Grand Rounds in Eye Care

1. Grand Rounds in Eye Care FROM THE LIDS TO THE MESHWORK Lee W. Carr, O.D. Jeff D. Miller, O.D.

2. 28 y.o. White female • C/O: “I had a big stye on my lid, and now it’s really swollen up, and it hurts really bad.” • No known health problems • No medications, currently • Allergic to penicillin • No other known allergies

3. Relevant History • First noted “sty” one week ago • Initially: small, non-tender “lump” • “Looked ugly. Made me look ugly.” • Patient squeezed it, “Like a zit.” • Patient tried to “pop it” using a sewing needle. • DID sterilize the needle in a flame • Did not disinfect skin first • Did manage to draw blood from the site • Worked on lesion “…for about 20 minutes.” • Worked on lesion “…till it started to swell pretty good and it really started to hurt.”

4. Currently… • “Swelling is spreading” • Lesion is becoming increasingly painful • “It really hurts now.” • “I’m afraid I’ve got an infection in my eye.”

5. The Exam • VA’s (sc): OD: 20/20 OS: 20/20 • Pupils: PERRLA, brisk OU • Motilities: full, unrestricted OD + OS • Conf Fields: full, OD + OS • SLE: quiet and clear cornea and anterior chamber • EXTERNAL: OD: quiet, WNL OS: extensive lid swelling

7. Assessment: Preseptal vs Postseptal Cellulitis • Re-checked EOM’s. Full, unrestricted • Took patient’s temperature: 97.5 degrees • Pulse & BP: 74 bpm; 122/78 • Questioned patient regarding current or recent sinusitis • Evaluated nasal passages with transilluminator light • Attempted sinus transillumination • Attempted combined scan ultrasound • Discussed monitor/empiric therapy or CT evaluation options with patient

8. Management • Rx: azithromycin (z-pack x 2)Take 2 (250mg) tablets twice per day for two days;Then reduce to 1 tablet per day until all tablets are gone • Rx: tramadolTake 1 (50mg) tablet qid x 2 days • Requested tetanus booster via Adult Med • RTC: 24 hours to re evaluate motilities,other findings

9. DILATED FUNDUS EXAM • All findings considered benign and WNLfor OD and for OS

10. 54 year old male • Yearly eye exam • C/O OD blurry for the last 3-4 weeks • Has happened before but intermittent • Refr. Hx: hyperopic/astigmat/presbyope • Medical Hx: Type II DM, HTN, elevated cholesterol • Meds:Metformin,HCTZ,Toprol-XL, Zetia,Vitamins

11. The Exam • VA’s sc OD 20/40 OS 20/30 • Pupils, motility, CVF all normal • BVA OD:+1.25-0.25x100 20/30 • OS:+1.25-1.00x097 20/20 • Ant Seg: trace SPK OD > OS • Quick TBUT OU • NS 1+ OU • IOP: 21/23 @3:25pm • Retina and ONH appear normal OU • .3 c/d OU • No BDR noted

12. Additional Testing • Lissamine Green • Cirrus OCT of Macula OU • Topography • Pachymetry OD 530 OS 509 • Additional History: always sleeps with ceiling fan on high

15. ##### Cirrus SD OCT

16. Topography OU

17. Working Diagnosis • Irregular topography OD secondary to Dry Eye • Suspect corneal thickness OS > OD (Ocular HTN/Glaucoma suspect?) • REC: D/C ceiling fan if possible, AT’s upon waking and throughout day, various samples given, consider “gel” HS • RTC 3-4 weeks progress evaluation

18. F/U Exam • Patient states mild improvement some days better than others • Using Soothe XP with some success • C/O of Mild itching • VA cc OD 20/25- OS 20/20 • Cornea eval trace SPK OD, clear OS • Everted Lids: clear however, lids very “flaccid” • Lids everted w/o any particular effort or technique

20. Additional History • At this point the spouse offered some information through a question • “We’ve stopped the ceiling fan however, he has just recently started using a CPAP for sleep apnea. Will that dry his eyes out more?” • Working Diagnosis Changed

21. FES, Sleep Apnea, and Glaucoma • Several ocular disorders have been found in association with Obstructive Sleep Apnea or OSA: FES, optic neuropathy, glaucoma, NAION, and papilledema. • 5-15% of OSA pts. have FES • 96% of FES pts. have OSA (collagen in esophagus / pharynx similar to tarsal plate – results in esophageal collapse) • 57% of NTG pts. Have sleep apnea symptoms • Glaucoma – 2% of general population, 7+% of OSA patients • Multiple studies have shown over 70% of NAION pts. have OSA Trigger: failure of AUTOREGULATION (all NAION pts. Should be advised to be evaluated for OSA) • www.slideshare.net/rhodopsin/sleep-apnea-and-the-eye • Rick Trevino, O.D.

23. GDX

24. Evidence of Ischemia’s Role in Glaucoma • Overwhelming evidence indicates high IOP contributes to the development of glaucoma • As many as 80% of Ocular HTN’s don’t develop glaucoma • What about NTG? – about 30% of glaucoma patients appear to have normal IOP yet go on to have their nerves collapse and deteriorate • The Key? – AUTOREGULATION

25. Management • Continue to treat Ocular surface disease • Continue to monitor for Glaucoma • Encourage patient to have continued f/u care with PCP discussed OSA and potential neurovascular, cardiovascular sequela as well as glaucoma and ION

26. 66 y.o. White female • Referred in from Low Vision Service and Rural Eye Program clinic for evaluation for ectropion repair—right lower lid • History of longstanding Bell’s Palsy, right side (“at least 14 years ago”) • Hx: Type 2 diabetes, on insulin Hypertension

27. Ocular History • General Ophthalmologist • Pan retinal photocoagulation OU (2002) • Retinal Specialist • PRP and grid (2002) • Vitrectomy, OD, (2003) • Low Vision Service (2003) • VA: OD: 10/400 OS: 20/150

28. Hx (continued): • Corneal Specialist • Exposure keratitis management (2005) • Cataract surgery, OD, (2005) • Lateral tarsorrhaphy, OD, (2005) • Recommendation: Cataract surgery OS • Retinal Specialist • More PRP (2006) • Cataract surgery, OS, (2006) • Low Vision Service • VA: OD: 10/100 OS: 10/350

29. Hx (continued): • Retinal Specialist • PRP, OU, (2007) • Anti-VEGF, OU (2007) • Vitrectomy and Retinal Detachment Repair, OS, (2007) • Low Vision Service • VA: OD: 6/80 OS: HM at 2 feet

30. Specialty Care Exam (4/22/08) • “I was advised to get my eye lid fixed again.” • “No pain; I’ve gotten used to it.” • “Sometimes I forget to use my artificial tears, but not often.” • Mx: insulin, Fosthopace, Systane, Thera-tears, Erythromycin ophthalmic ointment (prn use)

31. VA: OD: 20/400 at 4 feet OS: Light Projection • Ext: Severe right face droop—full facial palsySignificant edema below right lower lid.Mild ectropion, right lower lidGrossly incomplete lid closure, OD.Mild red eye reaction OD—wateryBlue tinge to right lower lidSolid nodule palpable within edematous right lower lid • Assessment: Atypical for ectropion

34. Consult with our clinical ophthalmologist • Additional Hx obtained: Patient last seen by her primary care physician in January, 2008. He recommended eye lid evaluation. • In late November, 2007, the PCP had removed a “skin lump” from outer canthus, right lower lid. • Pathology report identified basal cell carcinoma. • At March, 2008 exam, PCP expressed concern to patient that residual tumor may exist, and again recommended eye lid surgery.

35. Lesson Learned • PATIENT EDUCATION IS CRITICAL • This patient thought that the recommendation for ectropion repair and the recommendation for evaluation of the right lower lid for residual basal cell carcinoma were “one-and-the-same”

36. Management • Assessment: Probably deep basal cell carcinoma spread—potentially orbital invasion. • Plan: Made immediate referral to oculoplastic surgeon--Tulsa

37. 22 y/o male college student • Presented with c/o mild decreased vision OD associated with scratchy FB sensation and photophobia • Reports is being treated for a “stye” on his OD upper lid with lid scrubs and tobradex drops for 1 week – no improvement – in fact, getting worse • OD red, questions allergy to drops?

38. The Exam • Healthy young male no systemic conditions, no meds p.o. • VA sc OD 20/30 OS 20/20 • All entrance visual skills normal • SLE:

42. Assessment / Treatment • Herpetic lid lesion and HSK • D/C Tobradex • Begin Viroptic q1h OD • Begin 400mg Acyclovir p.o. 5 x day

43. Herpes Simplex Keratitis The Leading Cause of Corneal Blindness in the US

44. Ocular Herpes Simplex • Each year in the U.S. 25 million people have flare-ups of facial Herpes (95% of population exposed by age 6yrs) • 1/3 of the population worldwide has had HSV infection • 700,000 have developed HSV-related ocular disease in the US • 20,000 – 50,000 new cases/yr 28,000 reactivations/yr • Rarely is this bilateral however, has been seen bilaterally in children • After the first corneal infection, 25% re-occur with in 2 years • It is the most common cause of infectious blindness in the Western World

45. Ocular Herpes Simplex • After the second infection odds of further recurrences greatly increases • 40% of these patients have more than one recurrence Infectious Epithelial keratitis Neurotrophic Keratopathy Necrotizing Stromal Keratitis Immune Stromal Keratitis (ISK) Endotheliitis (Keratouveitis or trabeculitis) • One of the leading indications for PK in the US

46. Diagnostic Pearls • Evaluate lid margin and lash follicles closely • Look for a follicular vs. papillary response • Look for more of a serous vs. mucous discharge • Don’t forget decreased corneal sensitivity • Cotton wisp test (check before staining!) • Multiple raised epithelial defects vs. medium to large classic dendrites • Be careful with steroids on garden variety eye inflammation

47. Oasis Medical Inc. 909-305-5400

48. Treatment - Oral Antivirals • Valacyclovir hydrochloride • Trade name – Valtrex • Acyclovir • Trade name – Zovirax • Both inhibit viral DNA replication by interfering with viral DNA polymerase

49. Acute PhaseDosages and Precautions • Valtrex 500mg 1 p.o. bid x 7 days ($88) • Zovirax 400mg 1 p.o. 5 x a day for 10-14 days (14 days $20) • Contraindicated in patients with kidney disease, liver disease, and immunosuppressed patients (HIV)

50. Acute PhaseTreatment - Topical Antivirals • Trifluridine ophthalmic drops • Trade name – Viroptic ($125, generic $95) • 1 drop q1h (8 times a day) • Vidarabine ophthalmic ointment (UNAVAILABLE EXCEPT BY SPECIALORDER) • Trade name – Vira-A ung (5 times a day) • Effective against strains unresponsive to Viroptic and Acyclovir What about steroids to decrease scarring?