the time of his eye exam, however, he was still symptomatic for sticky discharge with a painful, red, and swollen lower left eyelid. He denied pain on eye movement. The patient was worried about this vision given his left eye is his good eye.
His personal ocular history is as follows: CRVO OD, neovascular glaucoma secondary to CRVO OD, phthisis bulbi OD, inactive PDR s/p PRP OU, h/o DME s/p Avastin injections OU, tractional detachment OD, and pseudophakia OU.
His personal medical history is as follows: diabetes type 1.5, chronic kidney disease, metabolic acidosis, peripheral vascular disease secondary to diabetes, hyperlipidemia, and essential hypertension.
His medications are as follows: amlodipine, fluticasone, cetirizine, furosemide, levothyroxine sodium, metoprolol succinate, albuterol sulfate, pantoprazole sodium, and sevelamer carbonate.
The patient’s diabetes is controlled via dialysis and has been taken off diabetic medications. His last dilated eye exam was on September 28, 2021.
Pertinent Findings:
The patient’s incoming uncorrected visual acuities were OD NLP (stable) and OS 20/50. The patient was previously BCVA OS 20/25. A quick refraction was performed with no improvement in VA OS. The pupil OD was unable to test secondary to phthisis bulbi, and OS was round and minimally reactive. The patient was unable to count fingers OD given NLP VA, and the OS confrontational field was full to finger counting. Extraocular movements were full with no restriction and no pain on movement OU.
Anterior segment findings OD showed phthisis bulbi with negative upper or lower eyelid edema, erythema or pain. Anterior segment findings OS showed abscess, erythema, ulceration, and scabbing of the lower lid along with a secondary mild conjunctivitis and mucus discharge. There was no frank proptosis observed in OS.
A small pupil examination was performed given the patient was recently dilated. The undilated posterior segment was unremarkable with no change compared to the patient’s last dilated exam.
The conjunctival mucus discharge was cultured in-office and sent to the laboratory for analysis. The preliminary culture result was positive for staphylococcus aureus. The final culture result was positive for MRSA.
Differential Diagnosis:
The differential diagnoses of a swollen eyelid were considered: hordeolum, chalazion, orbital cellulitis, and preseptal cellulitis.
Hordeolum is an acute and focal infection of either the meibomian gland (internal hordeolum) or Zeiss gland (external hordeolum) of the eyelid from the normal bacteria flora present. An internal hordeolum will be a palpable and inflamed mass without a visible external point. An external hordeolum will present with a visible inflamed mass and an external white head on the margin of the eyelid that may or may not be expressible in-office. The patient will present with acute pain on palpation of the mass and signs of erythema and edema.
Chalazion is a benign, chronic, and non-infectious lipogranuloma that can affect the upper or lower meibomian glands (MG) of the eyelid secondary to obstruction of the MG. The presentation is typically a non-painful mass near the margin of the eyelid. The patient will not display symptoms of pain or show signs of discharge. If large enough, the chalazion may disrupt the eyelid structure resulting in a pseudo-ptosis, however there should be no diplopia, pain on eye movement, or reduced vision. The chalazion should be palpable, if not, consider other differential diagnoses.
Orbital cellulitis is a serious infection of the eyeball and the surrounding tissues. It may be a complication from a sinus, tear duct, face, ear, or teeth infection, or even from trauma. It can also be a result of the normal bacteria flora around the eye. The patient may present with signs of edematous and erythematous upper and lower eyelids, pain to palpation, and proptosis. The patient may be symptomatic for diplopia, reduced vision, pain on eye movement, and a fever.
Preseptal cellulitis is typically a less serious infection of the eyelid. It can be caused by the normal bacteria flora around the eye or secondary to a scratch or insect bite around the eyelid. The patient may present with diffuse edema, erythema, and pain or tenderness upon palpation affecting either the upper or lower eyelid. The infection is limited to tissues anterior to the septum, therefore, there should be no proptosis, blurry vision, diplopia, or pain on eye movement. The patient may have difficulty opening the eye depending on the severity of the edema.
Diagnosis & Discussion:
The patient was diagnosed with preseptal cellulitis on the initial visit given the diffuse presentation and pertinent negatives. A conjunctival culture was completed at the initial visit to determine the bacteria underlying the infection. By the subsequent visit, the culture result came back positive for MRSA, thus, the patient was diagnosed with preseptal cellulitis secondary to MRSA. This new diagnosis of MRSA was important to inform the patient for them to be aware of future infections being treated appropriately.
Staphylococcus aureus (S aureus) is present in 30-50% of healthy individuals. In 1944, the first penicillin resistant strain of S aureus was found to produce penicillinase and by the 1950s S aureus had developed a resistance to almost all systemic antibiotics. The majority of the resistant strain emerged from hospitalization in the 1970s, however, community acquired resistance was starting to rise too. Methicillin was first introduced in the 1960s as a
A Case Report of Superior Orbital Fissure Syndrome in a 35-year-old Female
Published 2022 by Stephanie Solomon
Program Number: R2022123
Article Type: Residents Day
Board: 105
Abstract:
Acute onset of horizontal and diagonal binocular diplopia in a 35-year-old Caucasian female localized to the superior orbital fissure and resolved within 48 hours of initiating oral steroids.
Case History:
A 35-year-old Caucasian female complains of severe, constant horizontal and occasional diagonal double vision at distance for the last 1-2 weeks. Double vision resolves with monocular occlusion with either eye. Prior to this office visit, patient was seen by two separate eye care providers with one suggesting double vision was secondary to dry eye and another suggesting double vision was secondary to a 4th nerve palsy. Patient reports symptoms are worse upon awakening. No pain with eye movement, no correlation with increase body heat or hot showers, paresthesia or electric shock down arms, or difficulty breathing, swallowing, or speaking. Patient had COVID in October 2020 and still has altered tase and smell.
Pertinent Findings:
VA cc: 20/20 OD, OS, OU
IOP: 22 OU GAT
PERRL (-) APD
CVF: Full, No red desaturation, Full to red light in all quadrants OU
EOMs: Full (-) pain OD,10 degrees restriction of abduction (-) pain OS
Cover test at distance: 9 PD Esotropia OS, 2 PD Right Hypertropia comitant in 9 positions of gaze
Cranial Nerve Testing: OD CN II, III, IV, V1, V2, V3, VI, VII, VIII intact; OS CN II, III, IV, V1, V2, V3, VII, VIII intact. CN VI palsy
Anterior and posterior segment exam unremarkable
Blood work ordered: CBC w/ Diff, CMP, ANA, RPR, FTA-ABS, Lyme & WB, ACE, Anti-MuSk, AChR Bind. & Block., Lysosomal enzyme panel, SARS-CoV-2. All results negative or noncontributory.
MRI of brain and orbits with and without contrast: Unremarkable
Differential Diagnosis:
Primary: Orbital Inflammatory Pseudotumor with left CN VI palsy secondary to inflammatory superior orbital fissure syndrome
Others: orbital apex syndrome, cavernous sinus syndrome, Tolosa Hunt syndrome, orbital lymphoma, myasthenia gravis, multiple sclerosis, thyroid orbitopathy, space occupying lesion
Diagnosis & Discussion:
Superior orbital fissure syndrome is part of a group of orbital apex disorders resulting in ophthalmoplegia of cranial nerves III, IV, V1, and VI that pass through the superior orbital fissure structure in the orbit. Ophthalmoplegia without optic neuropathy and sympathetic fiber involvement differentiates superior orbital fissure syndrome from orbital apex syndrome and cavernous sinus syndrome, respectively. Other signs and symptoms can vary but include proptosis, ptosis, pain on eye movements, and decreased vision. Superior orbital fissure syndrome as well as the other orbital apex disorders can have an inflammatory, infectious, traumatic, neoplastic, iatrogenic, or vascular etiology.
Treatment, Management:
9 pd BO OS Fresnel prism. Due to unremarkable blood work, MRI results and continuation of patient’s symptoms, a mild inflammatory etiology not picked up on MRI had to be considered. Option of starting prednisone 60 mg PO was presented to patient with the understanding that if symptoms do not resolve within 48-72 hours, patient would be taken off prednisone and a lumbar puncture would then be ordered. Patient’s diplopia rapidly improved within 48 hours of starting prednisone 60 mg PO. Diplopia at distance resolved to a small esophoria at next visit. Comitant 2 PD of Right Hypertropia resolved completely. Patient instructed to begin prednisone taper with no recurrence of symptoms following taper.
Conclusion:
Symptoms of superior orbital fissure syndrome should improve very quickly if given the correct treatment for the offending etiology. This patient’s rapid improvement within 48 hours of initiating oral steroids is consistent with inflammatory superior orbital fissure syndrome.
Bibliography:
1) Badakere, & Patil-Chhablani, P. (2019). Orbital Apex Syndrome: A Review. Eye and Brain, 11, 63–72. https://doi.org/10.2147/EB.S180190
2) Goyal, P., Lee, S., et al (2018). Orbital apex disorders: Imaging findings and management. The neuroradiology journal, 31(2), 104–125. https://doi.org/10.1177/1971400917740361
3) Shama, & Gheida, U. (2012). Superior orbital fissure syndrome and its mimics: What the radiologist should know? Egyptian Journal of Radiology and Nuclear Medicine, 43(4), 589–594. https://doi.org/10.1016/j.ejrnm.2012.09.009
A Case Report on the Diagnosis, Treatment, and Management of Optic Neuritis
Published 2022 by Sydney Teragawa
Program Number: R2022127
Article Type: Residents Day
Board: 109
Abstract:
A patient presents with pain on eye movement OD. A follow up visit two days later diagnosed Optic Neuritis. MRI imaging confirmed optic neuritis. This case reviews the diagnosis, treatment, and management of Optic Neuritis
Case History:
a. 44 y/o AAF
b. CC: For past 5 days soreness in OD, tender to touch with pain on eye movement.
OD is red, with blurry vision and color desaturation.
c. POHx: Seasonal allergic conjunctivitis, Dry eye
d. PMHx: Asthma, Seasonal allergies, High blood pressure
e. Medications: Albuterol, Allegra, Phentermine
Pertinent Findings:
Initial presentation
a. VA cc: 20/20, 20/20
b. Pupils: PERRLA OD, OS, (-) APD OD, OS
c. EOMs: full and unrestricted OU, (+) pain in left and right gaze OD
d. CVF: FTFC OD, OS
e. Red Cap desaturation test: 75% saturation OD, 100% saturation OS
f. Slit lamp
OD: Moderate capped glands, 2 sec TBUT, trace injection, melanosis, mild
inferior palpebral conjunctiva papillae
OS: Moderate capped glands, 3 sec TBUT, trace injection, melanosis, mild
inferior palpebral conjunctiva papillae
g. IOP: 16mmHg OD, 17mmHg OS by Goldmann
h. DFE
OD: mild vitreous floaters, small and crowded disc, C/D 0.15 h/v, ONH (-) pallor
(-) edema, retina WWOP
OS: mild vitreous floaters, small and crowded disc, C/D 0.20 h/v ONH (-) pallor
(-) edema, retina WWOP
i. Macula OCT: unremarkable OD, OS
2-day follow up:
A. VAsc: 20/50 PHNI OD, 20/20 OS
B. Pupils: (+) RAPD OD, unremarkable OS
C. Red Cap desaturation test: 40% saturation OD, 100% saturation OS
D. DFE
OD: Slight hyperemia and elevation on temporal ONH
OS: Unremarkable
E. ONH OCT
OD: GCC shows temporal thickening, ONH scan shows elevation temporally
OS: unremarkable
F. VF: Octopus 900
OD: significant, deep central visual field defect
OS: unremarkable
G. Lab studies
Aquaporin-4 for NMO, negative
IgG antibodies for MOG, negative
H. Radiology studies
MRI of orbits – slight asymmetric enlargement of the intraorbital segment of
the right optic nerve
MRI or brain – unremarkable
I. Other
Lumbar puncture opening pressure – unremarkable
Differential Diagnosis:
Leading – Optic neuritis
Other – Neuromyelitis Optica, Myelin Oligodendrocyte Glycoproteinopathy, Non-
Arteritic Anterior Ischemic Optic Neuropathy
Diagnosis & Discussion:
Optic Neuritis
a. Race and gender predilection, Caucasian females
b. Estimated annual incidence is 5 per 100,000 in the United States
c. Age predilection, 20–40-year-old
d. Common clinical features
i. Unilateral loss of visual acuity
ii. Periocular pain, worse with eye movement
iii. Relative afferent pupillary defect
iv. Visual field defect
e. Etiology
i. Systemic demyelinating condition (Multiple Sclerosis)
ii. Antibody mediated (Neuromyelitis Optica)
iii. Inflammatory autoimmune (Sarcoid, Lupus Erythematosus, Sjogren Syndrome,
Bechet Disease)
iv. Infectious (Herpes Zoster, Lyme Disease, Syphilis, Rubella, Meningitis)
v. Post-vaccination
Treatment, Management:
a. Methylprednisolone1000mg/16mL; NS100 – 100mL bag
b. Dexamethasone 4 mg tablet by mouth twice a day for 4 days
c. Famotidine 40 mg oral tablet BID for 4 days
Conclusion:
a. Optic Neuritis is a focal inflammatory or demyelinating episode of the optic nerve
that can be idiopathic, associated or become associated with a systemic illness,
most commonly Multiple Sclerosis.
b. Although the first presenting symptoms are commonly ocular pain and a sudden
decrease in vision, visual prognosis is often excellent.
c. Early diagnosis and treatment are critical in preventing and slowing Multiple
Sclerosis related disability
Bibliography:
1. Hoorbakht, H. (2012). Optic neuritis, its differential diagnosis and management.
The Open Ophthalmology Journal, 6(1), 65–72.
https://doi.org/10.2174/1874364101206010065
2. Newman, N. J. (2020). The optic neuritis treatment trial. Ophthalmology, 127(4).
https://doi.org/10.1016/j.ophtha.2019.09.046
A Case Series of Geographic Corneal Abrasions secondary to Epidemic Keratoconjunctivitis
Published 2022 by Kathryn Hohs
Co-Author(s): Negar Sohbati, Megan Byer
Program Number: 225023
Article Type: Scientific Program
Board: 23
Purpose:
This case series describes three patients who presented to the Illinois Eye Institute with similar, but uncommon, clinical presentations of epidemic keratoconjunctivitis (EKC). All patients developed a large diameter central corneal epithelial defect during their infection. Corneal involvement in the form of sub-epithelial infiltrates (SEI) and punctate keratitis is commonly seen with EKC, but large geographic corneal abrasions are rarely encountered or documented.
Case Report:
Case #1: 40-yo AA female presented with redness, swelling and eye pain OD>OS. Her BCVA was 20/20 OD/OS. She had signs of EKC OD>OS which included diffuse conjunctival injection, follicular reaction, and a positive QuickVue Adenoplus test. She had no corneal involvement and was treated with supportive therapy for EKC. Two days later she returned with reduced BCVA OD and a 5mmx4.5mm central corneal abrasion that was treated to resolution through application of a soft bandage contact lens (BCL).
Case #2: 21-yo Hispanic male presented with redness OS>OD, onset 2 days prior. His BCVA was reduced OS>OD. He had signs of EKC which included palpable pre-auricular lymphadenopathy, diffuse conjunctival injection, follicular reaction, pseudo membrane (PM) formation OS>OD, and SEI OD. He had a 6mmx5mm corneal abrasion OS. A PM peel was performed OU, Betadine wash OD, and the patient was treated empirically for EKC with associated corneal abrasion OS. Corneal abrasion resolved at 3 day follow up and EKC resolved 10 days later.
Case #3: 35-yo AA male presented with redness OD>OS, onset 8 days prior. BCVA was reduced OD>OS. He had signs of EKC including diffuse conjunctival injection, follicular reaction, and PM formation RLL. He had a large, central superficial corneal abrasion OD. He was treated empirically for EKC with associated corneal abrasion OD, which resolved 3 days later.
Conclusion:
Human adenovirus serotype 8 (HAdV8) is the most common cause of EKC worldwide. Its distinguishing clinical features include SEI, punctate keratitis and severe conjunctivitis. Few case reports exist of EKC presenting with geographic corneal abrasion, and all patients reported had confirmed HAdV8. Not much is understood about the underlying pathophysiology, but it is thought to be due to pre-existing anterior segment disease and/or replication of the virus within the corneal epithelium. EKC is difficult to manage given the patient’s significant symptoms and additional discomfort of PM removal and Betadine wash. A concomitant epithelial defect exacerbates EKC related symptoms and presents concern for secondary infection. Additionally, it complicates the treatment options for the provider. Debate exists over the use of a BCL in the setting of viral infection, and a Betadine wash is contraindicated in the presence of an epithelial defect. Clinicians should be aware of this unique presentation of EKC and the management challenges it presents.
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