SECO 2012 - 2022 Multimedia Posters

TitleAuthorSecondary AuthorsCongress YearAbstractfolder
When it’s not Coat’s- HLA-B51 associated Posterior UveitisAlic202241-year-old white male presents to clinic with blurry vision and mild light sensitivity in the left eye for 5 months. He denies vision loss, flashes, floaters, irritation, redness, or eye pain. Clinically, the posterior segment has an appearance of Coat’s disease with exudative chorioretinopathy, serous retinal detachment and macular edema OS. Upon further testing with fluorescein angiography and blood work the diagnosis is unilateral posterior uveitis, without systemic involvement, secondary to positive HLA-B51. HLA-B51 has a high association for Bechet’s disease, however in this case the patient does not have systemic findings such as ulceration of the mouth or genital area. HLA-B51 is however an inflammatory marker which is the root cause of posterior uveitis. Patient was successfully treated with immunosuppressive therapy.alic_hla
Large cavernous sinus hemangioma causing isolated inferior rectus paresis in a young female: a rare clinical presentationAmaralShalhoub, Julie2022Isolated inferior rectus paresis is rare, particularly from space-occupying lesions. This case report highlights the unique clinical features that can arise from cavernous sinus (CS) tumors to avoid future delayed or incorrect diagnosis. A 24-year-old female presented with ​daily episodes of diagonal binocular diplopia and a left blown pupil upon awakening that would self-resolve within one hour and had been occurring sporadically over the last year. Clinical exam identified an ​intermittent incomitant left exotropia and hypertropia that worsened in superior right gaze as well as a significant anisocoria. MRI revealed a 3.3x3.5 cm CS hemangioma. The lesion extended anteriorly into the orbital apex and exerted mass effect against the internal carotid and ophthalmic arteries causing mild stenosis.amaral_hemangioma
A Tale of Two RAMsAngloMarlon Demeritt, OD, MBA, FAAO; Beata Lewandowska, OD, MS2022Uncontrolled hypertension can lead to retinal arterial macroaneurysms (RAM), a focal dilation within an artery wall, with blood observed in the vitreous, preretinal, intraretinal or subretinal space. We will present a case of extramacular hemorrhagic RAM and a case of exudative macular RAM. Cases: A 61-year-old male presented with reduced vision. Medical history revealed hypertension. The BCVA was 20/60 OD and 20/25 OS. The diagnosis was hemorrhagic RAM OD. A 70-year-old female reported a recent history of painless decrease in vision OS. Medical history revealed hypertension. The BCVA was 20/20 OD and 20/30 OS. The diagnosis was resolving exudative RAM OS. Conclusion: This case report will discuss the incidence, pathophysiology, diagnosis, management, and prognosis of RAM.anglo_ram
Dacryoadenitis secondary to Hidradenitis suppurativaAruca2022A 38-year-old Caucasian male presented to the ER 3 days prior with a complaint of “painful swelling over the left eye”. He was diagnosed at the ER with orbital cellulitis and was told to follow up with optometry in 3 days. Upon examination, there was extensive inflammation of the left lacrimal gland and the patient had reported this was the third recurrence in the same location within 2 years. Due to the atypical appearance, the patient was sent for same-day imaging, bloodwork, and a lacrimal gland biopsy. Upon negative results, the patient was then referred to dermatology for further evaluation since the patient had also reported flare-ups of painful bumps in other areas of the body. The patient was diagnosed with Hidradenitis Suppurativa which is a chronic inflammatory condition that causes boils near the sweat glands. Patients with Hidradenitis suppurativa have a higher likelihood of developing chronic inflammatory eye diseases.aruca_dacryo
Seeing the Sun at Night: Cortical Blindness Associated with Anton's SyndromeAtueyi2022Cortical blindness is characterized by bilateral loss of vision commonly due to ischemic strokes of the occipital lobe. It is often associated with Anton’s syndrome, a condition in which a patient will claim that they can see (visual anosognosia) and confabulate visual perceptions, despite clinical and radiological evidence of visual loss. Although there are many theories for why a patient with Anton’s syndrome denies their blindness, the exact mechanism remains unknown. Prognosis and recovery of visual function will largely depend on underlying etiology. Management of cortical blindness should focus on the underlying cause, with emphasis on secondary stroke prevention and rehabilitation. This poster will present on a case of a 72-year-old Caucasian male with cortical blindness as a result of an acute ischemic stroke.atueyi_cortical
Managing Ocular Manifestations of Susac SyndromeAuble202261 WF presents for worsening red eye and blurred vision OS x2d. POHx: Acute BRAO OD, retinal vasculitis OD PMHx: T2DM, htn, recent diagnosis of Susac Syndrome Medications: Mycophenolate mofetil, among others Pertinent findings BCVA OD: 20/200+2, OS: 20/30-2 SLE OS: (+)papillae/follicles, resolving SCH, conj chemosis, 2+ injection, ABMD, 1+ cell, combined cataracts DFE OS: C/D 0.2, (-)vitritis, superior venous dilation, AV nicking This patient was diagnosed with acute uveitis 2’ Susac Syndrome, along with concurrent conjunctivitis that was unable to be ruled out as viral. Susac Syndrome is a rare autoimmune disorder characterized by impaired hearing, vision, and brain function. Vision is typically impaired by branch retinal artery occlusions, although other common ocular manifestations include uveitis and retinal vasculitis. Long-term treatment typically requires immunosuppressive drugs, such as mycophenolate mofetil in this case. It is especially important to efficiently co-manage across specialties when treating patients with rare diseases such as Susac Syndrome. Successful co-management leads to quicker diagnosis of underlying conditions, which leads to both ease of mind and better long-term care for patients.auble_susac
Congenital Simple Hamartoma of the Retinal Pigment Epithelium in an Army AviatorBannerJames C. Dover, OD2022The purpose is to report the finding of a Congenital Simple Hamartoma of the Retinal Pigment Epithelium (CSHRPE) in a 24 year old female, active duty Army helicopter pilot candidate. The CSHRPE was first detected during a class one flight physical consisting of topography, cycloplegic refraction, and a comprehensive ophthalmic examination. Upon fundus exam of the right eye, a small round dark macular lesion was observed. Further testing was performed with an optical coherence tomography and fundus photography. Visual field testing was performed at a later date. A retinal specialist concurred with the preliminary diagnosis. Given the location of the CSHRPE, the patient was 20/20 OD, normal color vision and no scotoma.banner_hamartoma
Uveitis-Glaucoma-Hyphema Syndrome secondary to Pseudoexfoliation SyndromeBhavsarDouglas Grayson, M.D., Mia Klekos, O.D., Melanne Rosetta, O.D.,2022Uveitis-Glaucoma-Hyphema Syndrome (UGH syndrome) is a rare complication post-cataract surgery caused by mechanical trauma of an intraocular lens displacement, leading to chronic inflammation, microhyphemas and elevated intraocular pressures. A 73 year old female presents six years after cataract surgery with a unilateral anterior chamber reaction, elevated IOP, corneal edema, and a clot of red blood cells in the anterior chamber. Patient was treated with topical corticosteroids and hypotensives to reduce inflammation and intraocular pressure. Upon follow-up, signs and symptoms improved and it became evident the posterior chamber IOL had slightly subluxated due to pseudoexfoliation, potentially causing the previously elevated IOP and inflammation. Measurements for an IOL exchange were taken, however patient and surgeon elected to hold off on surgery and continue topical hypotensive and corticosteroids. Patients with UGH should be monitored closely to watch for rebound uveitis or elevated intraocular pressure; and suturing the IOL or exchanging the IOL remain as options in the case of greater malpositioning of the IOL.bhavsar_ugh
Let’s RAP it up - Retinal Angiomatous Proliferation in AMDBhulaMichelle Brown, OD, FAAO2022Retinal Angiomatous Proliferation (RAP) is a unique neovascular manifestation found in 15% of patients with wet AMD. The spectrum of wet AMD has expanded beyond the traditional classic and occult choroidal neovascularization (CNV). Understanding these variants can help predict patient outcomes and allow for better tailored disease management. The risk of developing neovascularization in the fellow eye is higher in patients with RAP versus those with other forms of AMD. We will provide a comprehensive overview of RAP variant of AMD including etiology, differential diagnoses, and treatment options as well as management options for patients with permanent reduced vision.bhula_rap
Ocular Manifestations of a Frontal Sinus MucoceleChen2022Frontal sinus mucocele is a rare occurrence that results from an accumulation of mucus in the sinus cavity that consequently leads to globe displacement and orbital bone erosion. A 64-year-old male presented to the eye clinic with a swollen upper eyelid OS with left upper lid ptosis and inferiorly displaced globe. Entrance testing showed 20/20 vision in both eyes with no restrictions on eye movements nor visual field loss on confrontational visual fields. Veteran was referred for further imaging and was subsequently diagnosed with a large frontal mucocele impinging on the orbit and into the cranial fossa This case report will further discuss the prevalence and surgical options for sinus mucoceles and how optometrists can play a role in managing these patients.chen_piggyback
Reverting Back to Old Contact Lens Technology: Successful Use of Piggyback System After Failure in a PROSE Device in a Post-PKP PatientChenElliot Myrowitz, OD FAAO2022Contact lens options for patients with irregular corneas have expanded tremendously over the last decade. However, even with the explosion of scleral lenses and the introduction of PROSE device, the role of GP lenses and the art of piggyback fitting should not be overlooked, especially in post-surgical corneas. This case demonstrates the successful use of piggyback system in a post-PKP patient intolerant to PROSE lens. 55YO M with bilateral keratoconus was referred for CL fitting following multiple complicated ocular procedures OS: PKP, DSEAK, ruptured globe repair, and a repeated PKP. Patient was initially fit with PROSE OU, with BCVA 20/30 OD and 20/100 OS. At follow-up, patient reported discomfort and foggy vision OS. OS was refit into a piggyback system with improved comfort and vision, from 20/600 uncorrected to 20/70. A daily silicone hydrogel lens was piggybacked underneath the GP lens to facilitate centration and protect the graft.chen_mucocele
Telling from The Rest: A Case of Macular Telangiectasia Type 2Cobbina2022A case of macular telangiectasia type 2 with telangiectatic intraretinal vasculature bilaterally, which may be difficult to diagnose in early-stage disease. A 40-year-old Native American female complained of gradual blur OU over years. She had type 2 diabetes and unremarkable ocular history. Acuities were 20/40 OD, 20/60 OS, and 20/40 with pinhole. Fundus exam revealed temporal parafoveal retinal opacity, telangiectatic capillaries, and right-angle venules bilaterally. OCT showed atrophy of photoreceptors within temporal maculas bilaterally, and subfoveal atrophic cleft OD. She was referred for low vision rehabilitation. A retinal specialist confirmed the diagnosis and ruled out neovascularization. This underscores the importance of multimodal imaging in identifying this condition from other differentials.cobbina_macular
OCT Angiography Assists in the Early Diagnosis of Macular Telangiectasia Type 2DasDr. Carolyn Majcher2022Macular telangiectasia is a rare bilateral, often asymmetric, idiopathic progressive neurodegenerative disease of perifoveal retina. A 39-year-old American Indian female presented for routine eye exam with no ocular complaints. Best corrected acuities were 20/40 OD and 20/30 OS. Fundus examination revealed pseudomacular hole appearance with dilated and blunted right-angle venules inferiorly in the right eye and a blunted foveal reflex in the left. Loss of the temporal perifoveal photoreceptors and ellipsoid zone was apparent with structural OCT bilaterally. OCT angiography showed enlarged foveal vascular zones in both eyes and revealed the presence of dilated telangiectatic capillaries especially within the deep capillary plexus of the temporal perifoveal region. In addition, the perifoveal superficial capillary plexus appeared dragged temporally. The patient was educated on the condition as well as the importance of amsler grid use and compliance with follow-up recommendations.das_oct
Management of Neovascular Glaucoma Secondary to Ocular Ischemic SyndromeDetwilerKate Muramoto, O.D.2022A 73-year-old male presents with decreased vision and dull pain in only his right eye for the past six months. Entering visual acuity was hand motion and intraocular pressure was significantly elevated at 44. Optical coherence tomography showed retinal nerve fiber layer thinning and automated visual field was significantly constricted. Dilated fundus exam was performed following adequate control of IOP which revealed midperipheral blot hemorrhages consistent with ocular ischemic syndrome. A diagnosis of neovascular glaucoma secondary to ocular ischemic syndrome was ultimately made. This case will highlight the clinical course of neovascular glaucoma including medical management and surgical considerations as well as indicated systemic workup for ocular ischemic syndrome.detwiler_neo
Don’t Play with Dysplasia: Identifying an Ocular Surface Squamous NeoplasiaDorvall2022Squamous cell neoplasia is the most common primary malignancy of the ocular surface. These conjunctival lesions can pose a challenge in terms of differentiating them from more benign lesions. Proper diagnosis and treatment are vital in delivering the best patient outcome, as untreated neoplasia can lead to severe morbidity including enucleation. This case will review an aggressive form of suspected ocular surface squamous neoplasia in a Caucasian female. The presentation will discuss key differentials, how the lesion was identified, and current monitoring strategies using multi-modal imaging. Determination of the best treatment strategy and when to adjust course will also be discussed.dorvall_ossn
Serous Business: A case of Chronic Recurrent Central Serous Chorioretinopathy (CSCR) and Treatment with Oral EplerenoneDunningDr. Loren Bennett, OD, MPH2022Central serous chorioretinopathy (CSCR) is an acute or chronic neuro-sensory retinal detachment characterized by accumulation of submacular fluid. CSCR spontaneously resolves in most acute cases; however, management of chronic CSCR is not standardized, with existing treatments showing varying degrees of success. A 60-year-old Caucasian male was diagnosed with chronic CSCR and treated with oral Eplerenone 50mg twice a day for 6 months by a comanaging ophthalmologist. Eplerenone was discontinued due to orthostatic hypotension, likely a side effect of the drug. The CSCR recurred, and photodynamic therapy is currently being considered. The pathophysiology of CSCR is not well understood; while previous results suggested that aldosterone inhibitors such as oral Spironolactone and Eplerenone might be effective, a recent study (ICVI trial) did not demonstrate improvement and recommended these agents not be used. More research is needed to determine the effectiveness of pharmacologic management for chronic CSCR.dunning_serous
Snowball Fight!: Managing Intermediate Uveitis Secondary to Multiple SclerosisEspantoWanda Martinez Navarro, MD, PhD2022Purpose: This is a case study of intermediate uveitis secondary to multiple sclerosis (MS). MS is a chronic autoimmune disorder that affects the central nervous system by causing inflammation, demyelination, and axonal loss commonly in younger women. An uncommon ocular manifestation is uveitis. Others include macular edema, epiretinal membrane, cataract, and optic neuritis, which are leading causes of vision loss in MS-associated uveitis. Case Report: A 33-year-old white female with MS presented with reduced vision and a "gray-like film" over both eyes with an associated complaint of worsening floaters over the last 7 months. Clinical examination revealed bilateral vitritis and macular edema. Results: MS-associated uveitis is typically managed with corticosteroids. Interestingly enough, this patient's uveitis stabilized with a slow taper of oral corticosteroids, and eventually, Tecfidera alone.espanto_uveitis
Not a Pinguecula After All!EspejoZoeanne Schinas, O.D., Luis Fernandez De Castro, M.D., Aaron Gold, O.D.2022Conjunctival nevi are typically located on the interpalpebral conjunctiva, near the limbus. They are usually unilateral in presentation and appear in the first-second decade of life. They may be pigmented or amelanotic, the later presentation is often confused with other lesions including that of the pinguecula. A 44 year old female presents to clinic concerned of recent changes to her “pinguecula” OD. It has remained relatively stable in appearance until a few years ago. After careful evaluation, it was determined that the conjunctival lesion was an amelanotic conjunctival nevus. Further evaluation of the conjunctival nevi with OCT depicted a normal epithelium overlying the subepithelial lesion. The appearance of cystic spaces via the OCT suggested chronicity of the lesion. We will discuss the importance of accurate diagnosis of conjunctival lesions and the role anterior segment OCT may have in the both the diagnosis and management of conjunctival lesions.espejo_pinguecula
A rare case of retinitis pigmentosaFarooqi2022Retinitis pigmentosa (RP) is a heritable retinal dystrophy that leads to progressive vision loss and night blindness. The classic triad includes arteriolar attenuation, waxy optic disc pallor, and pigmentary changes in the form of bone spicule and pigment clumping. Degenerative myopia, cataract, micro-cornea and staphyloma can be associated with RP under a rare spectrum of MRCS syndrome. A 50 year-old male presents with decreased best corrected vision of 20/40-2 OD and 20/40-2 OS. The patient reports decreased vision since childhood and decreased night vision. Confrontational visual field resulted in a restricted field 360 OD and OS. The patient's anterior and posterior segment examination revealed bilateral trace posterior subcapsular cataract, posterior staphyloma, waxy optic nerve pallor, arteriolar narrowing, and bone spicule throughout the posterior pole and mid-periphery. In our case, the patient does not have micro-cornea but demonstrates the importance of diagnosing a partial expression of MRCS syndrome. The patient can also benefit from learning about low vision devices to be able to maintain a legal driver's license and in this case patient education is vital.farooqi_rp
Peripheral Exudative Hemorrhagic ChorioretinopathyFattah2022An 81-year-old male with non-exudative age-related macular degeneration and peripheral retinal neovascularization presented with orange flashes of light and a “curtain” inferiorly OS. This case highlights an uncommon diagnosis, Peripheral Exudative Hemorrhagic Chorioretinopathy (PEHCR), a degenerative process involving sub-retinal hemorrhagic lesions in patients with presumed age-related macular degeneration. Entering visual acuity was 20/25 OD, 20/50 OS. Pupils, extraocular motilities, confrontation visual fields, and anterior segment were unremarkable. Posterior segment revealed macular drusen OU, epiretinal membrane and vitreous hemorrhage OS. A 2.5-disc-diameter multi-layer hemorrhage with fibrosis was noted superior-temporally OD, along with serous retinal detachment at 7:00 and hyperplastic patch at 9:00. A large multi-layer hemorrhage spanning 1:00-3:00 with adjacent retinal detachment and fibrosis at 3:00 was noted OS. The patient underwent anti-VEGF injection treatment by the retinal specialist. Although PEHCR can stabilize or spontaneously regress, close monitoring for recurrence is imperative to preserve vision in patients with age-related macular degeneration and polypoidal choroidal vasculopathy.fattah_chorio_EXTENSION
An Abnormal Presentation of Retinitis PigmentosaFerrazJulie Rodman, OD, MSc, FAAO2022A 13yo BF presented for a CEE with complaints of blurry vision D+N OU. BCVA 20/30 OD, OS, OU PHNI. CV was abnormal OD,OS. Funduscopic exam revealed macular pigmentary abnormality OU. Periphery and optic nerve was unremarkable. OCT revealed macular atrophy. Genetic testing confirmed a pathogenic variant in the EYS (eyes shut homolog) gene consistent with AR RP. Mutations in the EYS gene account for only 5% of AR. Patients with this mutation demonstrate classic RP symptoms including nyctalopia initially followed by constricted in VF and decline in VA later on in life. The fundus image may display bone spicules and atrophy of the RPE and choriocapillaris affecting the macula with disease progression. Ancillary testing performed included: OCT, OCT-A, Optos, FAF, and fundus imaging.ferraz_rp
“Cut This Off!”: Optometric Management of Lid LesionsFilesChris Wroten, O.D.2022A 48 YOWM presented for annual eye exam with a secondary complaint of a slowly enlarging growth on his left upper eyelid which was partially obscuring his superior visual field. Conservative pharmaceutical treatment was initiated without improvement, so the decision was ultimately made to excise the neoplasm. This multimedia poster briefly reviews several commonly encountered lesions of the lid and adnexa, along with surgical and non-surgical treatment considerations. Pre-and post-operative photos, and intra-operative video demonstration of surgical equipment, infiltrative anesthesia administration, and surgical excision technique using the Ellman radio frequency device are presented. Instrument settings, pathology reports, and clinical coding and billing considerations from this case are also discussed.files_lesions
Neovascular glaucoma as a consequence of chronic retinal detachment with proliferative vitreoretinopathyFleisher2022Chronic rhegmatogenous retinal detachment can produce posterior segment ischemia, triggering the release of angiogenic factors (vascular endothelial growth factor and interleukin-6) and inciting the formation of proliferative vitreoretinopathy. Consequently, proliferation of iris-based fibrovascular tissue (rubeosis), created as an extension of the retinal process, can “zipper” the anterior chamber angle and raise intraocular pressure. This results in neovascular glaucoma accompanied by uveitis and corneal edema. Over time, blindness and relentless discomfort prompts the discussion of enucleation. We review the pathophysiology of chronic rhegmatogenous retinal detachment, proliferative vitreoretinopathy and neovascular glaucoma. We then discuss treatment for inflammation and elevated intraocular pressure and long-term therapeutic/surgical options for the blind and painful eye.fleisher_nvg
River Blindness in the BluegrassFrancoeurErica Smith, OD, FAAO2022A 39-yo Hispanic male with medical history of Onchocerciasis and acne rosacea presented for consultation due to abnormal corneal findings in both eyes. Onchocerciasis is the second leading infectious cause of blindness worldwide and endemic to sub-Saharan Africa and areas of South America. Caused by the parasitic worm Onchocerca volvulus, it spreads by the bite of an infected Simulium blackfly, found near rapidly flowing streams, leading to the colloquial name ‘river blindness’. Slit lamp exam revealed deep corneal scarring and superficial neovascularization of the right eye. The left eye displayed a nodular, fleshy conjunctival mass with extensive stromal scarring and haze with multiple well-circumscribed opaque infiltrates without evidence of microfilariae. He was continued on oral doxycycline with the diagnosis of rosacea keratitis of the right eye and suspected onchocerciasis-related keratitis of the left eye. An infectious disease consultation is pending to confirm diagnosis of onchocerciasis and establish a treatment plan.francoeur_river
How Low Can You Go?: HyperDk scleral lenses for 2 cases of low endothelial cell count post-PKGagliardiDr. Crystal Victor and Dr. Thuy-Lan Nguyen2022Penetrating Keratoplasty (PK) is a surgical intervention to repair a poorly functioning cornea by replacing all the corneal layers with donor tissue. Consequences include a reduced endothelial cell count and a highly irregular corneal surface. Contact lens wear provides better vision, however, provides additional stress on the already fragile endothelium, due to the hypoxic environment. Stress that can induce polymegethous and polymorphism. A significantly reduced endothelial cell size and quality can be detrimental to patient’s graft status and vision. This poster will present 2 cases of patients who underwent penetrating keratoplasty, which resulted in endothelial cell count lower than 1000 cells/mm2 and required scleral permeable contact lenses with hyper Dk materials.gagliardi_scleral
Follow the Bread Crumbs: Three Generations of Granular DystrophyGuo2022Granular Dystrophy is often taught but rarely seen. It’s unique presentation leads to a straight forward diagnosis with numerous ways of treating its symptoms. As a slow progressive dystrophy, treatment is often sought when the symptoms become unmanageable. This case reviews a 17 year old female patient experiencing constant, red, blurry and painful eyes that was not responding to her usual artificial tear drops. The patient reports her mother and grandmother all have had similar episodes in the past. This review will include management and treatment of the various symptoms that can manifest from granular dystrophy.guo_breadcrumbs
What Lies Below? OCT-A Aids in Diagnosis of Occult Choroidal NeovascularizationHaytacStacy Zubkousky, OD, FAAO2022An asymptomatic 61 year-old Hispanic female presented for a comprehensive eye exam at Nova Southeastern University, The Eye Care Institute. Dilated fundus exam revealed a pigment epithelial detachment in the right eye and an elevated parafoveal yellowish lesion in the left eye. Ocular coherence tomography revealed a parafoveal serous pigment epithelial detachment in the right eye and low-lying fibrovascular pigment epithelial detachment in the left eye. OCT-A was then performed revealing a non-exudative occult CNV. En-face OCT slab imaging of the choriocapillaris best visualized the findings. OCT-A is a useful ancillary test to identify occult CNV by imaging the blood flow in the retinal and choroidal vasculature. This novel technology plays an important role in monitoring these often asymptomatic patients who are at risk for exudative choroidal neovascularization. It offers a convenient and non-invasive option for diagnosing and monitoring these cases.haytac_occult
Progression of Stargardt DiseaseHsiao2022Stargardt disease (STGD1) is one of the most prevalent inherited macular dystrophies, with an onset most commonly seen in childhood. Patients often suffer bilateral vision loss and clinical examination typically reveals macular atrophy and yellow-white flecks throughout the posterior pole. Indicated imaging for suspected STGD1 includes fundus autofluorescence (FAF), spectral-domain optical coherence tomography (SD-OCT), and electro physiological testing. Though there is no approved treatment available for STGD1 at this time, multiple avenues of intervention are currently being explored. This presentation will review the clinical course of Startgardt disease in a caucasion male with significant visual loss over a short span of time. This presentation will discuss fundoscopic characteristics, phenotypic variations, and disease progression.hsiao_stargardt
The Perfect Storm: Central Serous Chorioretinopathy and Its Association With Corticosteroids and Exogenous TestosteroneHuynh2022Central Serous Chorioretinopathy (CSCR) is a chorioretinal disease that causes idiopathic serous detachment of the retina, primarily affecting young and middle aged adults, between 20-60 years of age. In its most common form, patients affected by CSCR experience central vision loss due to a relative central scotoma and metamorphopsia. Male gender, corticosteroid intake, psychological stress, and type A personality are established risk factors for CSCR. However, recent studies have shown how elevated testosterone levels may play a role in the pathophysiology of CSCR. The following case report reviews a 38-year-old-Caucasian male with unremarkable ocular history who presented with classic symptoms of CSCR with associated fluticasone use and daily testosterone use with exercise.huynh_perfect
Corneal cross-linking outcomes in Keratectasia patients with very thin corneasIbachDaniel Terveen, MD, Abigail Nieuwsma, MD2022While corneal cross-linking (CXL) treatments generally stipulated an intraoperative minimum corneal thickness (MCT) of 400µm to preserve endothelial integrity, recent studies suggest this recommendation may be too conservative and subsequently exclude thinner keratectatic corneas from CXL benefits. We performed a retrospective review of 37 eyes undergoing FDA-approved CXL with thin corneas (Mean MCT = 328±68.9µm) who were monitored up to 1 year. Pre- and post-operative UVA, BCVA, MCT, K1, K2, and Kmax were recorded. Subgroup analysis was also performed in extreme thin corneas (MCT <300µm). Post-operatively, an average 3.5 D of Kmax flattening was observed with no endothelial failure or other adverse events. Our study findings indicate the original 400µm MCT recommendation may have overestimated the endothelial photo-toxicity of CXL. Thus, keratectatic corneas thinner than 400µm may undergo FDA-approved Epi-off CXL but more research with long-term outcomes is needed.ibach_crosslinking
A Case of Recurrent Red Eye: The Ocular Consequences of Uncontrolled Systemic DiseaseIrelandPinar Haytac, OD, FAAO2022A 33-year-old male presents for evaluation of blurred vision, light sensitivity, tearing, and redness of the right eye. The patient reports past episodes and history of sarcoidosis that was previously managed with systemic steroids until 4-5 months prior, when he reports he ran out of medication and has not followed up with his managing doctor. Examination reveals mutton-fat keratic precipitates, severe corneal edema, and vitreous cells preventing evaluation of the anterior chamber and posterior segment. This case discusses a classic presentation of recurrent granulomatous inflammation associated with uncontrolled systemic disease and overviews proper evaluation and management of this condition.ireland_sarcoidosis
Pachychoroid Neovascularization in Chronic Central Serous ChorioretinopathyJimenezEulogio Besada, O.D., M.S., FAAO, Felicia Timmermann, O.D., FAAO2022A 60-year-old Asian male presented with blurry vision OS of one-year onset. He was diagnosed with Type 2 Diabetes and denied use of corticosteroids. Best corrected visual acuities were 20/20 OD, 20/30 OS. Fundus examination revealed macular thickening with hemorrhages. Differential diagnosis included diabetic macular edema, pachychoroid syndrome and central serous maculopathy. Optical Coherence Tomography Angiography demonstrated macular subretinal fluid with neovascularization. The choroid appeared thickened with enlarged vessels. He was diagnosed with pachychoroid related neovascular chronic central serous chorioretinopathy OS. A referral to a retinal specialist was issued. Scleral rigidity at the site of vortex vein exit have been implicated in the development of pachychoroid spectrum.jimenez_pachy
In the "Gutter;" Identifying Non-Central Chronic Serous ChorioretinopathyKalbererShephali Patel2022While central serous chorioretinopathy quite commonly presents with visual distortion or reduction, peripheral lesions can occur and often go undetected. Non-central, chronic lesions of serous chorioretinopathy can be observed as "guttering" patterns of the RPE. Utilizing multimodal imaging technology, such as FAF and OCT, we can highlight a patient's previous peripheral lesions to better monitoring for future vision-threatening ones. This poster will present a case series of patients with non-central serous chorioretinopathy to alert providers of this possibility and prepare them to address and monitor such cases.kalberer_csr
Not So Dominant Presentation of Autosomal Dominant Best Vitelliform Macular DystrophyKarmaliDr. Sarah MacIver, Dr. Lisa Prokopich2022Best Vitelliform Macular Dystrophy (BVMD) is a rare autosomal dominant disease that affects up to 1 in 16,500 individuals. It is characterized by single circular macular lesions with an egg-yolk appearance and a good visual prognosis in at least one eye due to asymmetric manifestation. A lesser-known phenotype has been described as multifocal Best disease because of multiple vitelliform lesions in the retina. Despite the rarity of this condition, this case highlights an adult male with suspected multifocal Best disease with a central vitelliform lesion and vitelliform lesions superior to the optic nerve. OCT and autofluorescent imaging suggest active leakage of the lesions threatening peripheral vision. This abstract will also discuss the need for additional management and potential proactive treatment for this unique variant of BVMD.karmali_vitelliform
A Clinical Presentation of Conjunctival Intraepithelial Neoplasm Initially Diagnosed as an Inflamed PterygiumKhanThuy-Lan Nguyen OD FAAO FSLS, Pinar Haytac OD FAAO2022A 53-year-old AF presented to NSU TECI for sharp intermittent stabbing pain OS for one week. She had moderate redness nasally OS for many years but was always told by doctors that it is due to pterygium. Patient had an unremarkable PMH and POH. Upon clinical examination, the OS conjunctiva appeared to have an inflamed 1mm x 1mm pterygium along with a corneal stromal lesion. The appearance of the pterygium was suspicious for CIN (conjunctival intraepithelial neoplasm), it stained with RB and AS-OCT depicted features of CIN. CIN was confirmed and treated at a tertiary care hospital. This unique case outlines how CIN can be differentiated from a typical pterygium.khan_cin
Retinal Arteriovenous Malformation with Optical Coherence Tomography Angiography AnalysisKim2022A 61 year old male presents with reduced vision in his left eye. There were vascular abnormalities with tortuosity and a concentrated area superior to the fovea. This vascular network crossed the horizontal raphe as well as invade the foveal space. OCT angiography images were taken to showcase the vascular abnormality. Retinal arteriovenous malformations are often benign and do not affect vision. However, there are ophthalmic complications associated with this condition including retinal detachment, pigment epithelial detachment, retinal vein occlusion, vitreous hemorrhage, intra retinal hemorrhage, retina ischemia. This case helps showcases the use of OCT angiography to illustrate the retinal vascular circulation in such diagnoses as these.kim_ravm
A Strange Case of Subjective Vision Loss: Truth or LieKobariLoren W. Bennett2022When encountering vision loss in the absence of any apparent pathology, functional visual loss needs to be considered and requires extensive work up and testing before arriving at its diagnosis. Functional visual loss can be the result of an underlying condition that needs to be addressed and may require interdisciplinary coordination of care. This case report presents a patient with severe monocular vision loss whose previous records noted functional visual loss as the etiology based on test findings and numerous visits to various specialists. The necessary workup and testing are discussed for patients who are suspected of having functional visual loss.kobari_visionloss
ONSET-2: Phase 3 Trial of OC-01 (varenicline) Nasal Spray for the Treatment of Dry Eye DiseaseKoettingAlan G. Kabat, OD; Gretchen Blemker, OD; Andrea Gibson, PhD2022Background: OC-01 (varenicline) nasal spray, a cholinergic agonist, offers a novel approach for dry eye disease management via pharmacological neuro-activation of the trigeminal nerve, promoting natural tear production. Methods: 758 subjects were randomized to receive OC-01 0.6 mg/mL, OC-01 1.2 mg/mL, or vehicle control (VC) BID for 4 weeks. Outcomes included Schirmer’s Test Score (STS) and Eye Dryness Score (EDS). Results: At 4 weeks from baseline compared to VC, both OC-01 concentrations demonstrated statistically significant proportions achieving STS ≥10 mm improvement and nominally significant reductions in EDS ( p<0.01 and p<0.05, respectively). The most common adverse event was sneezing (82%-84%). Conclusion: OC-01 demonstrated improvements in both the signs and symptoms of dry eye disease with an excellent safety/tolerability profile under conditions of the study.koetting_nasal
Clinical Signs, Diagnostic Features and Imaging Techniques in Oculocutaneous AlbinismKoga2022Oculocutaneous albinism (OA) is an inherited deficiency in melanin synthesis resulting in various ophthalmic, integumentary and pilar abnormalities. Changes involving the visual system include strabismus, nystagmus, photophobia, and poor vision. Because symptom severity correlates directly with the affected individual’s level of melanotic expression, mild cases of oculocutaneous albinism (OA) may be difficult to diagnose. This case report will review the spectrum of genetic variability, associated clinical findings and management strategies, as well as the importance of non-invasive, cross-sectional retinal imaging to highlight characteristic morphological and angiographic features unique to this condition.koga_oca
“Hemi-drocephalus” Visual DefectKrabillChung To, O.D.2022Homonymous visual field loss typically results from a stroke but can be caused from numerous other causes. This case features a 20-year-old female with homonymous visual field loss and visual neglect secondary to complications from an intraventricular neurocytoma removal. The advanced management and treatment of this unique case, including visual rehabilitation and prism therapy, will be discussed.krabill_hemi
Concurrent Retinopathy of Prematurity and Juvenile GlaucomaLauri2022Retinopathy of prematurity is a disease affecting the retinal vasculature of premature infants who are treated with oxygen, and many of these patients end up highly myopic with some reduced vision. Additionally, studies estimate that 2-30% of ROP patients will develop a secondary glaucoma, especially in cases of advanced ROP. This presentation details clinical exam findings of a 38-year-old African American woman who presented to the Kaiser Permanente Pasadena Vision Essentials clinic for a comprehensive exam with a history of both ROP and concurrent juvenile glaucoma being treated with latanoprost by ophthalmology. This patient was lost to follow-up with ophthalmology for four years and was referred to them for continued care of her ocular conditions, while optometry managed her visual needs. Increased awareness of these associated ocular conditions and their complications can help clinicians provide appropriate treatment to these patients and help them live a life with functional vision.lauri_rop
Bardet-Biedl Syndrome: Genetic Testing, Interpretation, and CounselingLinn/a2022This case highlights the utility of genetic testing and importance of early diagnosis of syndromic retinal dystrophies. This patient did not receive a diagnosis until her adult years, causing significant delays to management of her rod-cone dystrophy and systemic conditions, including childhood night blindness, childhood obesity, and polydactyly. Though the genetic testing lab report indicated a “Potentially Positive” result (one pathogenic mutation and one variant of uncertain significance on the BBS1 gene), interpretation of the genetic results in combination with her ocular and systemic clinical features resulted in diagnosis of BBS1 mutation associated Bardet-Biedl syndrome. Counseling included discussion that children would be carriers but unaffected by the condition due to the autosomal recessive inheritance pattern.lin_ois
Blots and Blocks: Asymptomatic Bilateral Ocular Ischemic Syndrome with Complete Unilateral Internal Carotid Artery OcclusionLinEmily Mak, OD2022This case report highlights a rare case of asymptomatic Ocular Ischemic Syndrome in a patient with severe carotid stenosis. 74-year-old female presents with bilateral peripheral retinal vascular stenosis and moderate mid-peripheral blot hemorrhages in the setting of mild non-proliferative diabetic retinopathy without macular edema OU. Patient is asymptomatic for vision changes, eye pain, stroke symptoms, and amaurosis fugax. FA shows extensive peripheral retinal nonperfusion OU and peripheral neovascularization OS. Carotid doppler shows complete stenosis of left internal carotid artery and mild right ICA stenosis. Diagnosis of bilateral Ocular Ischemic Syndrome was made. Bilateral panretinal photocoagulation and interdisciplinary management of patient’s systemic vascular diseases led to improving ocular findings.lin_bardetbiedl
Resolution of bullae highlights the therapeutic potential of Netarsudil in corneal diseaseLiranzo2022Bullous keratopathy is a condition hallmarked by the cornea becoming permanently swollen. This occurs due to endothelial cell damage, either intrinsic or extrinsic, resulting in the cells not pumping fluid properly. Current therapy options for bullous keratopathy includes short-term topical ophthalmic treatment and endothelial keratoplasty surgery per the preferred practice patterns from American Academy of Ophthalmology for corneal edema and opacification. However, a limited supply of donor corneas and trained surgeons have driven research towards finding alternative treatments, such as the use of ROCK inhibitors. This case highlights the beneficial & unexpected effects of Netarsudil, a ROCK Inhibitor, as a potential non-invasive treatment for corneal disease after resolution of a patient’s bullous keratopathy with appropriate application.liranzo_resolution
Superior Segmental Optic Hypoplasia: An Investigation into Unilateral Visual Field LossLiu2022Optic nerve hypoplasia is a congenital malformation characterized by a decreased number of axons in the optic nerve with corresponding retinal nerve fiber thinning often resulting in visual field deficit. Bilateral or unilateral, the optic nerves appear small and pale, classically with pigmented peripapillary scleral halos. Less commonly, the hypoplastic change can be confined only to the superior portion of the optic nerve, termed Superior Segmental Optic Hypoplasia (SSOH). This case explores the diagnosis of SSOH in a 30 year old male with an asymptomatic, unilateral, inferior visual field loss. It will review the differential diagnoses, management protocols, as well as the importance of retinal and neuroimaging for a clinically difficult diagnosis.liu_hypoplasia
HEVL and UV Transmittance Properties of Lehfilcon A Contact LensesLoudermilk2022UV transmittance properties of lehfilcon A contact lenses were compared to senofilcon A and senofilcon C contact lenses. High energy visible light (HEVL) transmittance properties of lehfilcon A were compared to the same contact lens materials as well as Crizal® Prevencia® and DuraVision® BlueProtect spectacle lenses. UV blocking for all contact lenses met the criteria for Class 1 blocking (<1.0%T UVB and <10.0%T UVA). HEVL attenuation was 34% for lehfilcon A, versus 2% to 7% for the other contact lens materials. Spectacle lens HEVL attenuation ranged from 26% to 28%. In summary, lehfilcon A lenses demonstrated comparable UV blocking ability to the comparator contact lenses, while also providing significant HEVL filtration similar to the level of HEVL filtration in spectacle lenses marketed as providing blue-violet light (HEVL) filtration.loudermilk_hevl
A Case of a Conjunctival Cancerous Lesion and Topical ChemotherapeuticsMatejczyk2022An 86-year-old white male presented with a new, elevated papillomatous lesion with leukoplakic changes. The lesion measured 10mm vertically by 6.8 mm horizontally with areas of underlying scleral thinning and extended 3 mm onto the cornea. After excision and biopsy, the lesion was determined to be a squamous cell carcinoma in situ, with cancerous cells extending to the peripheral border of the biopsy. The patient was given 1% 5-Fluorouracil QID to treat the cancerous cells that remained after the excision. Conjunctival squamous cell carcinomas typically present with a gelatinous-like mass containing leukoplakic and papillomatous changes. Topical chemotherapeutic agents such as Mitomycin-C, interferon, and 5-Fluorouracil are effective both as a primary form of treatment and as an adjunctive treatment to excision and biopsy in malignant neoplasms of the conjunctiva. This case demonstrates the efficacy of using 1% 5-Fluorouracil as an adjunctive treatment to excision and biopsy when cancerous cells remain after the excision is performed.matejczyk_cancers
Unusual Presentation of Purtscher-Like Retinopathy In a Patient with Metastatic Castrate Sensitive Prostate CancerMayoJordan Zinn O.D., Nancy Shenouda-Awad O.D., Theresa Zerilli-Zavgorodni O.D.2022Purtscher retinopathy is a hemorrhagic and vaso-occlusive vasculopathy associated with severe head or chest trauma. Patients will typically present with cotton-wool spots, edema and/or retinal hemorrhage on or near the optic nerve. While the diagnosis of Purtscher retinopathy is typically straightforward, when a patient presents with similar clinical features but lack a history of compression injury to the head, chest, or a long bone fracture, it is referred to as Purtscher-like retinopathy. This case highlights a rare presentation of Purtscher-like retinopathy in a patient with metastatic castrate sensitive prostate cancer with T2 metastasis that caused cord compression, cauda equina syndrome, and paraplegia. Ophthalmic examination findings, radiographic imaging, laboratory findings, differential diagnoses, and management will be discussed. The important role of optometry in the medical team co-management will be highlighted.mayo_purtscher
GEMINI 1 and GEMINI 2 Pooled Phase 3 Studies: Duration of Efficacy of AGN-190584 on Mesopic and Photopic Distance-Corrected Near Visual AcuityMcGeeDavid Kading, Weston Pack, Yixin Fang2022Purpose: Evaluate the duration of effect in mesopic and photopic distance-corrected near visual acuity (DCNVA) in presbyopia study participants treated with AGN-190584 on day 30. Methods: The durations of attainment of ≥3-line, ≥2-line, and ≥1-line improvement in DCNVA were calculated in participants who received AGN-190584 bilaterally, once daily for 30 days (n=375). Results: The median final time point of sustained gains was at Hour 6 for a ≥3-line gain, Hour 8 for a ≥2-line gain, and beyond the 10-hour study visit duration for a ≥1-line gain in participants who achieved ≥3-line, ≥2-line, and ≥1-line gains on day 30, respectively, in both mesopic and photopic illumination conditions. Conclusion: Participants treated with AGN-190584 obtained ≥1-, ≥2-, and ≥3-line gains over the course of the 10-hour study visit on day 30.mcgee_gemini
Comparison of SYSTANE iLux and LipiFlow in the Treatment of Meibomian Gland Dysfunction: A 12-Month Multicenter StudyMillerLakshman Subbaraman, Katherine Bickle, Colton Heinrich, David Kading, Shane Kannarr, Gina Wesley, Sruthi Srinivasan2022Present study aimed to demonstrate non-inferiority between SYSTANE iLux and LipiFlow, at 12-months in meibomian gland dysfunction (MGD) subjects with evaporative dry eye. Subjects aged ≥ 18 years with Meibomian Gland Score (MGS) ≤ 12 in lower eyelids, noninvasive tear break-up time (NITBUT) < 10 seconds, and impact of dry eye on everyday life – symptom bother (IDEEL-SB) module score > 16 were randomized in a 1:1 ratio to receive a single treatment of iLux (n = 119) or LipiFlow (n = 117). Subjects were followed up at 2 weeks, 1, 3, 6, 9, and 12 months to evaluate change from baseline in MGS, NITBUT, and IDEEL-SB score. Findings demonstrated that SYSTANE iLux is noninferior to LipiFlow in change from baseline in MGS (95% lower confidence limit [CL] of least square mean difference > -5), NITBUT (> -2.5 seconds), and IDEEL-SB score (95% upper CL < 12) at all post-treatment visits.miller_esotropia
Utilizing Vision Therapy in the Management of Adult Esotropia: A Case SeriesMiller2022This case series explores diverse implementations of vision therapy (VT) when managing adults with esotropia. Case 1: A 46 year old Asian female presented with constant alternating esotropia, no stereopsis, alternating suppression, and oculomotor dysfunction. After 24 sessions of VT, the deviation was intermittent, the patient achieved stereopsis and she no longer suppressed. These findings remained consistent at a 4-month progress evaluation. Case 2: A 16 year old White male presented with a V-pattern constant left esotropia, no stereopsis, and intermittent suppression OS. After 9 sessions of VT, the patient was no longer suppressing but was now reporting occasional diplopia at distance. Fusion was reported with 8pd BO prism, and this was prescribed. VT was continued to improve divergence ability. Case 3: A 61 year old White female presented with diplopia and a constant right esotropia. The patient was resistant to strabismus surgery and opted for prism and VT. After 21 sessions, divergence had improved but was still inadequate to maintain single vision. She was more agreeable to surgery at this time and was referred for consultation.miller_systane
Penetrating Eye Injury caused by Wooden Splinter: Case ReportNanda2022Foreign bodies are common causes of ocular trauma. Location, depth of injury, and the type of foreign body greatly impact prognoses and as such, management should be tailored accordingly. A 10-year-old, an otherwise healthy female then suffered a penetrating injury to her left cornea which was caused by a wooden splinter while building a teepee during a girl scout trip. Patient presented with OS ocular pain, microcystic edema (MCE) and photophobia. Herein, this case report describes proper management of a corneal foreign body injury with that penetrated the anterior stroma, which are generally prone to scarring, but was minimized with the use of cryopreserved amniotic membrane.nanda_injury
Visual Recovery Following Traumatic Optic NeuropathyNguyen2022This case report details the visual recovery of a 17-year-old male who suffered a head-to-head soccer injury, resulting in a concussion and vision loss in his right eye. Baseline findings noted +RAPD OD, CF @ 12”, superior confrontational VF defect, abnormal red cap test, unremarkable DFE with normal nerve appearance, and normal CT/MRI. This patient was subsequently diagnosed with indirect traumatic optic neuropathy and a guarded visual prognosis was given. Visual recovery can vary in cases of traumatic optic neuropathy, with 40-60% chance of regaining vision after injury. It is important to monitor these patients closely to determine long-term visual outcomes.nguyen_traumatic
Pillow Talk: A Case of Rapid Keratoconus Progression in a Presbyopia Patient with Floppy Eyelid Syndrome and Sleep ApneaNguyenStacy Zubkousky, Almas Khan2022A 42-year-old Black female presented for an office visit at Nova Southeastern University, The Eye Care Institute. She complained of reduced vision and comfort in her habitual scleral lenses. She had a history of keratoconus, sleep apnea and floppy eyelid syndrome. Tomography exam revealed severe progression in both eyes. Three serial tomography maps taken over the course of 1.5 years were compared. The right eye showed a progression of 9.6 diopters of the maximum keratometry reading and a 11.8 diopter progression of the left eye. Pachymetry measurements revealed a 172-micron thinning of the right eye and 31 microns thinning of the left eye. Tomography comparison maps were generated to best illustrate the profound progression. This case demonstrates severe progression in a patient with keratoconus with comorbidities in their 5th decade of life, an atypical age for significant progression. The report highlights the importance of close monitoring of all patients with keratoconus and appropriate referral for corneal cross-linking evaluation, even in patients who fall outside the typical age of progression.nguyen_floppy
The One That Got Away: Migration of a Dexamethasone ImplantNoorani2022Dexamethasone has been shown to have a significant role in inhibiting inflammation and suppressing retinal edema, especially with the use of the Ozurdex implant. However, other ocular concerns involving the cornea may arise secondary to the migration of the implant from the vitreous cavity to the anterior chamber. This case reviews a 65-year-old female who received Ozurdex injections secondary to chorioretinal inflammation that was noted during a vitrectomy post-op due to a subluxed lens post-cataract surgery. Methods involving laying the patient back dilated and the use of pilocarpine to help the implant return to the vitreous cavity are discussed as well as the indications for an AC washout following this event.noorani_migration
Worth the Weight: Management of Exposure Keratopathy with Scleral Lenses Complicated by An Eyelid Weight and TarsorrhaphyNorrisJulieAnne Roper2022Although severe exposure keratopathy may necessitate surgical intervention, therapeutic scleral lenses can provide excellent nonsurgical treatment. We will discuss the unique challenges encountered when successfully fitting a 72-year-old Caucasian male with a scleral lens after extensive right eyelid reconstruction for paralytic lagophthalmos following basal cell carcinoma removal. Our fit was complicated by his lateral tarsorrhaphy, trichiasis, and platinum eyelid weight, including a weight exchange following an uncommon allergic reaction to his gold weight. In addition to improving vision from 20/50 with glasses to 20/20-2, the scleral lens provided therapeutic ocular surface protection and enabled avoidance of further surgery. We will provide a review of exposure keratopathy management, with an emphasis on a nonsurgical approach using scleral lenses. In addition, we will utilize OCT, photography, and corneal topography to illustrate our methods in fitting post-surgical scleral lenses, focusing on the importance of eyelid interaction, insertion and removal techniques, and oculoplastics co-management.norris_tarsorrhaphy
Orbital Invasion as the Presenting Feature of Richter Transformation of Chronic Lymphocytic LeukemiaPatel2022Richter syndrome is a rare complication of chronic lymphocytic leukemia (CLL) characterized by aggressive lymphoma development. A 67-year-old male presented with right proptosis, ptosis, supraduction and abduction motility restrictions, elevated intraocular pressure, and palpable orbital mass. Acuity was 20/40+3 OD and pupil testing was normal. He was being followed by oncology for CLL diagnosed 4 years ago. Complete blood count revealed elevated white blood cells, as well as decreased red blood cells, hemoglobin, and hematocrit. Computed tomography (CT) revealed diffuse lymphadenopathy along with a nodular mass of the right maxillary and frontal sinuses that extended into the right orbital floor and involved the inferior rectus and lacrimal gland. The patient was urgently admitted for magnetic resonance imaging, cerebrospinal fluid analysis, and biopsy, which confirmed an aggressive central nervous system diffuse B cell lymphoma, classified as Richter syndrome. The patient is currently undergoing MATRix regimen chemoimmunotherapy.patel_richter
Sports Vision Training in PracticePeterson2022Vision accounts for approximately 80% of sensory information received and processed by the brain. Improved sports performance is desirable for college-level athletes. Sports vision training can improve several fundamental skills to enhance athletic performance. Division-1 athletes of multiple sports teams participated in custom sports vision training. Team 1 had pre and post evaluations performed with the Senaptec Sensory Station. This revealed strengths and weaknesses for each individual, allowed for comparison to other D-1 athletes, and showed progress. Team 2 participated in a pre-game sports vision training program to sharpen visual skills just prior to game time as well as once weekly training during away-game weeks. Pre and post surveys were completed with subjective and objective results recorded.peterson_sportsvision
Use of Prosthetic Scleral Lens in the Treatment of Neurotrophic Keratitis Secondary to a Trigeminal SchwannomaPhamJanet Garza, OD, FAAO2022Neurotrophic Keratitis (NK) is a serious corneal condition that necessitates immediate treatment to prevent irreversible vision loss. Patients with NK are commonly unaware of their condition due to the complete loss of corneal sensitivity from cranial nerve five damage. The lack of symptoms experienced by patients with NK complicates early treatment. This case follows the management and treatment of a patient with NK secondary to a trigeminal schwannoma who was fitted with a prosthetic scleral lens.pham_neurotrophic
Wyburn-Mason SyndromeQuachJustin Simbulan, OD2022Wyburn Mason Syndrome is a disorder which causes a malformation of blood vessels between the retina and brain. An 8 year old Hispanic female presented with blurred vision OS after failing a school screening. Although she had a history of this syndrome, she did not have a recent MRI. Upon DFE, the left retina showed enormously dilated vessels. She was referred to a retinal specialist. FA showed delayed perfusion, microaneurysms, and peripheral capillary dropout OS. MRI revealed a large left ophthalmic artery with no active bleed. This syndrome requires close monitoring with a retinal specialist and imaging every 6 months to detect vitreous hemorrhages, retinal detachments, and brain tumors.quach_wyburnmason
Cenegermin-bkbj 0.002% in the Treatment of Stage 2 Neurotrophic KeratopathyRafiqueVin T. Dang, OD2022Neurotrophic keratopathy (NK) is a degenerative disease of the cornea, which in its later stages can lead to ulceration and risk of perforation. The advent of topical recombinant human nerve growth factor (rhNGF) has revolutionized treatment for all stages of NK, a condition for which a viable solution did not previously exist. This case discusses a 62-year-old Caucasian male referred for stage 2 NK, presenting with a corneal ulcer and associated uveitis. The patient was treated with a series of amniotic membrane transplants while awaiting approval for topical rhNGF. An 8-week course of cenegermin-bkbj 0.002% was then administered, resulting in regeneration of corneal epithelium and successful prevention of perforation, as well as an improvement in nerve function.rafique_neurotrophic
Augmenting corneal thickness in thin keratoconus corneas during corneal cross-linking via FDA-approved hypotonic riboflavinRasheedDan Fuller, OD; Subba Gallamudi, MD2022During corneal cross-linking (CXL), an intraoperative minimum corneal thickness (MCT) of 400µm or greater has been suggested for endothelial safety. With IRB approval, we conducted a retrospective review of 33 progressive KCN eyes with MCT <400µm. All corneas were swollen via a FDA-approved hypotonic riboflavin before proceeding with CXL. Outcome variables analyzed included pre-op MCT (MCT-1), after 30min of soaking with hypertonic riboflavin (MCT-2), after corneal swelling with hypotonic riboflavin (MCT-3), and mean swelling time required to reach >400µm. Hypotonic riboflavin led to a mean MCT increase of 75.9µm with a mean 13.7min. Interestingly, the maximum swelling within a 15min interval was 161µm, supporting a pre-op MCT as thin as 300µm to still be eligible for FDA-approved Epi-off CXL. Nonetheless, extra time should be allotted for intraoperative swelling when treating thinner KCN corneas with CXL.rasheed_augmenting
Multiple Manifestations of Thyroid Eye DiseaseRawls2022A 60-year-old Caucasian male with a history of hyperthyroidism presented to clinic as an emergency with a chief complaint of binocular, horizontal diplopia and decreased vision of the left eye for three weeks. Extraocular motility findings showed significant restriction in all gazes of both eyes (0% movement of abduction/adduction/superior gazes with 10% movement of inferior gaze). Upon dilated examination, there was evidence of significant optic nerve edema in the left eye and mild optic nerve edema in the right eye. Computed Tomography (CT) scan of orbits showed bilateral proptosis and enlargement of the extraocular muscle bellies, consistent with severe thyroid ophthalmopathy. The patient was diagnosed with thyroid eye disease with optic neuropathy in both eyes. The patient was referred urgently to oculoplastics and neuro-ophthalmology. Orbital decompression surgery was performed urgently, and later strabismus surgery was also performed of both eyes.rawls_thyroid
Fila-ment To Be: Atypical Etiology and Management of Filamentary KeratitisReynard2022Filamentary Keratitis is a disease of the ocular surface in which desiccating stress causes mucin and corneal epithelium to entwine into characteristic strands on the cornea. This condition can present with pain, foreign body sensation, conjunctival hyperemia and light sensitivity. This case poster presents a 30-year-old white male with congenital CN III Palsy and subsequent Filamentary Keratitis. The patient experienced significant symptomatic relief and visual improvement after being fit in a scleral lens. This case highlights not only the utility of scleral lenses in the management of Filamentary Keratitis, but also an atypical etiology of Filamentary Keratitis and the possibility of visual improvement beyond expectations using specialty contact lenses.ries_palsy
Abducens Nerve Palsy in a Patient with Type 2 DiabetesRiesPaula Johns, OD, MPH, FAAO, Joanna Tanaka OD, FAAO2022A 74-year-old male was referred to our clinic for suspected cranial nerve palsy. His medical history was significant for uncontrolled type 2 diabetes, hypertension, hyperlipidemia, and migraine. Exam findings were non-specific and did not correlate with any specific nerve palsy or extraocular muscle restriction. Over the next month, the patient’s symptoms improved and then worsened, finally presenting as a left abducens nerve palsy associated with headache. An MRI determined the palsy to be ischemic in nature. Abducens nerve palsies are commonly congenital, but trauma and microvascular causes are important etiologies to consider. This case will discuss the etiology, management, and expected clinical course of abducens nerve palsies.ries_palsy
Landing the Scleral Lens Fit: Navigating Conjunctival Abnormalities through NotchingRoper2022A 55-year-old patient with a history of a penetrating keratoplasty due to keratoconus presented with complaints of right eye conjunctival redness and irritation with his current scleral lens. Examination revealed significant compression of a new conjunctival elevation, which improved with scleral lens notching around the irregularity and proved to be a benign conjunctival finding. We will provide a comprehensive review of conjunctival lesions that may be encountered with scleral lens fitting, including differential diagnoses and management. We will also provide a practical approach to modification techniques to improve the peripheral scleral lens fit in patients with these landing zone abnormalities, as demonstrated by serial photography and OCT’s in our patient.roper_notch
The Curious Case of the COVID-19 Ischemic CRVOSeitz2022This poster highlights case of an ischemic central retinal vein occlusion (CRVO) as an ocular manifestation secondary to thromboembolic factors that are upregulated in Coronavirus disease (COVID-19).seitz_covid
Cytomegalovirus Retinitis in a Rare form of CancerSeymour2022Historically, cytomegalovirus (CMV) causes retinitis in a high percentage of patients with AIDS. More recently—with the emergence of highly active retroviral therapy, immunosuppressive therapies, and better survival rates for immunocompromised individuals—CMV retinitis has presented in HIV-negative populations. These patients often have complex medical histories and require a multidisciplinary approach in their treatment and management. This case presents a Caucasian male with T-cell prolymphocytic leukaemia who developed CMV retinitis despite being on long-term antiviral therapy. The presentation will review populations that are at higher risk of developing CMV retinitis, as well as the clinical signs, diagnosis methods, and treatment course involving infectious disease, hematology, oncology and ophthalmology.seymour_cmv
Exploring Genetic Testing for KeratoconusShan202215YO Native American male was referred to NSUOCO for genetic testing due to suspected keratoconus based on refraction and positive family history. AvaGen (Avellino Labs USA, Inc., Menlo Park, CA) is a genetic test that identifies the presence of high risk genes for keratoconus and corneal dystrophy conditions. This may allow for early diagnosis and management for these conditions. Corneal collagen crosslinking and refractive surgery decisions can also be impacted by these results. In contrast, it is also important to consider psychosocial interactions for the patient’s wellbeing. The patient was positive for the ADAMTSI8, COL4AI, and LTBP2 genes, placing him at a polygenic risk score of 43, correlating to a medium risk for keratoconus. Pentacam images were also obtained, which confirmed the diagnosis and argues against the need for genetic test after topographical signs are noted. The advantages and disadvantages of this novel new test are discussed, along with which case presentations will benefit the most from its implementation into practice. Furthermore, it will take a more in depth look at what each risk level for keratoconus indicates on this test.shan_genetic
Effect of OTX-101 on conjunctival staining and central corneal clearing: Pooled analysis of phase 2b/3 and 3 studiesShen LeeMelissa Toyos, Ranjan Malhotra, Robert Smyth-Medina, Brittany Mitchell, John Sheppard2022Conjunctival staining and central corneal clearing were assessed in patients with keratoconjunctivitis sicca (KCS) receiving 1 drop of OTX-101 0.09% or vehicle twice daily in an analysis of pooled, randomized, phase 2b/3 and 3 studies. Overall, 1048 patients were randomized (OTX-101 N=523, vehicle N=525). Mean (standard deviation) baseline total conjunctival staining score was 5.4 (1.7) for OTX-101 and 5.5 (1.7) for vehicle. Least squares mean (standard error) change from baseline to day 84 was −1.5 (0.1) for OTX-101 and −1.1 (0.1) for vehicle (P=0.0002). At baseline, 388 and 396 eyes receiving OTX-101 or vehicle, respectively, had a central corneal staining score >0. On day 84, 180 (50.6%) vs 151 (39.5%) eyes receiving OTX-101 vs vehicle had a score of 0 (P=0.0027). Adverse events were mostly mild. OTX-101 0.09% treatment caused greater improvement vs vehicle in conjunctival staining and central corneal clearing in patients with KCS.shenlee_otx
A Bleak Peak at Angioid Streaks: Managing Choroidal Neovascularization in a Patient with Angioid StreaksShtull2022A 53-year-old Hispanic female initially presents with 20/300 decreased vision in her right eye and 20/40 vision in the left eye. The patient is noted to have a choroidal neovascularization (CNV) in the right eye and bilateral angioid streaks. There is no neovascularization present in the left. As we follow this patient for the next 9 years, she goes through 16 intravitreal Avastin injections in her right eye and 20 injections in the left eye after subsequently developing a CNV. Her vision today is 20/150 in the right eye and 20/100 in the left. This patient is followed with fluorescein angiography, fundus autofluorescence and optical coherence tomography (OCT). Recent studies suggest an additional tool in monitoring hyperreflective foci found in spectral domain OCT imaging to monitor CNV activity.shtull_angioidstreak
Interdisciplinary Approach to the Scleral Lens as the Management for S/P Corneal Transplant from Neurotrophic Ulcer secondary to Adenoid Cystic Carcinoma of Oropharynx Radiation TreatmentSingh2022A 61 year old Caucasian male diagnosed with deviated septum allergic rhinitis and chronic sinusitis with no resolution. MRI revealed polypoid heterogeneously enhancing mass within the left nasal cavity that later revealed advanced local disease of Adenoid Cystic Cancer and staged as T4bN0M0 per ENT Tumor Board. Chemotherapy and radiation daily for 3 months resulted in significant dry eye and neurotrophic ulcer in the OS. He was treated with multiple modalities: artificial tears, Restasis, ophthalmic ointments, and Prokera without resolution. Visual acuity reduced to light perception. PKP was performed with a visual acuity 20/400 best corrected. He was fitted with Truform G1 scleral lens with resultant visual acuity of 20/25.singh_scleral
Serous MysterySranDr. Melissa Neuwelt, M.D.2022A 27-year-old female presented with distorted central vision OS. Visual acuity and confrontation fields OS were remarkable during entrance testing. Upon structural examination all findings were unremarkable except the posterior pole OS, which revealed a white lesion inferior to fovea within an ~2DD elevated yellow-grey blister. Macula OCT revealed serous macular neurosensory detachment, fundus autofluorescence revealed diffuse hyperfluorescence ~1DD in size inferior macula, and fluorescein angiogram showed leakage at the superior margin of the ONH. All findings OD were unremarkable. Differential Diagnoses: • Toxoplasmosis gondii • Central Serous Chorioretinopathy (CSCR) • Toxocaraiasis • Acute Retinal Necrosis (ARN) • Vogt Koyanagi Harada (VKH) • Sarcoidosis • Syphilis • Lyme Disease • Bartonella Henselae • Presumed Ocular Histoplasmosis Syndrome (POHS) Patient has a social history of exposure to multiple cats. Bloodwork was performed and returned positive for Bartonella Henselae/Quintana. At a 1 week follow up, classic signs of neuroretinitis appeared including macular star. Patient was treated with oral steroid and antibiotics (Prednisolone and Azithromycin + Rifampin) with recovery of vision from 20/125 to 20/25-3.sran_serous
That diplopia is all in your headSteiner2022Double vision is a symptom distressing to patient and provider alike. It’s propensity to produce a panic situation in the middle of a clinic day can make the knee-jerk reaction to any mention of double vision an immediate referral to a neurologist...or the nearest emergency room. For practitioners who deal infrequently with cases of neurologically-based diplopia, help is on the way! Simple guidelines for taking a meaningful case history, testing that can be done easily with equipment we bought in optometry school, and making the most effective referral will help rein in the flight to flight response. Case examples will illustrate triage of patients and make clear which cases are true emergencies.steiner_diplopia
Subjective Performance of Verofilcon A Daily Disposable Soft Contact Lens After 16 Hours of WearSubbaramanColton Heinrich, Gina Wesley, Bradley Giedd2022To evaluate the subjective performance of a novel, daily disposable silicone hydrogel soft contact lens (verofilcon A) after 16 hours of wear. This was a prospective, multicenter, pilot study, in which soft contact lens wearers were fitted with verofilcon A on a daily wear modality. The day before in-office visit, subjective ratings on visual analog scale (VAS) were completed for comfort, vision, and overall impression at 12 and 16 hours after lens insertion. During in-office visit ~10 hours after lens insertion, Likert questionnaires were completed. The results of VAS ratings (mean [SD]) for comfort, vision, and overall impression were 74.3 (21.9), 82.6 (16.6) and 80.1 (17.4) after 16 hours of wear, respectively. On Likert questionnaire, >90% of subjects agreed/strongly agreed for freshness, clarity and ease of use; and >80%, felt comfortable all day. Verofilcon A contact lens wearers provided high subjective performance ratings even after long hours of wear.subbaraman_verofilcona
Clinical Performance of New Lehfilcon A Monthly Replacement Silicone Hydrogel Toric Contact LensesSubramanianStephen Montaquila, Britt Gustafson, Susan Whaley2022This study evaluated the fit and rotational characteristics of the new lehfilcon A toric monthly replacement water gradient contact lens with the proven Precision Balance 8|4 design. Adult astigmatic soft contact lens wearers (n=69) wore lehfilcon A toric lenses for ~1 hour. Axis orientation; lens oscillation with blink; rotational recovery time following 30° manual dislocation; and subjective comfort ratings (1 to 10 scale) were evaluated. At 10 minutes after insertion, 94.9% of lenses had axis orientation within ±10° of the intended 90° axis. Mean absolute axis orientation was 3.0° at 3 minutes after lens insertion. 97.8% lenses oscillated ≤5° with blink. Mean rotational recovery time was 63.3 seconds after 30° manual dislocation. Mean insertion and overall comfort ratings were ≥ 9.0. The lehfilcon A toric lens provides a promising new monthly toric lens option with good axis orientation, on-eye rotation stability and excellent comfort ratingssubramanian_lehfilcona
Intravitreal Aflibercept in the Management of Chronic Retinal Arterial MacroaneurysmTacastacas2022A 70-year-old black male presents to the ophthalmology clinic for a 6 week follow-up for chronic retinal arterial macroaneurysm (RAM) OD and Eylea (aflibercept) injection OD. He has received a total of 3 Eylea injections OD with objective and subjective improvement in vision as well as a reduction in the size of the macroaneurysm evident on OCT. RAM, most commonly associated with hypertension, may be asymptomatic or cause visual decline with exudation or hemorrhage. This patient had a chronic, visually significant RAM that responded well to intravitreal aflibercept. Anti-VEGF injections, which may reduce RAM leakage, are a promising treatment for symptomatic RAM.tacastacas_macro
Treatment and Management of Bilateral Amblyopia due to Partially-Accommodative EsotropiaThomasDr. Ariela Baran2022Acquired esotropia can be classified by either refractive, non-refractive etiologies, or a combination of the two. In partially or fully accommodative esotropic patients, their deviation can be resolved or partly improved with full correction of their hyperopic refractive error. Isometropic amblyopia arises due to analogously high levels of uncorrected refractive error present in both eyes. This case report illustrates the multi-faceted management of a partially accommodative esotropia and isometropic hyperopic amblyopia in a 4-year-old patient. Treatment involved the implementation of patching, corrective lenses, and a near add to attain stable binocularity, alignment, and greatly improve visual acuity for the patient.thomas_amblyopia
Utilizing Anterior OCT to Visualize Residual Descemet Membrane Tissue in Keratoglobus Post Corneal HydropsVictorThuy-Lan Nguyen, OD, FAAO Stacy Zubkousky, OD, FSLS2022Keratoglobus is a rare non-inflammatory corneal ectasia which is characterized by globular protrusion of the cornea and profound corneal thinning. Acute corneal hydrops is a complication in patients with corneal ectasias such as Keratoglobus. Corneal hydrops occurs when Descemet’s membrane ruptures causing corneal edema, pain and blurred vision. Once corneal hydrops resolves, Anterior OCT is useful to visualize any residual Descemet tissue, which would not be seen with biomicroscopy examination alone. This case features the benefits of Anterior OCT for the diagnosis and monitoring of corneal hydrops.victor_oct
Bilateral CNVM secondary to Chronic Central Serous ChorioretinopathyVo2022Central serous chorioretinopathy (CSR) is a disease characterized by the serous detachment of the neurosensory retina due to a leakage from the choriocapillaris. Although CSR is often self-limiting, in a subset of patients, recurrent and chronic CSR may result in RPE atrophy and choroidal neovascularization. This case report depicts a 72-year-old white male who presented to Kaiser Permanente Los Angeles with a complaint of sudden vision loss in the right eye that started a few days prior. His BCVA was 20/60 OD and 20/20 OS. Pertinent medical history consisted of prostate adenocarcinoma. Our slit lamp exam showed a visually significant nuclear sclerotic and posterior subcapsular cataract OD>OS. OCT showed peripapillary intraretinal fluid OU and cystic macular edema OD. Upon retina consult, patient was diagnosed with likely bilateral CNVM secondary to chronic CSR due to chronic steroid usage.vo_cscr
Visual recovery in a case of COVID induced bilateral occipital ischemic strokeVo2022A 69 year old African American male experienced hospitalization with acute respiratory failure following CoVID-19 infection. CT scans revealed bilateral subacute strokes in bilateral occipital lobes at the time of admission. In the immediate months following admission, examinations revealed that patient was blind bilaterally. However, at the 6 month follow up, examination revealed greatly improved visual acuity (20/20), but with severely constricted visual fields (less than 5 degrees). This case reports outlines the impact of acquired brain injury on the visual pathway and discusses visual recovery through hypothesized mechanisms of brain plasticity or cortical re-perfusion.vo_stroke
Demodex BlepharitisVollmerScott Schecter2022Demodex blepharitis is a common and heavily unrecognized condition that can present with a wide range of signs and symptoms for our patients. While typically found with increased age, demodex blepharitis can be especially significant in the younger population, particularly those with meibomian gland dysfunction or patients who wear contact lenses. By decreasing the amount of demodex on patients lid margins, we can effectively lessen symptomatic complaints (burning, itching), and decrease tear hyperosmolarity as well as inflammatory cytokines found in the tear film. In the past, many physicians have even chosen to overlook demodex blepharitis due to the available treatment options. Fortunately, new treatment options are on the horizon. By recognizing and addressing demodex blepharitis, patients can discover an increased quality of life and minimize ocular symptoms often misdiagnosed as dry eye.vollmer_demodex
Too Much of a Good Thing? Suspected AACE Secondary to Device UseWest2022Acute acquired comitant esotropia (AACE) is a new onset esotropia that is moderate in size and usually occurs between the ages of 5 and 12 years-old. A couple of recent papers suggest excessive device use may contribute to the development of AACE. The purpose of this poster is to report a presumed relationship between increased device use and AACE in an adolescent patient. A 10 year-old female presented with new onset esotropia 7 months post-in-office vision therapy for mild convergence insufficiency with accommodative infacility. Upon further investigation, her mother reported a significant increase in the amount of screen time secondary to transitioning to virtual learning amidst the COVID-19 pandemic. A 25^ CAET was measured with nil stereo. On Worth-4-dot testing, the patient reported suppression at distance and uncrossed diplopia at near. The patient has mild a hyperopic Rx and little improvement in the strabismus with +2.00 add at near. Due to the sudden onset of the deviation, neurological imaging was ordered to rule out underlying disease. MRI results came back within normal limits. Bifocal lenses were prescribed to the patient due to subjective improvement; however a surgical consult was also recommended.west_aace
boTICKSulinum A case report of hemifacial spams secondary to Rocky Mountain Spotted FeverWhiteElizabeth Lemos2022A fifty-year-old male presents for an annual comprehensive eye exam. He has concerns of right facial muscle contractions that induce a sensation of periorbital pressure. He was recently diagnosed with subclinical Rocky Mountain Spotted Fever with significant systemic sequala. Although facial spasms are not appreciated in office and his ocular health examination is unremarkable, he is offered a consultation with an oculoplastic specialist for symptoms of presumed hemi-facial spasms. During his consultation, an onabotulinumtoxin injection is administered to manage symptoms. At follow up, he reports reduced frequency and intensity of spasms with increased dry eye. This case succinctly summarizes the pathophysiology, differentials, and treatment of a case of hemifacial spams with a unique etiology and the role of onabotulinumtoxin in treatment and its potential side-effects.white_fever
Safety Assessment of OC-01 (varenicline solution) Nasal Spray: A Novel Therapy for Dry Eye DiseaseWhitleyAlan G. Kabat, OD; Laura Hendrix, MS; Andrea Gibson, PhD2022Background: Three clinical studies evaluated the safety and efficacy of OC-01 (Tyrvaya®) nasal spray in patients with dry eye disease. Another study (ZEN) compared OC-01 with marketed doses of oral varenicline to determine systemic absorption. Methods: Integrated data from the three studies were assessed for adverse events in subjects treated with OC-01 vs. vehicle control. In ZEN, subjects received a single, bilateral dose of OC-01 and a single oral varenicline tablet in crossover fashion. Results: The most common adverse events were sneezing (82%), cough (16%), throat irritation (13%) and nasal irritation (8%). The mean plasma Cmax for OC-01 was 7.5% that of oral varenicline. Conclusion: This safety review supports that OC-01 was well tolerated in clinical trials. The systemic absorption of OC-01 was far lower than oral varenicline.whitley_nasal
Age is Just a Number: Successful Scleral Lens Wear in a 91 year old patientWootenSangita Vadapalli, OD2022BACKGROUND Herpes zoster (or shingles) is caused by the reactivation of varicella-zoster virus along the trigeminal nerve. Symptoms can include unilateral burning pain, headache, and a dermatomal vesicular rash. Acute keratitis is one of the most common complications to occur with HZO. CASE DESCRIPTION A 91-year-old Caucasian male was referred to a VA contact lens clinic for HZO associated keratitis. The patient complained of blurred vision in the right eye secondary to corneal scarring. He was interested in using contact lenses due to limited visual improvement in spectacles. A Jupiter Reverse Geometry scleral lens was successfully fit and prescribed. CONCLUSION Scleral contact lenses are visually beneficial to patients with a wide spectrum of corneal irregularities. Furthermore, scleral lenses serve as a protective moisture chamber and assist in preventing physiological disruptions to the ocular surface.wooten_scleral
Clinical Lens Fit Evaluation of the Delefilcon A Toric Daily Disposable Silicone Hydrogel Soft Contact LensWuKatherine Bickle, MS, OD, FAAO; Britt Gustafson, OD; Bradley Giedd, OD, MS, FAAO2022The new delefilcon A toric (DT1fA) lens features a core lens material containing 33% water that transitions to a hydrogel surface layer that exceeds 80% water. Precision 8|4 toric lens design enables quick lens settling and minimizes oscillation with blink. Subjects (n=47) were fitted with DT1fA lenses in this prospective, multi-center, bilateral clinical study. Lenses were worn for approximately 1 hour. Lens settling time; axis orientation at 1 and 3 minutes; lens oscillation with blink; lens movement and centration were assessed. Mean (SD) lens settling time for the DT1fA lens was 36.7 (54.6) seconds. Mean (SD) absolute axis orientation was 3.2 (5.3) degrees after 1 minute and 2.1 (3.2) degrees after 3 minutes. All lenses oscillated ≤ 5° with blink after lenses settling. Lens movement and centration were optimal for the majority of the lenses. Overall, DT1fA lenses achieved excellent alignment, stability and fit shortly after insertion.wu_toric
Hand-Me-Down Jeans or Genes: Pediatric Ocular-Management of Marfan SyndromeYaminMichael Au, OD, FCOVD2022A 12-year-old male with a third generational diagnosis of Marfan Syndrome was referred for a contact lens fit to manage amblyopia and aniseikonia influenced by bilateral subluxated crystalline lens bisecting the visual axis. Visual acuities refractively improved from 20/125 OU to ~20/40 OU in the distance with fluctuating clarity dependent on lens position throughout the day. He demonstrated considerable improvement in visual acuity in dim vs. bright conditions. Several lens options were considered ranging from bifocal to tints. Slit lamp evaluation revealed subluxated lenses superior nasally OU. This poster will review ocular and systemic prognosis for a pediatric patient with Marfan Syndrome and include helpful insight into visual accommodations necessary for school.yamin_marfan
Cataract progression and asymmetric myopia development following hyperbaric oxygen therapyYuanLisa Christian, OD, FCOVD, FAAO Angela Peddle, OD, FCOVD2022Hyperbaric oxygen therapy (HBOT) uses pure oxygen (pO2) in a pressured environment to enhance tissue oxygenation and cellular metabolism to treat decompression sickness, and more recently for neurological conditions such as traumatic brain injury (TBI). With its increased use, reports have shown a link between high pO2 exposure with the development of cataracts and a myopic shift. Onset is seen following prolonged treatment (> 150 sessions) but appears to occur more quickly in patients with pre-existing cataracts (< 25 sessions). A case study will be presented to highlight this association and will discuss treatment options.yuan_hyperbaric
An Exponential Increase in Cutaneous Ocular Herpetic Reactivation Following SARS-COV-2 Variant Spike and Natural Disaster in Southeast Louisiana: A Retrospective StudyZhaoAmy Puerto, O.D., FAAO2022Cutaneous herpetic reactivation is widely associated with infection, physical and psychological stress. Following the SARS-COV-2 Delta variant spike in the United States Gulf Coast July 2021, another natural disaster, Hurricane Ida, simultaneously affected the region. During this tumultuous time, one southeast Louisiana eye clinic experienced an exponential increase of herpetic eye infections by 433% compared to the previous pandemic year (i.e. 26 patient cases vs. six cases measured between May-November 2021 and 2020). SARS-COV-2 dysregulates the body’s innate and adaptive immune response. This has the potential to render lymphocytes unable to inhibit herpetic viral replication and risk further herpetic reactivation. Significantly, literature concedes the Delta variant is 50% more virulent than its original SAR-COV-2. With this understanding, the authors retrospectively suggest the increased illness rate of the Delta variant, coupled with the stressor of Hurricane Ida, escalated the frequency of herpetic eye disease observed in the clinic.zhao_herpetic
Functional Vision Loss in a Child with Chronic Inflammatory Demyelinating PolyneuropathyAddyKaila Osmotherly, O.D., FAAO2020A 14-year-old female with established diagnosis of Chronic Inflammatory Demyelinating Polyneuropathy (CIDP) and under care of a neurologist for progressive limb weakness was evaluated for severe bilateral vision loss. Visual acuity was 20/250 OD/OS and visual field was constricted to less than 40 degrees. Fundus examination was normal, as were visually evoked potentials and optical coherence tomography. Electroretinogram could not be recorded due to electrode intolerance. While CIDP has been associated with vision loss from demyelinating optic atrophy, the patient’s objective clinical findings and observed conduct and affect point to functional vision loss not due to organic etiology. The case highlights strategies for differentiating between organic and functional vision loss.addy_functional
Juvenile open angle glaucoma with bleb leak and associated hypotonyAnderson2020A 51 year old white male new to clinic with reported longstanding history of juvenile open angle glaucoma presented with acute onset blur in the right eye for 1 month. Pertinent patient history included a trabeculectomy in the left eye in 2009, the right eye in 2011, and a baerveldt valve in the left eye in 2012. Clinical examination revealed a 3 diopter hyperopic shift from his habitual prescription in the right eye only. IOPs were 7mmHg in the right eye and 24mmHg in the left. A large scleral defect was present superiorly in the right eye with a thin bleb which was Seidel positive. Fundus examination showed choroidal folds through the macula with an elevated appearance to the posterior pole. Fundus photography and spectral-domain optical coherence tomography were performed as well as B-scan ultrasonography to confirm hypotony of the right eye. Referral was then made to a glaucoma specialist where patient underwent bleb revision surgery.anderson_juvenile
Cranial Nerve VI Palsy in a patient with Spontaneous Intracranial HypotensionAnderson2020In most diabetic or hypertensive patients, CN VI palsies are vascular in nature. However, one should consider other potential causes when patients present with unusual symptoms. One of these causes is intracranial hypotension as it can cause displacement of the brain and compression of CN VI. A 56 year-old female presented to clinic with complaints of double vision, periorbital pain, headache and nausea for one week. The patient was noted to have a complete left CN VI Palsy. She was sent for MRI, CT and lumbar puncture. Low opening pressure and immediate improvement of headache upon placement of lumbar epidural blood patch confirmed the diagnosis of Spontaneous Intracranial Hypotension.anderson_cranial
Non-ischemic Central Retinal Vein Occlusion with Paracentral Acute Middle MaculopathyBaker2020This case study describes a 65-year-old diabetic Navajo woman who presented to Zuni Comprehensive Community Health Center in July 2019 complaining of blurry vision with grey spots in the right eye. In addition to classic signs of central retinal vein occlusion (CRVO), funduscopy revealed patchy whitening of the macula, which was photodocumented. SD-OCT demonstrated corresponding hyperreflective bands in the outer nuclear layer. The patient was diagnosed with non-ischemic CRVO with paracentral acute middle maculopathy (PAMM) and followed until resolution. PAMM is thought to be caused by ischemia to the deep retinal capillary plexus. It is associated with several retinal vascular disorders, with CRVO being the most common.baker_crvo
Under the Sea-Fan: A Case of Proliferative Sickle Cell Retinopathy with Seafan NeovascularizationBateh2020Sickle cell retinopathy is the most common ocular complication of sickle cell disease, an inherited hemoglobinopathy causing a genetic mutation that prevents normal blood flow and results in increased venous stasis, hypoxia, acidosis, and inflammation associated with various systemic and ocular conditions. Disease progression into the proliferative stages include seafan neovascularization and can further lead to irreversible blindness if not diagnosed and treated properly. This case evaluates various causes of peripheral neovascularization ultimately leading to a clinical finding of seafan neovascularization in an African American male with sickle cell disease.bateh_seafan
Effectiveness of Low Vision Telerehabilitation on Improvement in Reading with the Use of Vision Assistive DevicesBerezu2020Low vision rehabilitation is an important component in managing visually impaired patients. For many low vision patients, it is challenging to comply with in-office rehabilitation appointments due to difficulties related inability to drive, have access to other transportation options, and ambulation issues. Telerehabilitation is a new modality in delivering patient care that overcomes the transportation and ambulation obstacles for visually impaired patients. In our case report, we assess telerehabilitation effectiveness on improvement in reading with vision assistive devices for low vision patients. Additionally, provider and patient satisfaction with telerehabilitation as a method of delivery of care will be discussed.berezu_telerehab
Central Retinal Vein Occlusion with associated Paracentral Acute Middle MaculopathyBhavsar2020Paracentral Acute Middle Maculopathy is a rare condition characteristic of hyper-reflective spectral-domain OCT lesions at the level of the INL. It is likely caused by ischemia in the deeper retinal layers. A healthy 54 year old female presents with a sudden patchy loss of vision OD upon waking. The patient’s BCVA is 20/20 OD, OS and OU. The posterior pole OD is characteristic of a vein occlusion. SD-OCT imaging shows subtle intraretinal opacification at the level of the INL OD without any macular edema OU. PAMM can be often underdiagnosed unless SD-OCT is performed and evaluated carefully. This poster will introduce PAMM: its presentation, etiology and provide recent literature review.bhavsar_crvo
Gonococcal ConjunctivitisBianciotto2020Gonococcal conjunctivitis is a bacterial ocular infection that is typically contracted during sexual activity. It is diagnosed through confirmation of cultures obtained from conjunctival swabs. Those infected with gonococcal conjunctivitis typically exhibit high-risk behaviors and lifestyles that put them at high risk for other infections. This poster presentation reviews the diagnosis, treatment, lab tests and referrals for gonococcal conjunctivitis.bianciotto_gono
CADASIL; implications in treatment, diagnosis and management of glaucomaBisighini-FikseTam Ying, Theresa Zerilli-Zavgorodni2020Cerebral Autosomal Dominant Arteriopathy with Subcortical Infarcts and Leukoencephalopathy (CADASIL) is a rare inherited small vessel arteriopathy that is characterized by recurrent subcortical ischemic lesions, vascular dementia, mood disturbances and migraine with aura. While there isn’t an ophthalmologic finding that can be considered a hallmark of the disease, CADASIL can affect both the afferent and efferent visual systems. As with other degenerative neurological diseases, studies have confirmed reduction in retinal nerve fiber layer (RNFL) thickness in patients with CADASIL. This poster will review the case of a 54 year old with CADASIL, exhibiting large optic nerve cupping, RNFL loss, and unreliable perimetry testing to further confound the diagnosis of glaucoma. Ocular complications of CADASIL will also be reviewed.bisighini_cadasil
The Weekend Red EyeBlakley2020As optometrists, red eyes are one of the most common medical conditions encountered in the office. And while there are numerous causes for this peculiar chief complaint, what happens when artificial tears, antibiotics, or steroids will not be enough? This presentation covers a case in which one weekend red eye was the result of neovascular glaucoma and became a swift referral to a retinal specialist, glaucoma specialist, and endocrinologist. When a patient with diabetes presents with a red eye, keep the broadest of differentials.blakley_redeye
A Case Report: Complications of Congenital GlaucomaBrar2020Congenital glaucoma presents itself in the pediatric population, typically before 3 years old, and can result in various complications if left untreated or misdiagnosed. Signs and symptoms, other than elevated intraocular pressure, are key in the diagnosis of this condition such as corneal haze, haab striae, myopic shift, extreme photophobia secondary to corneal edema, and buphthalmos. Presentations vary based on severity and time of diagnosis. Unlike adult primary open angle glaucoma, treatment for congenital glaucoma is primarily surgical with trabeculotomy or goniotomy. If treated early and successfully, this condition can be resolved! Due to the congenital nature of this condition, majority of patients will need lifetime follow up plans.brar_glaucoma
When the Tests Don't Add UpBroganMargaret Moore, OD2020Functional vision loss (FVL) is a diagnosis that can often seem overwhelming and difficult to identify when patients experience loss of vision. Patients who experience FVL will display a loss of visual acuity and/or visual field constriction. FVL is a diagnosis that often requires a multidisciplinary approach as patients typically require neurological testing to rule out more occult disease processes, as well as mental health counseling to guide them towards recovery. This poster presents a case of FVL and provides tools that can be utilized to achieve full visual function as well as illuminate when to refer your patient for care outside of the optometric scope.brogan_tests
Disulfiram toxicity: an additional consideration in patients with sudden vision lossCapriTheresa Zerilli, OD, FAAO; Nancy Shenouda-Awad, OD, FAAO2020Disulfiram, a medication prescribed to treat alcoholism, has been associated with inducing a reversible bilateral optic neuropathy. In rare cases, a sudden and severe decrease in both visual acuity and visual field has been linked to the use of disulfiram. Diagnosis can only be presumed after excluding all other possible causes for bilateral optic neuropathy with extensive blood and imaging studies. Once diagnosis is suspected, cessation of medication is mandatory and prognosis in most cases is expected to be good. This poster presents an atypical irreversible bilateral optic neuropathy in a patient treated with disulfiram. Differential diagnosis, recommended work-up along with treatment and management will be reviewed.capri_toxicity
Mapping of Shattered Glass Vision in Systemic Lupus Erythematosus-Associated Central Retinal Artery OcclusionChan2020A 55 year old Native American female with poorly controlled systemic lupus erythematosus (SLE) reported atypical shattered glass vision OS, described as clear windows in between opaque gray streaks, unchanged since central retinal artery occlusion (CRAO) one year prior. This case illustrates structural and functional mapping of the shattered glass pattern through ancillary testing. Optical coherence tomography angiography and retina map using Optovue revealed reduced flow signal and scattered areas of thinning confined to the inner retinal layer, respectively. These defined areas had high spatial correlation with focal visual field defects on Humphrey Field Analyzer. Microperimetry using Macular Integrity Assessment simultaneously mapped out varying retinal sensitivity with retinal imaging in real-time. Unlike the common embolus, vaso-occlusive diseases in SLE are immune complex-mediated and secondary to micro-thrombosis. Absence of true vasculitis supports that the inner retinal layer was unevenly susceptible to ischemic stress, leading to incomplete or speckled retinal infarction. Successful mapping of this pattern was able to satisfactorily address the patient’s longstanding visual complaint.chan_lupus
Knowing When to Do Nothing: Macular Edema in Diabetic PatientsChan202047-year-old Hispanic male presents with acute blur in the left eye. Ocular history was unremarkable; medical history was significant for well-controlled Diabetes Type 2, Hypertension, and Hyperlipidemia. Examination revealed mildly reduced vision in the left eye with correlating retinal exudate. Given the lack of other signs for diabetic retinopathy, the patient was referred to retina for central macular edema of unknown etiology. Differentials included macular BRVO and Macular Telangiectasia, but etiology remained unclear after ophthalmology consult. Literature suggests concomitant microvascular disease increases risk of macular edema in diabetics. Evidence-based practice proves successful treatment of macular edema with laser or anti-VEGF injections, however new studies show observation is appropriate. Ophthalmology chose to observe our patient and he recovered without treatment, as outlined in these 2019 studies.chan_edema
Healthy male with not so healthy retina: Vasoproliferative tumorChenJarett Mazzarella2020A 36 y/o male presented with decreased vision OD. His BCVA was 20/30- OD. The DFE revealed intraretinal lipids along the inferior arcade with a serous detachment of the inferior macula OD. Peripheral examination revealed an elevated subretinal lesion with overlying hemorrhages, lipids, and telangiectatic vessels. Retinal vasoproliferative tumors (VPT) are uncommon, unilateral, benign vascular tumors commonly located in the inferotemporal peripheral retina. Presenting symptoms can include floaters, decreased vision, photopsia and metamorphopsia. Common associations include macula edema, progressive erm, exudative RD or vitreous hemorrhage. VPT share similar features with other retinal vascular tumors which can be associated with systemic manifestations. This poster heightens the awareness of prompt diagnosis of VPT in clinical practice.chen_vasoproliferative
Diagnosis of mitochondrial optic neuropathy in a case of presumed traumatic optic atrophyChivettaKristen Buskirk OD, Allison Schafers OD, Matthew Simpson OD2020A 34-year-old white male presented for a low vision exam for adjustment of a bioptic and a complaint of worsening vision. With a history of head trauma and exposure to an IED blast, he was previously presumed to have bilateral traumatic optic atrophy. However, progressive vision loss since the age of eighteen necessitated further investigation, and a referral to neuro-ophthalmology was made. Differential diagnoses included nutritional, toxic, and hereditary optic neuropathies. MRI, nutritional labs, and toxic lab testing were normal. Examination and review of prior records revealed bitemporal atrophy, central scotomas, and abnormal VEP consistent with mitochondrial optic neuropathy (MON). Treatment for inherited disorders are a growing area of research.chivetta_mitochondrial
A Clinical Case Study of Atypical Intradermal Melanocytic Nevus of the Eyelid MarginChronister2020This case study will review a biopsy confirmed acquired intradermal melanocytic nevus of the upper right eyelid margin in a 75 year old African American female. Based on the clinical appearance it was tentatively diagnosed as an apocrine hidrocystoma by an optometrist and as seborrheic keratosis by an oculoplastic ophthalmologist. Therefore, the intradermal melanocytic nevus had an atypical presentation. This poster will review the histology of the eyelid skin and eyelid. Included will be a review of the etiology/pathology of melanocytic nevi of the eyelid margin, their varied clinical presentations, their risks of malignancy and their management.chronister_melanocytic
An Out of Water Experience with Torpedo MaculopathyColl2020Torpedo maculopathy is a congenital and typically benign retinal anomaly that occurs rarely within the population. This poster outlines two case reports of the unique retinal finding. Both patients presented with best-corrected visual acuities of 20/20 in the affected eyes, and were completely asymptomatic. Imaging techniques such as fundus photography, red-free filtering, SD-OCT 5-line raster, and visual field testing were performed in order to delve deeper into the etiology and structural nature of the lesions. The results call into question some of the current hypotheses regarding the origin of torpedo maculopathy, as well as how to appropriately manage patients with this peculiar retinal abnormality.coll_torpedo
Clinical performance comparison of a novel SiHy and a HEMA-based daily disposable contact lensCummingsAnne Brobst, OD2020Purpose: To assess lens preference, comfort, handling and quality of vision of verofilcon A compared to etafilcon A. Methods: 22 subjects completed this prospective, randomized, double-masked, parallel crossover pilot study. After 7-10 days of lens wear, comfort, handling and quality of vision were rated on a 1-10 scale. Overall lens preference was assessed.. Results: 77.3% of subjects preferred verofilcon A. Comfort was rated 9.2 and 8.1; handling was rated 9.5 and 7.5; quality of vision was rated 9.2 and 8.8 for verofilcon A and etafilcon A, respectively. Conclusion: Subjective ratings were higher than 9/10 for comfort, handling and quality of vision, with a high overall preference for verofilcon A.cummings_novel
Eccentric Viewing: Tailoring the View to the GoalDanielTheresa Zerilli, O.D., F.A.A.O., Nancy Shenouda-Awad, O.D., F.A.A.O.2020Eccentric Viewing (EV) is a technique that utilizes a non-foveal preferred retinal loci (PRL) for fixation. EV is an invaluable part of low vision rehabilitation (LVR), as it can significantly increase threshold vision in patients with central scotomas.  Typically, a patient will have one ideal PRL that is trained and utilized to meet all visual goals. However, in certain cases, accessing more than one PRL may be necessary depending on the demands of the task and the need for global versus local information.   This case demonstrates the selection and training of 2 PRLs to successfully meet the patient’s goals. Characteristics that influence PRL function and usefulness will be discussed.daniel_eccentric
Early experience with iStent inject® trabecular micro-bypass implantation with phacoemulsificationDavidsonDr Josh Davidson, OD (Dr. Davidson is part of Dr. Blake Williamson’s team and is reporting Dr. Williamson’s inject data.)2020Purpose: Evaluate initial outcomes with iStent inject combined with phacoemulsification for OAG Methods: Case series (n=76 eyes) evaluating IOP and medications in eyes implanted with iStent inject Results: Postoperative IOP at Month 1 (M1) 16.1±3.2 mmHg (n=54), M3 15.5±3.7 mmHg (n=26), M6 17.0±2.3 mmHg (n=12), Year 1 16.9±3.4 mmHg (n=9) (p<0.001 compared to preop for all timepoints). Represents 21-28% reduction in IOP (4.6-6.1 mmHg). Postoperative mean number of meds at M3 0.8±0.9 (n=25), M6 1.0±1.2 (n=12) and Year 1 0.2±0.4 (n=9) (p<0.05 compared to preop for all timepoints). Favorable safety profile. Conclusion: Early evidence provides clinically and statistically favorable outcomes with iStent inject implanted with phacoemulsification.davidson_istent
Management of Oculopharyngeal Muscular Dystrophy: A Case ReportDavis2020A 68-year-old white male with a history of Oculopharyngeal Muscular Dystrophy presented to the low vision clinic for evaluation and management of bilateral eyelid ptosis. Visual field testing and low vision device evaluation were performed. The patient was not interested in surgical intervention and was fit with ptosis crutch glasses with extensive dry eye education and management. Oculopharyngeal Muscular Dystrophy is named for its effect on the muscles of the upper eyelids and the throat, causing ptosis and dysphagia, respectively. It is a slowly progressive autosomal dominant inherited condition affecting 1/100,000 people. This report will review the dystrophy and ocular management of associated symptoms.davis_macular
Masquerader and The CrusaderDemerittBeata Lewandowska2020Introduction Multiple myeloma is a hematological malignancy of older adults where there is an abnormal proliferation of plasma cells. Malignant diseases can masquerade as intraocular inflammation and often be misdiagnosed as chronic idiopathic uveitis. We report a case of multiple myeloma masquerading as a bilateral anterior uveitis. Case Report A 60-year old black female presented with complaints of tearing, mild redness, pain and photophobia OU. PMHx is positive for multiple myeloma. BVA was 20/20 OD, OS. Biomicroscopy revealed trace cells in the anterior chamber OD and 1+ cells in the anterior chamber OS. Conclusion Ophthalmic involvement associated with multiple myeloma is rare; however, eye care providers should be aware that malignant diseases can masquerade as intraocular inflammation.demerritt_crusader
Capsular Bag Distention SyndromeDuan2020Capsular Bag Distention Syndrome (CBDS) is a rare complication of cataract surgery where turbid fluid flows between the posterior chamber intraocular lens (PCIOL) and a distended posterior capsule. Capsular distention can result from intraoperative high irrigation pressures during hydrodissection, retained viscoelastic between the PCIOL and posterior capsule in early-onset CBDS, or gradual inflow of fluid in late-onset CBDS. Symptoms most commonly include a gradual decrease in vision in the affected eye due to fluid turbidity, a possible shift in PCIOL positioning, and eventual posterior capsular opacification compared to a clear fellow eye. Initiation of treatment with YAG laser is determined subjectively based off the severity of reduced vision experienced by the patientduan_capsular
Scleral contact lenses used for visual rehabilitation in a patient with bilateral corneal perforationEmiah2020This is a case of a 56 YO AA male who developed severe graft vs host disease (GVHD) post bone marrow transplant from a rare form of leukemia called myelodysplastic syndrome. While being on maximum topical therapy for keratoconjunctivitis sicca he developed severe corneal thinning, ulcer formation and subsequent perforation in both eyes. As a result of this corneal irregularity he was unable to drive or work due to severe visual impairment and extreme photophobia and pain. After being fit successfully in scleral contact lenses in both eyes this patient achieved a visual acuity of 20/25 OD and 20/30 OS which then allowed him regain a much higher quality of life.emiah_scleral
The Pseudo-Foster Kennedy ConundrumFERRAZJulie Rodman OD2020A 46 y/o diabetic, hypertensive, overweight BF presented for comprehensive eye exam complaining of intermittent “vision black outs” that occurred a few times a month over the last 5 years. She reported past imaging of the brain/orbits with unremarkable findings. BCVA measured 20/25 OD and 20/20 OS with evidence of a RAPD OD. Fundoscopy revealed diffuse optic nerve pallor OD and mild disc edema OS with a small, crowded ONH appearance. Neuro-ophthalmologic consultation was requested to assess for differential entities presenting with prior optic atrophy and acute optic disc edema including inflammatory, vasculopathic, and compressive etiologies.ferraz_foster
Uveitis: How are you going to React(ive Arthritis)?Flanagan2020Non- granulomatous uveitis is usually idiopathic, but can have systemic associations. Recurrent or bilateral episodes of non-granulomatous uveitis are more likely to have correlations with systemic conditions. Those conditions most highly associated are those inflammatory conditions with the HLA-B27 marker. These conditions may require more aggressive treatment than the initial visit, especially if the systemic conditions are newly diagnosed and not fully systemically managed. A systemic condition causing a non-granulomatous uveitis can go undiagnosed if related symptoms such as lower back pain, joint stiffness, or difficulty with urination.flanagan_uveitis
Safety profile of a novel oxymetazoline hydrochloride solution in development for the treatment of acquired blepharoptosis: integrated results from two clinical studiesFosterDavid Jacobs (Vertical Pharmaceuticals, LLC, Bridgewater, NJ); Tina deVries (Vertical Pharmaceuticals, LLC, Bridgewater, NJ); Mark Jaros (Summit Analytical, Denver, CO); Charles Slonim (University of South Florida Morsani College of Medicine, Tampa, FL)2020RVL-1201 (oxymetazoline hydrochloride ophthalmic solution, 0.1%) is an investigational, first-in-class pharmacologic agent developed for the treatment of acquired blepharoptosis. The safety of RVL-1201 once-daily administration for 6 weeks was evaluated in 203 subjects across two randomized, double-masked, controlled phase 3 clinical studies. Additionally, 101 subjects received vehicle across the studies. The frequency of treatment-emergent adverse events (TEAEs) was 31.0% for RVL-1201 and 35.6% for vehicle. Most TEAEs were mild and not considered treatment-related. No clinically significant mean shifts in visual acuity, pupil diameter, or intraocular pressure were observed. Among subjects receiving RVL-1201 for 6 weeks, 95.5% rated RVL-1201 as causing no discomfort.foster_safety
“Beyond 20/20: A Case of Vestibulo-Ocular Reflex Dysfunction Secondary to Wallenberg Syndrome.”Fowler2020An 81 year old white male presented for acute onset vertical diplopia after a lateral medullary stroke and diagnosis of Wallenberg Syndrome. After thorough testing, we prescribed vertical prism for a constant right hypertropia and nystagmus in primary gaze. Still learning how to walk, swallow, and smile again, the patient was content with his 20/20 vision and had a complete resolution of his diplopia after four months. Eight months after his initial visit, the patient had persistent difficulties when driving; specifically when checking for oncoming traffic over his left shoulder. After further examination, we found that the stroke had damaged his Vestibulo-Ocular Reflex. Although some may view this problem as a purely neurological issue, vision therapy programs addressing cerebellar, vestibular, and ocular disconnects have had marked success in improving patients’ quality of life. This case emphasizes the importance of continuing to dig deeper into patient complaints rather than settling for 20/20.fowler_beyond
Qsymia: a lesser known cause of Acute Angle ClosureFreeney2020A 28-year-old female presented with a 4.0 diopter myopic shift, pain, elevated intraocular pressures bilaterally, and other clinical signs consistent with bilateral acute angle closure (AAC). Further review of medications revealed the patient was taking Qsymia, a lesser known, weight loss medication containing Topiramate and Phentermine. This case reviews the diagnosis, treatment, and management of medication-induced AAC.freeney_acute
VERSITILITY AND EASE OF USE OF HEAD-MOUNTED ELECTRONIC MAGNIFIERS VERSUS SMARTPHONES: An optometry student’s perspectiveGermanDr. Karen Squier, OD2020This survey study determines how optometry students compare the ease of use and intuitive nature of three devices used in a low vision clinic. The devices include smartphone adaptations (iPhone IOS or Android platform), IrisVision, a head-mounted unit that uses smart phone technology, and the Jordy, a standalone low vision device. Preliminary survey results indicate fourth-year optometry students tend to favor the Jordy based on image quality and simplicity of design. Additional data will include third, second and first-year students in addition to non-optometric staff as a control. As technology advances it is helpful to assess potential preferences and biases optometry students may develop when assessing assistive technology with patients.german_versatility
Evaluation, Management, and Treatment of Acute Posterior Multifocal Placoid Pigment Epitheliopathy: Clinical Imaging and Neurological ConsiderationsGilletteErica Smith O.D.2020A 62-year-old male presents with bilateral vision loss and central scotoma OD. History is remarkable for recent “flu-like” symptoms. Initial exam was unremarkable, but follow-up exam showed a severe reduction of vision from 20/25 OD, 20/125 OS to 20/125 OD/OS with an increase in retinal pigment epithelium inflammation. Retinal evaluation using optical coherence tomography, fundus autofluorescence, fluorescein angiography, and indocyanine green angiography supported the diagnosis of acute posterior multifocal placoid pigment epitheliopathy. Recommended treatment is systemic steroids. Further systemic and neurological testing, including magnetic resonance imaging and angiography, is indicated due to an association with central nervous system vasculitis. Patient was steady improving until he was lost to follow-up.gillette_acute
The efficacy of ventricularperitoneal shunts in the presence of papilledema secondary to a third ventricular tumor.Gonzales2020Patient is a 16 year old white female originally presenting for progressive headaches, vomiting and visual blurring. She had bilateral grade 4 papilledema with constricted visual fields secondary to an enhancing third ventricular tumor with significant non-communicating hydrocephalus. An image guided endoscopic transventricular transforaminal biopsy of the tumor was performed. Neuro surgery fenestrated the septum pellucidum and left ventricular drain which they converted to a right frontal ventriculoperitoneal shunt. The surgery was uncomplicated and the patient did remarkably well postoperatively. Pathology showed low-grade astrocytoma with pilocytic features and molecular analysis demonstrated a BRAF mutation. One month post op with our clinic showed improved symptoms and resolved edema with intact visual acuity, fields, and color vision. This presentation will show case the efficacy of a ventricularperitoneal shunt as immediate treatment for papilledema.gonzales_shunts
Unexpected Visual Field Defects following Pituitary ResectiongoyalDr. Sharon Bisighini O.D.2020A 69 year old male presents with complaints of decreased peripheral vision OU following his pituitary adenoma resection four months ago. Examination revealed dense bitemporal visual field defects with optic nerve pallor OU, despite displaying a completely clear VF three month before the resection was performed. Due to persistent tumor growth, gamma knife radiosurgery was recommended. A pituitary adenoma is a benign, slow growing tumor of the pituitary gland that can put pressure on the optic nerve resulting in visual field loss. We present a unique case of a repeat pituitary macroadenoma which displayed a complete bitemporal hemianopsia months following removal of the tumor, further complicated by a subdural hematoma.goyal_pituitary
Ocular Surface NeoplasiaHaidetPaul Gruosso, Vanessa Santos-Nevarez202097-year-old white male presented to clinic with significant ocular irritation of both eyes. Patient has history of severe ectropion in both lower lids and early corneal pannus on the left eye. Slit lamp examination revealed a gelatinous lesion with atypical vasculature extending onto the cornea in the left eye. Lissamine green confirmed suspicion of ocular surface neoplasia (OSN) of the left eye. The term OSN encompasses a broad range of similar malignant conjunctival and cornea lesions. Patient was referred to a cornea specialist for further evaluation and treatment. A typically very efficacious interferon drop therapy was initiated, however, after four weeks the lesion appears unchanged. At this time, surgical excision is being considered.haidet_neoplasia
Enhancing Scleral Lens stability for post-surgical ectasiaHenderson2020• Background o Patients who have undergone LASIK who develop corneal ectasia often experience a disappointing visual outcome after the procedure. Scleral lenses that vault the cornea may provide a more optimal refractive surface and including toric landing zone can increase stability on the asymmetrical surface, resulting in a comfortable fit and improved vision correction. • Case Summary o A patient had LASIK performed OU in 2007. Subsequently, ectatic changes occurred resulting in very poor vision. Some traditional scleral designs were previously unable to provide an optimal fit for the patient. By designing the a lens with toric landing zone and front toric optics helped maintain rotational stability while correcting residual astigmatism.henderson_scleral
Managing MisdirectionHerlitzke2020Malignant glaucoma is defined by a shallowing of the AC in an eye with an elevated intraocular pressure (IOP). In this condition, misdirection of aqueous humor posteriorly causes an increased vitreous volume leading to forward displacement of the lens-iris diaphragm, shallowing of the anterior chamber (AC), and can lead to secondary angle closure glaucoma. In this case report, a 55-year-old female with no visible angle structures and a patent laser peripheral iridotomy undergoes cataract surgery to relieve a narrow AC angle. At her 1-week post-operative visit, she presents with a flat AC, no visible AC angle structures, and an elevated IOP. Temporary relief is found through therapeutic management with timolol and atropine. Pars plana vitrectomy is required due to multiple recurrences and has since effectively deepened the AC and lowered the IOP. Detection of malignant glaucoma may be difficult due to its slow progression; however, prognosis is good with current treatment modalities. Eye care providers should consider malignant glaucoma and its unique management as a differential in post-surgical cases to prevent permanent vision loss due to glaucomatous optic nerve damage.herlitzke_misdirection
Recalcitrant Filamentary Keratitis- Initiation of Amniotic Membrane TreatmentHigaJacqueline Pan, OD2020A 66 YO Black female presented for evaluation of a red left eye x 1 week. The patient had a history of bilateral recalcitrant filamentary keratitis in both eyes. Examination was remarkable for filamentary keratitis in the left eye. The patient was a tetraplegic requiring full treatment by nurse-assisted care and family members. Consequently, there was poor compliance with topical treatment initiated previously. A Prokera slim amniotic membrane was inserted into the left eye and followed until full absorption of the membrane. This case demonstrates alternative treatment options for filamentary keratitis in patients with poor compliance with topical therapy.higa_keratitis
ANCA Associated Peripheral Ulcerative KeratitisHinel2020A case of a chronic unilateral red eye previously treated unsuccessfully by multiple eye care providers is presented. Differential diagnoses with pertinent laboratory findings are discussed, revealing a rare case of granulomatosis with polyangiitis (GPA). Previously referred to as Wegener's granulomatosis, GPA is part of a group of related systemic vasculitides caused by Anti-Neutrophilic Cytoplasmic Autoantibodies (ANCA). These conditions are characterized by necrotizing granulomatous inflammation of blood vessels throughout the body, particularly in the sinuses, lungs, and kidneys. Ocular involvement may be a presenting sign of the disease. Hence, the optometrist must consider the diagnosis of ANCA associated vasculitis as a potential etiology in cases of orbital and ocular inflammation.hinei_anca
The Ramifications of Retinal Arterial MacroaneurysmHogan2020Retinal arterial macroaneurym (RAM) is characterized by acquired focal arteriolar dilation at a bifurcation or arteriovenous crossing and classified relative to the main clinical component and/or by the physiologic nature of the condition. Associated clinical findings including intraretinal or subretinal hemorrhaging in the macular region, macular edema, or vitreous hemorrhage can be sight threatening and require prompt intervention. A case of chronic RAM with macular edema in tandem with new-onset RAM with retinal edema will be presented. This poster will also discuss the clinical findings and associated complications of RAM which require appropriate testing, systemic and ocular management, and expound on potential treatment options.hogan_retinal
Confounding Findings in a Patient with PTEN Gene MutationHoldenChris Wroten, OD (Residency Supervisor)2020A 23-year-old Caucasian female with a known PTEN gene mutation presents with symptoms of intermittent blurry vision, headaches, tinnitus, and paresthesia in the right hand. She is five weeks postpartum and reports a previous diagnosis of optic disc drusen. Initial fundoscopy and OCT of the optic nerve suggest concurrent disc drusen and mild papilledema. Altogether, the factors of disc drusen, papilledema, postpartum status and a genetic predisposition to tumor formation confound the investigation for an underlying etiology of the patient’s symptoms. This presentation will explore the utility of ultrasound sonography, OCT, OCT-Angiography, automated perimetry, autofluorescence fundus photography, and MRI in guiding the appropriate diagnosis and management of this patient.holden_pten
A Drance at a Glance: Management of Optic Disc HemorrhagesHouser2020Many times, optometrists will see an optic disc hemorrhage and immediately assume that the patient has glaucoma, when in reality, it may be caused by a number of other ocular and systemic diseases. This case demonstrates the importance of using the SD-OCT 5 line raster to help differentiate between true glaucomatous damage and other common causes of optic disc hemorrhages such as vitreopapillary traction. By understanding the other etiologies of optic disc hemorrhages and using new technology, optometrists can properly diagnose and manage patients with optic disc hemorrhages and avoid unnecessary and costly special testing and treatment.houser_drance
Reactive Arthritis and Its Ocular ManifestationsHuang2020Reactive arthritis (ReA) is a spondylarthritis that occurs secondary to an infection, often gastrointestinal or urogenital. It frequently affects young adults, especially those with the human leukocyte antigen B27 (HLA-B27) marker. HLA-B27 is associated with more severe arthritis and anterior uveitis, the main ocular manifestation of ReA. This presents with significant inflammation that requires aggressive steroid treatment. Without intervention, complications such as synechiae and ocular hypertension can occur, resulting in vision loss. Since ReA is often recognized by its ocular symptoms prior to its rheumatic findings, optometrists should seek to understand this condition’s presentation and management. This case presentation reviews the diagnosis and management of ReA and its ocular manifestations.huang_arthritis
In and Out of Ocular MelanomaHur2020Flashes of light leads to an unusual diagnosis of Choroidal Melanoma in the presence of Basal Cell Carcinoma on the eyelid. This case will discuss the characteristics of Basal Cell Carcinoma and Ocular Melanoma, the importance of the early diagnosis of ocular melanoma for treatment preference, the different types of testing to confirm the diagnosis, and other the types of testing to rule out metastasis of melanoma. The Collaborative Ocular Melanoma Study will briefly be reviewed to emphasize the importance of melanoma size in the treatment plan and prognosis. Finally, treatment options for ocular melanoma will be discussed.hur_melanoma
Rare Objective Inner Retinal Trans-synaptic degeneration S/P Traumatic Brain InjuryIselyMichelle Brown OD, FAAO; Anthony Van Alstine, OD, MS, FAAO; JulieAnne Roper, OD,MS,FAAO2020We will present an excellent case involving rare objective retrograde retinal changes. A 55 y.o. AAF presented with left sided vision loss s/p traumatic brain injury and subdural heme evacuation from the right brain 1 year prior. HVF revealed homonymous left hemianopsia. OCT demonstrated retrograde RNFL and ganglion cell loss. Macula OCT revealed homonymous left-sided micro-cystoid trans-synaptic degeneration of the inner retina. All OCT findings were bilateral, respected the vertical midline, and correlated perfectly with objective TBI sequelae on brain MRI. This form of retinal involvement has been rarely documented in the literature and will be detailed in this presentation with compelling HVF, OCT, and MRI images.isely_rare
Careful fundus examination led to the discovery of a solid non-ocular malignancy.Jerjos202070-year-old female presented for a diabetic eye exam. Patient was asymptomatic. Examination of the fundus revealed bilateral mid-peripheral Roth spots. Patient was referred for blood work which was remarkable for extremely low hemoglobin levels of 3 g/dl. CT scan of the abdomen revealed a solid stomach lesion along with massive internal bleeding. Biopsy of the lesion indicated that it was malignant, and surgery was performed to remove the tumor. Patient had full recovery. Retinal examination six months later was unremarkable with complete resolution of the Roth spots. Only one literature article has indicated an association between Roth spots and solid malignancies.jerjos_careful
Peripapillary Choroidal Neovascular Membranes and OCTA UtilizationJonesJessica Haynes, OD, FAAO2020A 77 year-old WF presented for her annual diabetic eye exam. Dilated posterior segment evaluation revealed a gray discolored area on the temporal aspect of the ONH OS as well as an adjacent intraretinal hemorrhage. This case demonstrates the importance of timely diagnosis and treatment of peripapillary choroidal neovascular membranes (PCNV). It also highlights the usage of OCTA in detecting PCNV. While OCT representation of retinal anatomy can reveal evidence of CNV based on tissue reflectivity, use of OCTA now allows direct visualization of the vascular network without use of dye angiography. OCTA and OCT images will be included from the initial exam as well as OCT images from the follow-up exams showing patient response to treatment.jones_octa
Effect of OTX-101, a novel nanomicellar cyclosporine formulation, on corneal staining in the worse eye over a 3-month treatment period: Results from a pooled analysisKabatAlan Kabat, Ranjan Malhotra, Abayomi Ogundele, Charles Darby, Bridgitte Shen Lee2020Corneal fluorescein staining (CFS) was evaluated in patients with keratoconjunctivitis sicca (KCS) receiving one drop OTX-101 0.09% or vehicle twice daily in pooled randomized, controlled studies. Baseline mean total CFS±SD for OTX-101 vs vehicle was 4.2±2.7 vs 4.4±2.8. At day 84 in the inferior, lateral, central, and medial zones, LS mean changes from baseline±SE for OTX-101 vs vehicle were −0.43±0.034 vs −0.21±0.033 (P<0.0001), −0.28±0.024 vs −0.18±0.024 (P=0.0028), −0.30±0.025 vs −0.17±0.025 (P=0.0002), and −0.36±0.028 vs −0.18±0.028 (P<0.0001), respectively. Treatment-emergent adverse events were mild; instillation site pain was reported by 21.8% (OTX-101) vs 4.0% (vehicle). OTX-101 treatment produced greater overall significant improvements vs vehicle in corneal surface staining in patients with KCS.kabat_otx
Confirmatory Value of Macular Imaging in a Patient with Posterior Staphyloma and High Suspicion of GlaucomaKaltakdjian2020Optic nerves can differ widely in young versus geriatric patients, large versus small sizes, and hyperopic versus myopic eyes. It is imperative to undersand how various ONH characteristics can confound technology and how to adapt to that technology to overcome such confounders in order to appropriately distinguish between physiological and pathological. Due to axial length and insertional issues, OCT measurements of the ONH may result in a false glaucoma designation. In these cases, the macula is often spared from the issues the optic nerve heads face allowing macular OCT to be diagnostically viable. This case demonstrates the usefulness of macular imaging for a high myopic patient with posterior staphylomas.kaltakdijian_macular
Escalating Complications of Fungal Keratitis due to Infection with Pseudallescheria boydiiKamibayashi2020This case explores the devastating effects of initial fungal corneal ulcer due to infection with invasive Pseudallescheria boydii in an immunocompetent Park Ranger who had been testing lake water. Despite aggressive and extensive antifungal treatment, the ulcer progressed to corneal perforation, and subsequent emergent PKP was performed. The graft unfortunately became host for substantial fungal keratitis recurrence. Progression to globe involvement was soon evident, at which point evisceration was performed to prevent spread to sinuses. The patient’s complications still persisted even after evisceration as his orbital implant was extruded two weeks later due to broken down sclera which was healthy and intact at the time of surgery.kamibayashi_fungal
Leber Congenital Amaurosis: Correlating Classic Clinical Knowledge to Modern Gene TherapyKernBen Konig, O.D., James Rogala, O.D.2020Leber congenital amaurosis is a family of rod-cone dystrophies causing profound visual loss with onset at birth or the first few months of life. Mutations are commonly autosomal recessive, but may follow other inheritance patterns, be syndromic, or arise de novo. This case focuses on the importance of clinically differentiating features of congenital disease against later onset forms of inheritable retinal disease (IRD) and incorporating ground-breaking technology to enhance patient care through genetic testing and gene therapy, specifically RPE65 gene therapy. It is imperative that optometrists are aware of the features of congenital retinal dystrophies, specifically leber congenital amaurosis, and are able to provide patients with current testing and treatment.kern_leber
ASYMPTOMATIC OCULAR INVOLVEMENT OF SARCOIDOSIS AFTER YEARS OF REMISSION IN A 51 YEAR OLD WHITE MALEKhanAlmas Khan OD and Julie Rodman OD, MS, FAAO2020A 51-year-old WM presented to NSU The Eye Care Institute for evaluation of slight distance blur in both eyes. BCVA was 20/20 in each eye with unremarkable preliminary tests and biomicroscopy. Intraocular pressures were within normal limits. However, fundus examination revealed multifocal, elevated posterior, creamy lesions inferiorly in both retinas. There was no clinical evidence of keratic precipitates, anterior chamber reaction, vitritis or periphlebitis. Patient denied having active granulomatous lesions anywhere else in his body. SD-OCT over the choroidal lesion showed focal elevation of the RPE and retina with shadowing deep to the lesion. The lesion was homogeneous in nature with choroidal thinning and absence of anatomical changes surrounding the lesions. The lesions were suggestive of confirmed choroidal granulomas secondary to a long-standing history of systemic sarcoidosis. The patient was referred to a tertiary care ophthalmology clinic for further evaluation and was advised to also consult with his infectious disease doctor regarding the ophthalmoscopic findings. Hence, optometrists need to be aware of the clinical presentations of sarcoidosis and confirm with their PCP using proper diagnostic tests.khan_sarcoid
Managing Advanced Keratoconus with DALK and PKKimRebekah Montes OD2020This presentation follows the case of a 23-year-old African American female who presented with acute hydrops secondary to advanced keratoconus. The hydrops were treated with prednisolone acetate, moxifloxacin, and brimonidine. After the resolution of the hydrops, the patient underwent a deep anterior lamellar keratoplasty (DALK) and a penetrating keratoplasty (PK) in the right and left eye, respectively. The patient exhibited significant improvement in visual acuity in both eyes after the corneal transplants. Interestingly, the patient experienced several episodes of graft rejection and exhibited changes in corneal endothelium cell characteristics only in the left eye which received the PK. This case highlights the challenges presented with corneal transplant outcomes in patients with keratoconus, as well as additional structural post-operative changes which may arise.kim_dalk
Nevus of OtaKrabillDr. Chung To, O.D., F.A.A.O.2020Nevus of Ota is a hyperpigmentation of the ocular adnexa and globe. Patients with this condition are usually of African and Asian descent. It rarely occurs in Caucasians. This case report features a 71-year-old Caucasian male with Nevus of Ota that presented with a choroidal mass OS. Clinical features of the mass include dome shaped elevation with indistinct borders and orange pigment spots on the surface. Evaluation with B-scan and OCT imaging confirmed the elevation with underlying subretinal fluid. This is a rare case of a Caucasian patient with Nevus of Ota that progressed into a primary uveal melanoma. The advanced management and treatment of this case will be discussed.krabill_nevus
Salzmann Nodule Removal: What's Stopping You?Leung2020This case highlights Salzmann nodular degeneration by demonstrating the improved visual stability, reduction of irregular astigmatism, and decreased dry eye symptoms after Salzmann nodule removal. Often misdiagnosed as arcus or corneal haze, Salzmann nodular degeneration is easily overlooked and its consequences are commonly underestimated. Superficial keratectomy with manual nodule removal is the preferred treatment method in patients where conservative treatment is insufficient. The skills and technique required for this procedure are within an optometrist’s armamentarium. This procedure with regards to scope of practice across North America is discussed. Inter-practitioner reasons for not performing Salzmann nodule removal may vary. This poster aims to encourage optometrists to overcome such barriers where possible.leung_nodule
Primary Atypical Bilateral Herpes Simplex Keratitis in a Patient with Hyperglycemic Uncontrolled Diabetes Mellitus Type IILewis2020This is a case presentation of an atypical herpes simplex keratitis in a 52-year-old Hispanic female with hyperglycemic uncontrolled type II diabetes mellitus. Herpes simplex viral (HSV) keratitis generally presents unilaterally with pain, decreased vision, photophobia, vesicular skin rashes, and a dendritic epithelial corneal ulcer. A 52-year-old with type II diabetes mellitus presented with eye pain and photophobia left eye more than right. Clinical examination revealed a small branch-like lesion in the right eye and a large symmetrical macro punctate lesion in the left eye. The association of herpes simplex keratitis and diabetes mellitus are discussed, as well as immunological changes during herpes simplex infection.lewis_herpes
A case of ocular involvement in a patient with incontinentia pigmentiLewis2020This is a case presentation of a 33-year-old patient with ocular manifestations of Incontinentia pigmenti. This condition is a rare X-linked dominant disease that manifests in ectodermal organs. The skin is mostly affected, other common places of manifestation include dental, ocular, neurological, and musculosckeletal systems. If ocular involvement is suspected, this disease can be sight threatening. A 33-year-old female presented to the clinic with moderate pain in the left eye. Clinical examination revealed severe visual impairment in the left eye secondary to corneal and vitreoretinal disease. The ocular manifestations of incontinentia pigmenti will be discussed as well as investigation and treatment protocols.lewis_ocular
Complication from Nd:YAG Anterior Capsulotomy; the Extruded DebrisLim2020Long time severe primary open angle glaucoma patient undergoes uncomplicated cataract surgery with MIGs procedure. Patient develops visually significant posterior capsular opacification of the better seeing eye and undergoes uneventful YAG capsulotomy of the PCO; at which time, surgeon simultaneously performs YAG capsulotomy to relax significant anterior capsular phimosis contraction within the visual axis. Upon follow up; patient was seen to have inert debris in the anterior chamber which was determined to be the anterior capsulorhexis that had extruded forward after laser disruption. Patient underwent another round of YAG laser to break capsular debris into smaller fragments within the A/C with post operative topical steroid treatment to prevent significant inflammatory response.lim_yag
Long-term safety of OTX-101 0.09%, a novel nanomicellar formulation of cyclosporine A, and its efficacy in patients with keratoconjunctivitis siccaLuchsJodi Luchs, Barry Schechter, John Sheppard, Abayomi Ogundele, Charles Darby, Mark Bergmann, Paul Karpecki2020This analysis determined percent of eyes with a clinically relevant improvement in tear production (increase ≥10 mm from baseline Schirmer’s test) in the worse eye in patients with keratoconjunctivitis sicca after 84 days and evaluated long term (12 months) safety of OTX-101. At day 84, 76 eyes (20.5%; OTX-101) vs 42 eyes (11.3%; vehicle) had Schirmer’s score increase ≥10 mm (P=0.0005). A total of 258 patients completed treatment phase and enrolled in extension phase; 149 patients reported ≥1 AE although most were mild in intensity. Instillation site pain (22.9%) was most common AE for OTX-101. OTX-101 treatment produced clinically relevant improvement in tear production vs vehicle and was considered well tolerated.luchs_otx
Secondary Primary Open Angle Glaucoma in Presumed Ocular Histoplasmosis SyndromeLucy2020Presumed ocular histoplasmosis syndrome (POHS) is an infection caused by the fungus Histoplasma Capsulatum. There are diverse ocular and systemic manifestations, ranging from influenza-like illness, cavitary lung disease to life threatening dissemination affecting multiple major organ systems. Once considered to be a public health threat mainly to Ohio, Mississippi River valley areas of the United States and South America, this case represents a new epidemiological report from another area of the world. This case represents an otherwise healthy patient who presented to our clinic in the United States from Turkey with POHS that required treatment resulting in secondary primary open angle glaucoma.lucy_glaucoma
When Good Drops Go BadMassey2020Glaucoma is a devastating disease in the ophthalmic community. Fortunately we have means at our disposal to combat glaucoma as optometrists. There is great education, imaging and field machines that aid in our diagnosis. Once we have that diagnosis we have plenty of topical options to choose from as therapy. Anti- hypertensive drops are standard of care for first line therapy. These work well for the majority of our patients and we can stop the progression of the disease. However, these drops are not perfect. What happens when our favorite drops cause unfavorable side effects or don’t work? What are our options if there are no drops?massey_drops
Incidence of Dry Eye Disease Among Patients with Continuous Positive Airway Pressure or Other Nasal Mask Therapy Devices to Treat Sleep ApneaMatossianYang Zhao, Nicole Princic, Ishveen Chopra, Abayomi Ogundele2020The study examined the real-world incidence of dry eye disease (DED) among adults who used continuous positive airway pressure (CPAP) or other nasal mask therapy (NMT) devices to treat sleep apnea in the United States. Using the IBM MarketScan retrospective claims data, adult patients with ≥1 claim of CPAP or other NMT devices between 2014 and 2017 were selected. All patients included had ≥1 diagnosis of sleep apnea, continuous enrollment, and no DED diagnosis in the 12 months prior to the device use. A total of 330,926 patients were selected, 63% were male, median age was 53 years. Most common comorbid conditions were diabetes (22%) and chronic pulmonary disease (COPD) (18%). The 1-yr, 2-yr, and 3-yr incidence rate (IR) of DED were 4.0%, 7.3%, and 10.3%, respectively. Incidence of DED increased with age, ranging from 1.6% in the ‘18-24’ to 11.2% in the ‘75+’ group. Incidence of DED was higher among female than male (5.8% vs. 3.0%). Among CPAP users who had psoriasis, COPD, irritable bowel syndrome, diabetes or rheumatoid arthritis, the IR of DED were 9.1%, 5.4%, 5.3%, 5.1%, and 5.0%, respectively. CPAP users who were female, older, or had comorbid inflammatory or metabolic conditions may experience a higher incidence of DED.matossian_dryeye
Empty Sella Turcica Masquerading as GlaucomaMcMahonAysha N. Chaudhry2020Empty sella syndrome exists when the sella turcica is filled with cerebrospinal fluid and the pituitary gland which resides within is abnormally flattened and difficult to visualize. Patients may present with headaches, optic disc swelling, leakage of CSF from the nose, blurry vision, or visual field defects. Without the diagnosis of an empty sella, these VF defects may appear glaucomatous on initial presentation. This case study highlights a patient treated over many years for glaucoma, whose stable field defect was ultimately attributed to empty sella syndrome. This condition should be considered in normotensive glaucoma patients as well as those whose fields do not correlate well with other ocular findings.mcmahon_sella
The Clinical Application of Fundus Autofluorescencefor Evaluating Intraocular TumorsMercadoAmber Louprasong2020Fundus autofluorescence (FAF) is an imaging tool that allows clinicians to detect and monitor a variety of retinal disease. FAF provides a non-invasive view of certain disease processes from a metabolic perspective. The images provided by FAF are often dramatic compared to standard fundus photography and this poster will review not only how FAF works, but demonstrate how FAF can be used as an effective clinical tool to evaluate common and uncommon retinal lesions in everyday optometric practice.mercado_fundus
Anti-viral Treatment Options for Pre-existing Ocular Surface DiseaseMichaud2020A 57 year old male presented to the clinic with an acute onset herpes simplex keratitis. The treatment of this was complicated by a history of severe keratoconjunctivitis sicca status post bone marrow transplant for chronic myeloid leukemia. His symptoms were well controlled with scleral lens use along with preservative free artificial tears and topical cyclosporine. Managing herpes HSV keratitis with pre-existing severe keratoconjunctivitis sicca can be complicated and uncomfortable for the patient. In this case we explore anti-viral treatment options in a patient with severe pre-existing ocular surface disease.michaud_antiviral
One of the white dot syndromesMiskovich2020Serpiginous choroidits is a rare disease that results from inflammation of the RPE and choroid. Typically the presentation is bilateral but asymmetric Patients typically present with acute, painless, vision loss. The cause is idiopathic but may be due to immune mediated vasculitis affecting males >females. The clinical presentation is interesting with placoid lesions extending from optic disc and scars extending from disc peripherally in a serpignious like pattern. The lesions may appear white to gray. The prognosis is ~40% of patients have VA of 20/200 to count fingers in affected eye. Fluorescein angiography can be a useful tool to distinguish this syndrome from other white dot syndromes and to confirm the diagnosis. There is no general consensus on treatment but typically will involve oral steroids. Immunomodulation therapy may be needed and can include cyclosporine, cyclophosphamide, and azathioprine. Typically patients require long-term therapy. Serpiginious choroiditis has a unique presentation that can be helpful in diagnosing and treating this rare condition .miskovich_whitedot
Not your average AMD patient: an acute onset of Peripheral exudative hemorrhagic chorioretinopathyMoussa2020An 81-year-old, white male presented to the Optometry clinic noticing sudden, orange flashes of light and curtaining of vision in the left eye only for 2 weeks. Peripheral fundus examination revealed bilateral, choroidal neovascular membranes causing multi-layer hemorrhages in the superior temporal quadrant with adjacent exudative detachments. Patient was sent for same day intravitreal Eylea injection for treatment. Peripheral exudative hemorrhage chorioretinopathy (PEHCR) is a rare degenerative process of the retina characterized by sub-retinal/sub-RPE hemorrhages and exudative detachment of the retina located outside of the macular region. Symptoms vary from visual loss/decrease, floaters, photopsia, metamorphopsia and least commonly, pain. Risk factors of note are age, hypertension, AMD, anti-coagulant therapy. This case highlights the importance of management, prognosis and treatment of PEHCR.moussa_amd
Utilizing Anterior Segment OCT to Effectively Monitor Peripheral Ulcerative Keratitis Secondary to Rheumatoid ArthritisMyersRenée E Reeder OD, FAAO, FBCLA, FSLS, FIACLE2020This is a case presentation of peripheral ulcerative keratitis (PUK) in a 67-year-old white male with rheumatoid arthritis. Clinically, PUK presents as a crescent-shaped area of inflammation adjacent to the limbus and is associated with an epithelial defect and stromal thinning. Treatment involves controlling the underlining systemic condition while promoting epithelial healing and preventing infection. In this case, the patient was treated with an amniotic membrane, antibiotic prophylaxis, prednisolone, and adalimumab. Anterior segment optical coherence tomography (AS-OCT) was used to monitor corneal thickness, corneal organization, and degree of inflammatory activity. AS-OCT is a quantitative measurement that optometrists should utilize to effectively monitor PUK progression and response to treatment.myers_oct
Successful Treatment of Chemical Burn with Self-retained Cryopreserved Amniotic MembraneNanda2020Purpose: To report an acute case of chemical burn successfully treated with cryo-preserved amniotic membrane. Case: A 35 year-old male with extensive (90%) corneal and conjunctival epithelial defect secondary to acid burn OD was referred after no improvement with conventional treatment for 5 days. Standard treatment included antibiotic drops, steroid, artificial tears with a bandage contact lens. Patient was then treatment with four self-retained cryo-preserved amniotic membranes which resulted in complete re-epithelialization of the cornea and conjunctiva in 31 days. VA improved from 20/60 to 20/30 OD. During 12 months of follow-up visits, the eye remained stable with clear cornea and signs of perforation.nanda_chemical
ICE ICE Baby: 2 Case of Iridocorneal Endothelial SyndromeNguyenJulie Tyler OD, FAAO2020Iridocorneal endothelial (ICE) syndromes represent a group of three rare ocular conditions: Progressive Iris Atrophy, Cogan – Reese Syndrome and Chandler Syndrome. They are characterized by unilateral changes to the iris and corneal endothelium manifesting in iris atrophy, correctopia, and polycoria, which can lead to obstruction of angle structures, corneal edema and secondary glaucoma. This poster will present two cases of ICE syndrome. The first case is is a very early ICE with progressive correctopia and pinpoint iris atrophy including a transillumination defect. The second case is likely Cogan – Reese Syndrome due to correctopia and iris atrophy with concurrent iris nodules and elevated intraocular pressure.nguyen_ice
That "Shunt" HappenNguyenJoni Scott-Weidman O.D.2020Idiopathic intracranial hypertension is a condition that is characterized by increased intracranial pressure due to unknown causes. It can cause papilledema, decreased visual acuity and decreased visual field. These patients are treated with either general weight loss, medications, or surgical stents. Surgical stents are the last option due to the invasive nature but will bring quick reduction in intracranial pressure, which in turn improves papilledema and vision. However, long term prognosis leaves much to be desired. A literature review has shown a 11% or 14% shunt failure rate, with 30% or 60% of shunts needing revision, depending on the type of shunt.nguyen_shunt
Atypical Resolution of Type II Idiopathic Juxtafoveal Telangectasia with Chronic Macular EdemaNguyenTheresa Zerilli- Zavgorodni, OD, FAAO, Sharon Bisighini-Fiske, OD, FAAO2020Primary retinal telangectasia is a group of rare, idiopathic, congenital or acquired retinal vascular anomalies. Late-stage complications include macular atrophy and subretinal neovascularization. A 67 year-old patient was found to have intraretinal hemorrhages and cystoid macular edema (CME) OD. Capillary dilatations were seen temporal to the macula OS. The patient was diagnosed with type II idiopathic juxtafoveal telangectasia (IJFT). Three years later, acuity normalized, and OCT scans showed intraretinal disruption and retinal filling of previous cystic spaces. This patient represents an atypical case of spontaneous resolution of CME secondary to IJFT without treatment. This poster examines characteristics, ocular complications and classifications of IJFT, as well as it’s treatment and management.nguyen_atypical
Herpes Keratitis: Do You Know The "Drill"?Nicholas2020This is a case presentation of a 58-year-old Hispanic male who initially presented with a sudden onset red, painful right eye two weeks after a dental procedure. The patient had been diagnosed with Herpes Keratitis a few days ago and was prescribed Polytrim and Valacyclovir. Today the patient reports an increase in tearing, photophobia, and foreign body sensation. Vision was slightly decreased OD and clinical examination revealed a dendritic keratitis. It is imperative that clinicians keep in mind that Herpes Simplex Virus may be triggered by dental extractions and procedures. Current literature states 50% of patients who undergo surgery involving the trigeminal root experience HSV reactivation.nicholas_herpes
Acute exudative polymorphous vitelliform maculopathy: a rare caseNieuShannon Santapaola, OD, FAAO; Nancy Shenouda-Awad, OD, FAAO; Theresa Zerilli, OD, FAAO2020Acute exudative polymorphous vitelliform maculopathy (AEPVM) is a rare condition with few cases reported in the literature. Clinical features include multiple serous retinal detachments with lipofuscin deposits within, which may be resorbed slowly over time. Blurred vision and central distortions are the main chief complaints, with good visual prognosis in most patients. This case highlights an asymptomatic patient with multiple bilateral lipofuscin and serous detachments in the posterior pole and macula, with surprisingly stable vision of 20/25 in both eyes. Retinal diagnostic testing and consultation with retina/uveitis specialists confirmed the AEPVM diagnosis. Clinical features, required testing, and management of this unique condition will be discussed.nieu_exudative
An impressive presentation of a sub retinal band following a chronic untreated macula off retinal detachmentPatelBarry Frauens OD, Eulogio Besada OD, Julie Rodman OD2020A sub-retinal band formed from migration of RPE cells, following surgery to repair a retinal detachment has been documented. This case study report looks at similar migration of cells following a chronic untreated macular off retinal detachment. A significant depigmented sub-retinal band can be seen on fundus examination, not to be mistaken with a choroidal rupture. Uncommonly reported otherwise, the sub retinal band in this case has been documented well with fundus photography and OCT images. Particularly when previous ocular history is unknown, it is important to understand the etiology and subsequent pathophysiology of clinical findings, to ensure correct management.patel_subretinal
Extruded IOL through a Perforated Full Thickness Corneal TransplantPattonJames (Jim) Hays, MD2020A 66-year-old female with a history of penetrating keratoplasty, OS, presented with reduced vision, but minimal pain. Her visual acuity was light perception only. Clinical examination revealed that the donor portion of her left cornea was perforated, with the intraocular lens partially outside the cornea, extruding through an open corneal wound. Further microscopic examination of the damaged donor tissue revealed a disruption in the epithelium and Bowman’s layer, ulceration of the stroma, and a scarcity of endothelial cells. Fragments of iris and lens capsule were visible as well. A repeat corneal transplant was performed a few days later, and the patient is currently comfortable and is demonstrating some visual improvement.patton_iol
The Swollen Eyelid: A Simple Stye or Sarcoidosis?Petrik2020This case will demonstrate how a seemingly benign swollen eyelid led to the diagnosis of Sarcoidosis in a 27 year old Army soldier. The patient had no previous significant medical history and was currently being treating for “walking pneumonia”. He was experiencing a persistent cough, recent weight loss and general malaise along with a swollen left upper eyelid. Ocular examination revealed enlargement and prolapse of the left lacrimal gland. Dilated fundus examination revealed the presence of cotton wool spots in the right retina. The ocular findings combined with his systemic symptoms led to suspicion of Sarcoidosis which was confirmed through chest x-ray, blood work, and CT scan.petrick_swollen
Turbulence over the posterior pole: a young pilot with new hyperopia and chorioretinal foldsPolster2020Chorioretinal folds appear as alternating light and dark bands on fundus examination as a result of relative compression of the sclera which causes the overlying choroid, Bruch’s membrane, retinal pigment epithelium, and neurosensory retina to become rippled. Patients may complain of metamorphopsia or symptoms of increasing hyperopia or they may be asymptomatic. A variety of underlying etiologies including tumors and inflammatory disease may account for these folds, therefore a thorough investigation is warranted. This case study examines the differential diagnosis of chorioretinal folds in a young male pilot with a hyperopic refractive shift and the subsequent work-up to ensure his fitness to perform his occupational duties.polster_turbulance
The Hidden CataractPurman2020Sometimes the simplest explanation of vision loss can be overlooked. While it is important to find the cause of unexplained vision loss, it is equally important to take the entire exam into consideration and keep an open mind before settling on a diagnosis. Milky nuclear sclerosis has a way of hiding in plain sight, not following the traditional signs we associate with nuclear sclerosis. Patients with milky nuclear sclerosis often go through multiple referrals to numerous different specialists before finding their way to a cataract surgeon. This case report presents a patient who was diagnosed with milky nuclear sclerosis and their treatment.purman_cataract
Limbal Stem Cell Deficiency Induced by Contact-Lens Wear for Traumatic Mydriasis Post Iris injuryRanaMatthew Horton, OD, FAAO2020Limbal stem cell deficiency (LSCD) occurs when there is a loss of the stem cells at the limbus which are vital for corneal re-epithelialization and the barrier function of the limbus. Once the limbal stem cells are lost, the corneal epithelium cannot repair and renew itself. Loss of the stem cells causes recurrent epithelial defects, corneal scarring, chronic inflammation, corneal conjunctivalization and neovascularization. There are various etiologies for limbal stem cell deficiency: genetic, acquired and idiopathic. A case of contact lens related LSCD will be presented in a patient with traumatic mydriasis. In effort to prevent disease progression, the patient is being evaluated for artificial iris implantation.rana_limbal
Atypical Cilioretinal Artery Occlusion with PAMM Post-Myocardial InfarctionRicciSarah MacIver, OD, FAAO and C. Lisa Prokopich, OD, MSc2020A 43-year-old Caucasian man presented with an acute central scotoma and blur OS following myocardial infarction. Medical history included diabetes, hypertension, hyperlipidemia, and smoking. VA was reduced to 20/25 OS. Posterior segment exam revealed hemorrhages, cotton wool spots, and an area of retinal whitening adjacent to cilioretinal arteries OS. An inferior 10-2 field defect was noted. Multi-modal imaging findings were consistent with a diagnosis of cilioretinal artery occlusion and associated paracentral acute middle maculopathy. The patient was closely followed with imaging and fields. No treatment for cilioretinal artery occlusion exists but visual prognosis is favorable. It is crucial the optometrist closely monitor to ensure resolution and arrange appropriate systemic testing.ricci_cilioretinal
Fungal Keratitis: Going Beyond Standard TreatmentRisting2020Fungal keratitis can be extremely difficult to diagnose during the early stages of the disease. Being aware of current culture standards and promptly initiating treatment is critical to a patients’ visual outcome. This case follows a 68-year-old Caucasian female who initially presented with a central corneal abrasion in her right eye that occurred after removing her contact lens. At a subsequent visit, the patient presented with a stable abrasion, but new infiltrate. Cultures were obtained at this visit and were positive for Fusarium. Despite compliance, standard antifungal therapy for this patient was ineffective, so rose bengal photodynamic antimicrobial therapy was performed.risting_fungal
Developmental Double Trouble: Bilateral Duane’s Syndrome and Bilateral Foveal HypoplasiaRoberts2020A 26-year-old white male presented for examination complaining of blurred vision, longstanding lazy and “smaller” right eye, and diplopia in horizontal gazes. Medical history included premature birth. EOM testing showed abduction and adduction deficits with globe retraction upon adduction OD, and abduction deficit with globe retraction upon adduction OS. BCVA was 20/40 OD and 20/20 OS without amblyogenic factors. DFE revealed no foveal light reflex OD and minimal reflex OS. OCT showed lack of foveal contour OD>OS, decreased central outer-segment height OD>OS, diffuse ganglion cell defect OD, and temporal ganglion cell defect OS. OCT-A indicated minimal foveal avascular zone OD>OS. He was diagnosed with Duane’s Syndrome Type 3 OD, Type 1 OS, and bilateral foveal hypoplasia. He will return for visual fields and fundus photography.roberts_double
Amiodarone-associated optic neuropathyRogala2020Amiodarone is the most commonly prescribed anti-arrythmia medication in the United States. Most optometrists are aware of the corneal changes it induces which seldom cause problems for the patient. Unfortunately, many doctors are unaware of the potential for amiodarone to cause optic neuropathy that can result in severe irreversible vision loss. This case will demonstrate that optic neuropathy is a potentially avoidable cause of permanent vision loss in those taking amiodarone for cardiac arrythmias and provide guidance for optometrists on how to monitor and manage patients to reduce the risk of such a devastating outcome.rogala_amiodarone
What’s Really Bugging Your Patients: The Role of Optometric Management in Delusional ParasitosisRoper2020As a rare psychiatric disorder, delusional parasitosis causes patients to have an unshakeable, irrational belief of being infested by parasites or other infectious organisms. Although the infestation is not real, delusional parasitosis can have significant consequences, including vision-threatening self-inflicted trauma. We will present two cases of patients plagued by delusional parasitosis, who were both concerned for systemic parasitic infections with secondary ocular invasion. We will explore pertinent systemic and ocular findings, diagnostic testing, and multidisciplinary treatment techniques in these patients. Finally, we will present a comprehensive overview of the optometrist’s challenging role in the management of delusional parasitosis, with an emphasis on clinical examination pearls, communication techniques, and interdisciplinary comanagement.roper_bugging
“A Disc at Risk You Shouldn’t Miss”Salomon2020Non-arteritic ischemic optic neuropathy (NAION) is the result of infarction of the optic nerve head caused by occlusion of the posterior ciliary arteries. The exact pathophysiology is not fully understood, but common risk factors include diabetes, nocturnal hypotension, obstructive sleep apnea, hypercoagulable states, and vasospasm. In addition, patients typically have a small cup-to-disc ratio, commonly referred to as a “disc at risk”. This case report presents a patient with sudden painless vision loss, an afferent pupillary defect, reduced color vision, and optic disc edema from a NAION likely due to nocturnal hypotension. This poster highlights the current diagnosis, management, and treatment strategies of NAION.salomon_risk
From vision to ocular surface rehabilitation, a paradigm shift in scleral lens prescribingSeverinsky2020To evaluate the penetration rate of scleral contact lenses (SCL) into ocular surface disease (OSD) practice and determine what conditions have the best success rate with scleral lens therapy. Methods: Retrospective chart review of 183 consecutive patients fitted with SCL at the Ophthalmology Department of Emory University from April 2018 to March 2019. We evaluated the fitting indications, time required for the ocular surface stabilization and the vision rehabilitation success. Results: This study included 281 eyes of 183 patients. 94 eyes (33.5 %) were fitted for the management of OSD. Main surface conditions were Keratoconjunctivitis Sicca (KS) of autoimmune etiology 38 eyes, Ocular Graft-Versus-Host Disease (GVHD) 18, Neurotrophic Keratitis (NK) 15, Ocular Cicatricial Pemphigoid (OCP) 11, Stevens-Johnson syndrome (SJS) 6 eyes. 88% of eyes fitted for ocular surface-related indications responded well to therapy and continued scleral lens wear. The highest success rate was recorded in GVHD ( 86%), OCP (98%) and NK (84%) groups. Conclusions: this study shows higher, than previously reported in the literature, rate of SCL use for OSD management. Referral to scleral lens fitting is not limited to ophthalmology.severinsky_rehab
Lung Cancer Metastasis to Clivus Causes Abducens Nerve PalsyShinAnthony W. Van Alstine OD, MS, FAAO; Sarah Wilson OD, FAAO2020This excellent teaching case highlights the importance of neuroimaging when a cranial nerve palsy arises in the setting of systemic cancer. A 72 y.o. WM presented with a complaint of constant horizontal diplopia. Medical history was remarkable for malignant lung cancer. EOMs showed restricted abduction of the right eye. MRI of the brain revealed metastatic disease at the area of the right clivus directly in the pathway of the abducens nerve. The diagnosis of CN 6 palsy secondary to metastatic cancer was made. This poster will include excellent MRI and CT images highlighting the affected area of the CN 6 pathway and detailed discussion of pathophysiology and treatment.shin_lung
Corneal complications, treatment, & management of bullous keratopathySmithDr. Daniel Fuller, OD, Dr. Laurel Roberts, OD2020This report presents a case of pseudophakic bullous keratopathy in a 66 year old African American male. The patient has a history of uveitic glaucoma OS 2’ to Posner Schlossman, s/p tube shunt OS 10 years ago. He was treated for 1 month with Muro 128 QID OS, Pred QID OS, & Systane QID OU. The patient then presented urgently with acute pain OS & left side facial swelling. SLE revealed large ruptured epithelial bullae OS which was treated with BCL & Tobramycin QID OS. Significant improvement was noted at 1 day follow-up. He was referred to a cornea specialist to discuss surgical options, further treatment, and BCL was removed.smith_corneal
Optical coherence tomography of proliferative hypertensive retinopathySteen2020A 29-year old black female presented for a second opinion of bilateral worsening vision for the past 2 months with photopsia of the left eye. Medical history was positive for essential hypertension diagnosed in 2016 with reported systolic blood pressure consistently greater than 200mmHg and non-adherence to medical therapy until 2 months ago. Pinhole visual acuity was 20/30 OD and 20/400 OS. Blood pressure was 140/100mmHg in office with reported adherence to losartan and hydrochlorothiazide. Anterior segment findings were unremarkable. Ophthalmoscopy revealed cotton wool spots, retinal neovascularization and epiretinal membrane in the right and left eye with sclerosis of parafoveal vasculature of the left eye. OCTA revealed areas of capillary non-perfusion parafoveally in the right eye, retinal neovascularization of both eyes and complete loss of the superficial and deep parafoveal capillary plexi of the left eye. Proliferative hypertensive retinopathy is a rare complication of untreated hypertension. OCTA is useful for detection of capillary non-perfusion and retinal neovascularization in proliferative hypertensive retinopathy where findings can be used to inform prognosis and management.steen_optical
It’s NOT a tumor: Triage of adult-onset strabismus in the primary care worldSteinerAudra Steiner, OD, FCVOD2020Strabismus strikes fear into the hearts of many practitioners, never more so than when the turn is new-onset in an adult patient who is new to your practice. Missing an underlying pathology could spell disaster, but over-referral causes patient anxiety and is a poor use of healthcare time and dollars. Being able to quickly sort through possible causes of a strabismus, using equipment in a general practice office, is key to educating patients and getting the day back on track. This poster presents common, non-emergency causes of strabismus. Emphasis will be on understanding underlying etiology and basic, practical management of symptoms.steiner_tumor
APD comes with friendsSugaharaMajor Justin Holbrook, OD202067 year old Asian female presented to the urgent care clinic with decreased vision in right eye only for the last four days. She had a history of right frontal glioblastoma s/p total resection in 2016. The patient underwent two rounds of radiation and at the time of the visit was enrolled in a clinical trial for systemic Avastin. At the initial visit, the patient reported that her last MRI indicated remission. This presentation will a highlight a rare condition known as radiation induced optic neuropathy (RION). RION has subtle early findings and can often difficult to diagnosis and therefore treat effectively.sugahara_apd
Double Trouble: When an optometrist can save a lifeTlumakNancy Shenouda-Awad, OD, FAAO, Theresa Zerilli, OD, FAAO2020Timely recognition of signs/symptoms of stroke is essential in preventing devastating outcomes. Prompt imaging limits morbidity/mortality from cerebrovascular accidents (CVA). Patients with stroke history are at greater risk of recurrence. Repeated imaging is often not performed on patients who demonstrate new stroke-like symptoms in close succession to the original CVA due to not recognizing them as a separate event. This case presents a patient suffering 2 subsequent strokes within 5 weeks interval with newly developed sixth nerve palsy. The new symptoms prompted re-imaging showing new acute left pontine infarct, separate from the primary left basal ganglia stroke. Proper management of episodic CVA will be discussed with emphasis on imaging importance.tlumak_double
Visual Field Loss Secondary to Cerebrovascular Accident Associated with Cardiac CatheterizationVu2020A 72-year-old white male with a recent history of cardiac catheterization presents for a comprehensive eye exam, complaining of difficulty reading and trouble seeing to make right turns when driving. Confrontation visual field revealed a possible quadrantanopia. The results from 30-2 Humphrey visual field testing confirmed findings for a superior right homonymous quadrantanopia. An MRI was ordered to identify the location of the stroke, which is suspected to involve the left temporal lobe. Cerebrovascular accident is a potential complication of cardiac catheterization and may result in visual impairment. This case reviews the literature and discusses the evaluation and management of patients with visual sequelae after cerebrovascular accidents associated with cardiac catheterization.vu_visualfield
Von Hippel Lindau Retinal AngiomasWongBurton Wisotsky, MD2020A 30 year old Hispanic male presents to clinic for blurred vision with a gray spot in the left eye. Patient has a history of Von Hippel Lindau Syndrome and prior bilateral retinal laser treatments for angiomas. Patient was found to have macular edema with a circinate ring and two active angiomas in the left eye. The first angioma was superior nasal with feeder vessels and the second angioma was inferior with active bleeding. Patient was treated with cryotherapy first then multiple laser photocoagulation treatments subsequently after. Patient is followed every 3-6 months and has improved since initial visit.wong_lindau
A Curious Case of Asymmetric Macular Edema in a 67-Year-Old PatientWong2020Fluid accumulation in the macula indicates a breakdown in the blood retinal barrier and may lead to significant visual impairment. It occurs in patients afflicted with diabetes, retinal vein occlusions, macular degeneration, vitreomacular traction, inflammatory eye disease, and status post intraocular surgery. Management of macular edema may involve anti-VEGF injections, anti-inflammatory medication, laser procedures, or surgery. Depending on the underlying pathology and other associated conditions present, one of the aforementioned approaches may be preferred over another. The case presented details the thought process and steps it took to arrive at the diagnosis and treatment of asymmetric cystoid macular edema (CME) in an overall healthy 67-year-old patient.wong_curious
Familial exudative vitreoretinopathyXieJanet Garza O.D., FAAO2020Familial exudative vitreoretinopathy (FEVR) can present with great variability between the eyes and it is a lifelong condition that needs close monitoring. This case describes a 6 year-old Hispanic male who was lost to follow-up for 3 years and presented to re-establish care. He was diagnosed with FEVR in 2015 and had subsequent surgeries in both eyes. Dilated fundus exam showed stage 2 FEVR in the right eye (OD) and stage 5 FEVR in the left eye (OS). In addition, genetic testing showed a positive mutation for FZD4/LPR5 genes. This case highlights the clinical characteristics of FEVR, benefits of using ultrawide field fluorescein angiography, treatment and management of FEVR.xie_exudative
Clinical Presentation and Management of Bilateral Ocular ToxocariasisYanase Park2020Ocular toxocariasis is an uncommon infection caused by roundworms, and the eye’s inflammatory processes can provoke serious visual consequences. The presentation of the infection can be endophthalmitis as well as granulomas in the posterior pole or peripheral retina. A less reported sequela is choroidal neovascular membrane formation. This case illustrates ocular toxocariasis in a teenaged female with a central posterior granuloma and coincident choroidal neovascular membrane. Clinical features, differential diagnoses, and management considerations are also discussed.yanase_bilateral
Scleral Lens Success StoriesYingTheresa Zerilli-Zavgorodni, Sharon Bisighini2020Advances in lens design over the past few decades have brought scleral lenses to the forefront as a practical treatment option for patients with a wide variety of corneal conditions. We present a case series of successful scleral lens fittings in patients with the Ampleye® scleral lens. Case conditions include descemetocele after staphylococci infection and neurotrophic ulcer, keratoconus, central corneal thinning and scarring secondary to microbial keratitis, and high irregular astigmatism following complicated cataract surgery. Historical milestones in lens material and design will be reviewed. Indications, complications, as well as fitting strategies and pearls for scleral lenses will also be discussed.ying_scleral
Demonstrating Successful Fit of Wearable Technology in Low Vision Rehabilitation: Case SeriesZerilli-ZavgorodniSharon Bisighini, OD, FAAO Tam Ying, OD, FAAO, MS2020Wearable technology (WT) refers to electronic aids that attach to a user’s head and presents information visually and/or auditorily. These devices offer visually impaired patients a solution for meeting unique functional needs not adequately addressed by conventional low vision (LV) aids. The process of recommending WT requires careful consideration of factors including patient candidacy and device selection which can influence success. Three case presentations will be used to demonstrate how patients’ goals were addressed by utilizing WT in conjunction with conventional optics, non-optical devices and LV rehabilitation compensatory strategies. Clinical guidance for matching goals with the most suitable WT device to ensure a successful outcome will be highlighted.zerilli_wearable
The Problem is with your Gums not your Contacts: A Case of Ocular Cicatricial PemphigoidZimmerman2020This case follows a patient with acute severe eye pain, injection, and poor contact lens habits. She presented with an atypical linear keratitis, which was originally believed to be contact lens related. However, it was later determined that she was being evaluated by an Oral Surgeon for bleeding and blistering of the gums. With persistent communication, information regarding a recent diagnosis of Mucous Membrane Pemphigoid was discovered. Referrals and treatment modalities were adapted for the suspicion of early Ocular Cicatricial Pemphigoid. This case serves to demonstrate the importance of proper follow through and co-management with other specialties for full scope disease management.zimmerman_gums
Squamous Cell Carcinoma Metastasis onto the Right Cornea and into Right Orbit from Maxillary SinusZippiDerek A. Richardson, O.D.2020An 86-year-old white male presented with a complaint of blurred vision in his left eye. Incidentally, squamous cell carcinoma metastasis onto the right cornea extending to the visual axis, as well as extension into the right orbit from the maxillary sinus, was discovered. The veteran was previously blind in the right eye secondary to geographic atrophy from advanced nonexudative macular degeneration, so there was no related visual complaint. CT scans were consistent with extensive squamous cell carcinoma invading the patient’s right orbit. Ultimately evisceration of the right eye was conducted.zippi_carcinoma
Bilateral Non-arteritic Anterior Ischemic Optic Neuropathy Post Open Heart SurgeryAbazari2019This case reviews a 64-year-old insulin dependent diabetic patient who developed bilateral non-arteritic anterior ischemic optic neuropathy (NAION) following open heart surgery. A review of literature regarding ischemia of the optic nerve head secondary to hypoperfusion is provided on this rare but devastating complication post major surgeries especially cardiac and spinal procedures. This case report suggests performing a more holistic pre-testing procedure before major surgeries. It is important to obtain a prior eye exam in order to evaluate eye pressure and disc at risk factors. These tests become more crucial for patients with co-existing systemic vascular conditions that cause reduction in peripheral perfusion.abazari_naion
A Choroidal Nevus Transformation 50 Years LaterAhmedApril Stursma, O.D.2019A 87 year-old asymptomatic white male with a long-standing history of a choroidal nevus presents with new highly suspicious features. Clinical examination revealed changes to the size and thickness of the nevus, presence of subretinal fluid and lipofuscin. The decision to treat a melanoma is multifactorial, the patient's ocular oncologist decided to observe the lesion. Although rare, choroidal nevi have a 1% risk of malignant transformation, converting 1 in every 8,845 cases. Ancillary testing including B scan, OCT, fundus photography, and fluorescein angiography should be implemented to determine progression. It is important to detect ocular melanomas early, as with every 1 mm increase in thickness there is a 5% increased risk of metastasis.ahmed_pemphigoid
Aneurysm Induced HemianopsiaAnderson2019A 72-year-old white male with medical history remarkable for HTN & BPH reported to clinic with concerns of losing his place while reading and difficulty picking up cars to his right while driving for the last 3-4 months, progressing the last 6 weeks. No other associated symptoms. On examination, visual acuity was 20/25 in each eye while missing last 2 letters on multiple lines. Slit lamp and ophthalmoscopic findings were unremarkable. 30-2 HVF showed an incomplete right hemianopsia. An urgent CT and CTA were ordered revealing a 1.6 cm aneurysm of the terminal portion of the left internal carotid artery. He was then referred to neurosurgery for evaluation on urgent outpatient basis.anderson_aneurysm
Characteristics and Artifacts of Multi-Modal Imaging of Foveal Choroidal Excavation: A Case ReportBerezuRim Makhlouf. OD2019Diagnosis and management of focal foveal choroidal excavation (FCE) necessitates multi-modal imaging approach, including SD-OCT, OCTA, FAF, and fundus photos. A 62 yo male presents with long-standing blurry vision OS. The exam findings include normal pupils, EOMS, CVF, BCVA 20/20- OD and 20/50- OS, unremarkable anterior segment findings, and hypopigmented foveal lesion OS ½ DD in size on DFE. Multi-modal imaging of the lesion OS reveals non-conforming FCE with intervening hyporeflective space and increased visualization of choroid on OCT; increased hyperfluorescence on FAF; and hyperfluorescence on OCT-A. The above imaging findings suggest presence of subretinal fluid and transmission artifact due to thinned retinal tissue. Several studies noted rare co-existing CSCR and NVM; however, no causative relationship has been established. FCE are stable and are managed by monitoring. The diagnosis of FCE is established by SD-OCT. OCT-A, FAF, and fundus photography aid in diagnosis and monitoring the condition. It is important for eye doctors to recognize characteristic findings and artifacts of multi-modal imaging of FCE and differentiate FCE imaging from CSCR and NVM that might appear to have similarities to FCE on imaging.berezu_fce
Pilot Case Study: Anterior Segment OCT as Part of Multi-Modal Imaging of Tapioca Iris LesionBerezuAaron Gold, OD2019Anterior segment OCT (AS-OCT) has been an underutilized technique for iris lesions diagnosis and monitoring due to posterior shadowing. This is the first case report study investigating the features, quality, and potential benefits of AS-OCT for tapioca iris lesions assessment and monitoring. A 33 yo female presents with tapioca lesion OS. The exam findings include normal pupils/EOMS/CVF, uncorrected VA 20/20 OD/OS, unremarkable anterior segment findings OD, tapioca iris lesion OS at 6 o’clock, unremarkable DFE. Lesion OS has been monitored for 3 years and has not changed. Multi-modal imaging of the lesion OS reveals irregular 1.3mm thick lesion without ciliary body involvement on UBM; tapioca lesion on slit lamp photos; multilobulated iris lesion with diffuse high reflectivity without significant posterior shadowing on AS-OCT. Both anterior and posterior faces of the lesion are clearly imaged on AS-OCT. This is a pilot study describing AS-OCT features of tapioca iris lesions. Clear imaging of both anterior and posterior faces of the lesion allows for accurate efficient measurement of lesion thickness via non-invasive technique as well as for the possibility of using Eye Tracker for progression monitoring.berezu_tapioca
Is Head-Borne Technology Appropriate for my Low Vision Patient?: What to ConsiderBroganMicaela Small, OD; Theresa Zerilli, OD FAAO; Nancy Shenouda, OD FAAO2019Low vision rehabilitation (LVR) aims to maximize visual function by enhancing residual vision using various aides. Conventional devices prescribed include various spectacles, telescopes, hand-held magnifiers, and video magnifiers. Technological advances have developed new devices with the intent to further optimize visual performance and increase quality of life in patients who have typically struggled with traditional low vision devices. While these devices are exciting and tend to get a lot of press coverage, they may not be suitable for every patient. This poster provides the optometrist with clinical guidance when implementing technology into LVR. It reviews candidate eligibility and criteria to consider when determining the appropriateness of a head-borne device.brogan_lowvision
From Leukemic Retinopathy to Graft-Versus-HostButts2019This report describes the presentation of leukemic retinopathy in a 33-year-old male with acute myeloblastic leukemia who then developed ocular graft-versus-host disease (GVHD) following bone marrow transplantation (BMT). Leukemic retinopathy can mimic the retinal findings of other conditions including anemia and bacterial endocarditis, thus accurate diagnosis can be life-saving. As leukemic retinopathy resolves with cancer remission, follow-ups should include screening for ocular complications of treatments, in this case, BMT. In a patient with a history of leukemia, dry eye symptoms with minimal signs could have been overlooked. This report emphasizes the importance of prompt diagnosis and treatments, including autologous serum tears, in the prevention of potentially vision-threatening sequelae of GVHD.butts_leukemia
The Meg(alocornea) Does Exist. How do you Safely Capture (Put a Contact Lens on) it?ChenJulie Dekinder OD, FAAO2019Megalocornea is a rare, bilateral, nonprogressive congenital abnormality characterized by a corneal diameter greater than thirteen millimeters. Additional ocular and systemic abnormalities may also be present, including iris transillumination, lens subluxation, and mental retardation. Patients may not be able to safely wear typical soft contact lenses due to insufficient corneal coverage and improper fit as the cornea’s increased sagittal height creates a steeper lens to cornea relationship for the central base curve. This case report describes a patient with megalocornea and a history of unsuccessful contact lens wear who achieves good vision and fit with customized soft toric contact lens parameters and design.chen_contact
Utilizing Neurostimulation in Recalcitrant Keratoconjuncitivitis Sicca in a Sjogren’s PatientConnolly2019A 75 year old female presented with a history of Sjogren’s related keratoconjunctivitis sicca of many years duration. Prior treatment options included: artificial tears, cyclosporine 0.05%, lifitegrast 5%, amniotic membranes, 50% autologous serum, hypochlorous acid spray,and steroid pulses. Symptomatology had improved considerably with treatment; however, she was still limited in day to day activities due to her level of discomfort. Most recent Shirmer testing was 2mm OD and 2mm OS. The patient was currently using 50% autologous serum QID OU, liquigel drops QID OU, and hypochlorous acid spray QHS OU. She agreed to try a new treatment for dry eyes: TrueTear™, an intranasal tear neurostimulation designed to temporarily increase tear production during neurostimulation. This case study presents another treatment option for recalcitrant keratoconjunctivitis sicca secondary to Sjogren’s syndrome.connolly_neurostimulation
The Identification and Visual Outcome of Early Corneal Graft Rejection: A Case ReportWhen and How to Treat Optic Pit Maculopathy: A Case ReportCorzoThuy Lan Nguyen FAAO OD2019Though visual prognosis for corneal graft survival in patients with keratoconus is considered excellent, corneal graft rejection has been found to occur in 44% of grafts 10 years after penetrating keratoplasty (PKP) for keratoconus. Classically, the early signs of epithelial rejection is made evident by the appearance of an elevated epithelial rejection line which represents an anterior migration of damaged donor epithelial cells while stromal rejection is characterized by peripheral stromal infiltrates and haze. In this presentation we will identify the ocular signs and visual outcome for a 45 year old male status post PKP who presented to Nova Southeastern University, The Eye Care Institute with acute progressive decrease in vision secondary to early epithelial/stromal corneal graft rejection.corzo_graft
When and How to Treat Optic Pit Maculopathy: A Case ReportWhen and How to Treat Optic Pit Maculopathy: A Case ReportCorzoBeata Lewandowska, OD2019Optic pit maculopathy (OPM) is a complication that can arise from the presence of a congenital optic disc pit. Although spontaneous resolution with improvement in vision has been reported, the majority of cases have a poor prognosis, with a natural history of deteriorating visual acuity. At the moment, there is no clear consensus for treatment of OPM: currently, OPM is surgically treated with a combination of vitrectomy, barrier juxtapapillary retinal laser photocoagulation, ILM peeling, and an expansive gas tamponade. In this poster, the different surgical treatment options will be discussed for a 29-year-old female who presented to clinic with decreased visual acuity secondary to OPM.corzo_opticpit
Tel Me MoreCotter2019A 56-year old Hispanic female presents with decreased and distorted vision OU. Dilated examination of the macula revealed RPE changes and hypopigmentation temporal to the fovea with right angle venules OU, as well as graying of the foveal region OS. OCT and OCTA revealed specific findings confirming a diagnosis of Macular Telangiectasia Type 2. This lecture will discuss the clinical presentation of Macular Telangiectasia Type 2, the treatment and management of this disease, and the various ancillary testing available to diagnose and monitor disease progression.cotter_telmemore
If You In CystCotterEllen Butts, OD2019A 44-year old Hispanic male presented with a chief complaint of decrease in peripheral vision over the past month. Humphrey Visual Field 30-2 revealed left inferior homonymous hemi-quadrantanopia. Further evaluation included an MRI of the brain which showed a large right parieto-occipital cystic lesion with small peripheral focus of enhancement. The patient was referred to neuro-surgery for a right craniotomy for tumor resection, after which the patient was confirmed to have Neurocysticercosis. Treatment plan included oral steroids and antiparasitic therapy. Follow-ups will consist of monitoring with serial field testing.cotter_cyst
Purtscher Like Retinopathy Due to Thrombotic Thrombocytopenic PurpuraDesai201950 year old female presented for a comprehensive eye exam. She had a history of thrombotic thrombocytopenic purpura diagnosed 5 years ago without any history of retinopathy. The patient visits hematology regularly and the condition is successfully treated with Xarelto, an anticoagulant medication. Examination revealed a few intraretinal hemorrhages, few superficial hemorrhages, and grade 2 arteriosclerotic changes in the blood vessels in both eyes. In the right eye, examination revealed two cotton wool spots adjacent to an easily observable NFL wedge defect. The patient was monitored in 2 months with OCT and VF testing and correspondence letter was sent to her hematologist. Alteration in treatment will be considered if retinopathy continues to progress.desai_thrombotic
Ocular Complications of Immune-Modulated Cancer TherapiesDraperKelly Seidler, OD2019The latest generation of chemotherapy drugs acts to enhance the body’s natural immune response. The drugs work at the T cell level to create an autoimmune response to fight metastatic malignancy. As a result, there is a high incidence of immune-related adverse events due to misdirected immune responses. The eye and surrounding structures are known areas for autoimmune inflammation. Patients on these therapies may present with various ocular manifestations as side effects of the drugs such as uveitis, optic neuritis, myasthenia gravis, and cranial nerve palsies. This case presents a patient treated with Nivolumab for metastatic throat cancer who experienced side effects of vision loss and sudden onset Horner syndrome.draper_complications
Prescribing Considerations In Patients With Renal InsufficiencyDzurinko2019The overall prevalence of chronic kidney disease (CKD) in the United States is 14%. Hypertension and diabetes are the main drivers of CKD, with over half of CKD patients also diagnosed with diabetes. Further, CKD also rapidly increases in incidence in patients over age 65. With both the rise of diabetes and an aging population, it is vital that optometrists be aware of the prescribing considerations in patients with renal impairment. This poster will review the importance of the kidney in drug clearance and highlight the medications that require special attention by optometrists when prescribed to these specific patient populations.dzurinko_ckd
Nosebleeds: A Side Effect of Prostaglandin AnaloguesEngs2019Case Report: A 78 year old woman with primary open angle glaucoma developed severe nosebleeds after initiation of topical prostaglandin analogues. She was instilling a protaglandin in the right eye only and the nosebleeds started shortly after drop initiation in the right nostril. This occurred separately with each latanoprost 0.005%, travoprost 0.004%, and bimatoprost 0.01% and resolved upon discontinuation of the drops. She has not developed nosebleeds with topical beta blockers or topical alpha-agonists.engs_nosebleeds
Atypical Optic Neuropathy With Abnormal Prodrome And Visual Field DefectFasano2019The most common acute optic neuropathy for patients over 50 years old is non-arteritic anterior ischemic optic neuropathy (NAION). Often patients awake with sudden, painless, monocular, visual loss accompanied by disc edema and inferior altitudinal visual field defect. Prodromal symptoms present in 25% of patients and can include amaurosis fugax. While the work-up is extensive to rule-out other concerning etiologies, no known scientific proven effective treatment exists. Clinicians should work to aggressively decrease risk factors to avoid another ischemic event. The presence of an atypical prodrome and visual field defects superior and inferior to the horizontal raphe make this presentation unique. This case report will discuss the clinical features; work up, differential diagnoses and management of NAION.fasano_naion
Acute Acquired Comitant Esotropia (AACE) - Identifying These Patients From the RestFerreira2019AACE is characterized by (1) comitant, non-accommodative esotropia with acute onset, (2) diplopia, (3) potential for normal binocular vision. This condition makes up 0.3% of childhood strabismus. Causes of AACE include idiopathic, excessive smart phone usage, or neurogenic. Diagnosis of AACE poses a challenge given its sudden onset and potential for neurologic origin, but is likely benign. This case presents a 12yo male with new onset esotropia and double vision. Ocular history significant for moderate myopia. Pertinent exam findings include visual acuity 20/20 in both eyes, 35pd RET at distance/near, and normal MRI. The patient was diagnosed with AACE and referred for ophthalmology surgical consult secondary to large deviation.ferreira_peds
Non-Arteritic Ischemic Optic Neuropathy in the Setting of Amiodarone UseFonseca2019Non-Arteritic Anterior Ischemic Optic Neuropathy (NAION) often manifests in patients with compromised systemic health, affecting optic nerve head perfusion. In particular, patients with small, crowded optic discs possess a common clinical feature of the condition, known as the “disc at risk.” In rare cases, a toxic optic neuropathy can develop secondarily to medication use, including the anti-arrhythmic drug Amiodarone. This clinical investigation reviews the development of bilateral hemorrhagic optic neuropathy after prolonged use of Amiodarone in a hypertensive, diabetic patient with crowded discs, addressing the unique clinical presentation apart from the classic NAION case.fonseca_naion
Amniotic Membrane & Topical Steroid Therapy for Stromal Corneal Scar Post-Corneal AbrasionForstall2019A 45 year old Caucasian female presented to the clinic with a large central corneal abrasion, extending into the stroma. She was initially treated with a bandage contact lens and topical antibiotic/steroid combination. One week post-incident, the abrasion was healed but the patient reported monocular diplopia secondary to subsequent central scarring. The stromal scar was treated with heavy topical steroid therapy for one week without success. Two weeks post-incident, the corneal epithelium was debrided and a cryopreserved amniotic membrane was applied to the affected cornea while topical steroid therapy was continued. Throughout the course of patient care, the patient’s corneal integrity and visual function were monitored with visual acuity, corneal topography, anterior segment OCT, and digital photography. This poster reviews options for management of corneal scars and presents the results of this case’s therapy utilizing topical steroids and amniotic membrane placement.forstall_amniotic
A Rare Case Of Cerebral Vision Impairment with PolyopiaFox2019Cerebral vision impairment is not common in adults but can occur after brain injury, usually anoxic brain injury. Polyopia (multiple images surrounding a fixated stimulus) is extremely rare and most often occurs with occipital and temporal lobe lesions. A 36 year old male inpatient with bilateral occipital infarcts secondary to cardiogenic shock presented with blurred vision and complaints of multiple images in each eye. This case discusses the clinical presentation and management of cerebral vision impairment with polyopia.fox_polyopia
Shaking Up Amblyopia: Underlying Maculopathy Obscured By Amblyogenic FactorsFunariJo Ann Bailey, OD, FAAO2019Background: A 5-year-old hispanic female presents for amblyopia follow-up due to strabismic amblyopia. After thorough medical history review, shaken baby syndrome contributed to her unique presentation. Case Summary  At 8 months old, AD presented with subdural hygroma/hematoma with mass effect, 6th nerve palsy, esotropia, and retinal hemorrhage due to trauma consistent with shaken baby syndrome. As this occurred during the critical period of development, no sensory and motor fusion developed. Resolved esotropia led to subsequent exotropia and amblyopia. Upon examination, maculopathy was noted OU. Discussion: It is important to always rule out pathology when assessing amblyogenic factors. Here, maculopathy is significant for reduced acuity in the presence of constant exotropia.funari_amblyopia
Differential Diagnosis of the Masquerading Macula: Dystrophy or Degeneration?GobeilleGrace Tan OD; Gina Cardone OD; Shephali Patel OD, MS2019Macular dystrophies and age-related macular degeneration present similarly but differ in etiology, prognosis, and treatment. Consequently, misdiagnosis can easily lead to mismanagement. This case series reviews three patients whose incoming AMD diagnoses were revised after clinical examination. Patient 1: 52 year old with pisciform drusen and fundus flavimaculatus-like clinical presentation. Patient 2: 73 year old with yellow subfoveal vitelliform lesions which hyperautofluoresced. Patient 3: 71 year old with abnormal linear macular pigmentation and a small pocket of sub-foveal fluid on OCT. Here, we explore differential diagnoses (e.g. fundus flavimaculatus, vitelliform, and pattern dystrophies), their clinical presentations, and ancillary test findings. Patient management will be reviewed for each case.gobeille_dystrophy
Relief in Sight: Use of Scleral Lenses in Management of Immune-Mediated Dry Eye in the Setting of Chronic Ocular Graft-Versus-Host DiseaseGobeilleLynn Finnegan OD; Marina Meyerowitz OD; Shephali Patel OD, MS2019A 68 year old male presented with severe dry eye symptoms associated with chronic ocular Graft-Versus-Host disease following bone marrow transplant for Myeloid Dysfunction Syndrome. Previous medications included prednisolone forte and Celluvisc. Symptoms were exacerbated by recent initiation of off-label Restasis QID OU. Clinical examination revealed keratinized lid margins and diffuse conjunctival injection with filaments adhered to the cornea. Acute management included irrigation to mechanically dislodge filaments, as well as topical treatment. Chronic management included punctal plug insertion and scleral contact lenses fitting. This case will review treatment of severe dry eye symptoms, illustrating novel concepts in the management of immune-mediated dry eye disease.gobeille_scleral
Management of Neurotrophic Keratitis Secondary to Iatrogenic Trigeminal Nerve Palsy with a Scleral Contact LensGong2019Neurotrophic keratitis (NK) is a degenerative corneal disease characterized by decreased corneal sensitivity, epithelial compromise, and delayed epithelial healing secondary to trigeminal nerve damage. Management is aimed at optimizing corneal integrity using various therapeutic and surgical interventions. This case report illustrates a 29-year-old female with a history of iatrogenic cranial nerves V, VI, VII palsies following choroid plexus papilloma surgery, who developed neurotrophic and exposure keratitis among other sensory and motor deficits. Her ocular sequelae are managed with palliative therapy, topical antibiotic, tarsorrhaphy, gold weight implant of the upper lid, and a scleral lens in the left eye. Scleral lenses are a good option for patients with NK due to their ability to protect and rehabilitate the cornea.gong_neurotrophic
Unilateral Third Nerve Palsy As An Ocular Sign Of Giant Cell Arteritis: Recognizing Neuro-Ophthalmological EmergenciesGrewalKassaundra Johnston, OD, FAAO2019A 64 year-old male with extensive neurological history (including subdural hematoma, Chiari malformation and ventriculoperitoneal shunt) presented with a complaint of sudden vision loss in the right eye. Examination revealed light perception in the right eye with pupil-involving right cranial nerve three palsy and bilateral disc edema. Based on the findings and worsening headaches/ pain localized to the right temple, urgent laboratory testing was performed and intravenous steroids were initiated for high suspicion of giant cell arteritis. This case discusses giant cell arteritis as a cause of third nerve palsy and the importance of recognizing this potentially life-threatening condition in the context of a complex neurological patient.grewal_gca
Treatment Of Neurotrophic And Exposure Keratitis Caused By Tumor Resection With Bostonsight PROSE Scleral LensHarrisChirag Patel2019A 27 year old female with Ollier disease was referred to the clinic for treatment of neurotrophic keratitis OS, exposure keratitis OS, and persistent epithelial defect (PED) OS. The patient also had corneal opacity OS, corneal neovascularization OS, lagophthalmos OS, ptosis OS and ophthalmoplegia OS. Ollier disease is a non-hereditary disease where benign cartilaginous enchardromas form causing bone and skeletal malformations, with an increased susceptibility to secondary chondrosarcomas. All ocular symptoms OS occurred iatrogenically after resection of a pituitarty chondrosarcoma 10 months prior. Traditional methods were unsuccessful in treating the PED. The patient was successfully fit with a PROSE scleral device resulting in full resolution of the PED.harris_neurotrophic
A Vault Above: The Successful Utilization of Scleral Lenses Following Acanthamoeba KeratitisHiattJulieAnne M. Roper, OD, MS2019Acanthamoeba keratitis (AK) is a rare sight-threatening parasitic condition with potentially devastating consequences. Although surgery may be warranted it is not without risk of extensive complications. Scleral lenses are becoming a popular non-surgical intervention for the treatment of corneal irregularities. We will demonstrate the effectiveness of sclerals on a patient with visually significant corneal scarring secondary to AK from soft contact lenses. We will utilize photography, OCT, and topography to illustrate a systematic approach to fitting sclerals for corneal irregularities. We will review differential diagnoses, diagnostic testing, treatment, and co-management of AK. Finally we will provide a literature review of AK with RGPs, including clinical pearls for prevention with sclerals.hiatt_acanthamoeba
Don’t be fooled; Spasm Of The Near Triad- A Case ReportHigaErin Draper, OD2019Believed to be functional in nature, spasm of the near triad is a rare benign condition that manifest with miosis, accommodation and excessive convergence. A 16YO AAF presented with blurry vision, headaches and binocular horizontal diplopia x 1 year. The patient’s medical history was unremarkable and her ocular history was remarkable for bilateral myopia. EOM testing demonstrated dysconjugate movements in lateral gazes mimicking a bilateral CNVI palsy. Dampening of the dysconjugate motility pattern was observed post-cycloplegia. No evidence of ONH edema or signs of increased intracranial pressure were found. An MRI brain completed 2 weeks prior was unremarkable. A bifocal prescription was provided and the patient was reassured that the eye movements were likely stress related. Behavioral therapy was also recommended. It is important for the eye care provider to be knowledgeable about the presentation of this condition as to discern the presentation from the more serious, bilateral CNVI palsy.higa_spasm
Choroidal Melanoma: The Importance of a Thorough Fundus ExaminationHolland2019Although considered to be extremely rare (affecting approximately six out of one-million people per year), choroidal melanomas represent the most common primary intraocular tumor encountered in eye care. Arising from pigment-producing melanocytes found within the vascular choroid, melanomas present as dome or button-like tumors that vary in pigmentation from dark to amelanotic. While often asymptomatic and found solely on routine fundus examination, these cancerous lesions are associated with significant visual effects and potentially fatal systemic metastasis, making it imperative for all ophthalmologic practitioners to accurately identify and manage choroidal malignancies. This case study focuses on the clinical features, differential diagnoses, and various treatment options of choroidal melanomas.holland_melanoma
Transient Visual Field Loss Associated with Suprasellar Arachnoid CystJayCharles N. Davis OD, PhD, FAAO2019Arachnoid cysts are rare, only representing 1% of intracranial masses. Arachnoid cyst within the sellar region are even more rare but commonly symptomatic when present. As the accumulation of cerebrospinal fluid increases within the cyst at this location, the neighboring anatomy, including the optic chiasm, is impinged and patients are likely to have visual symptoms. We present a case of a patient with a symptomatic suprasellar arachnoid cyst who complained of decreased vision and an expanding visual field defect. Imaging showed a cystic expansion within the sella causing an upward bowing of the optic chiasm. Following transphenoidal fenestration/drainage of cyst, the patient’s visual symptoms improved. Imaging, lab reports, etc included.jay_arachnoid
Traumatic Optic Neuropathy Secondary to Motorcycle AccidentJonesAlicia Groce, OD, FAAO2019A 39 year old AAM presented with a complaint of severe blur and scotoma in his superior field OS since his motorcycle accident 3 months prior. He reported a brain hemorrhage occurred, and that he was in a coma for a period of time. He was undergoing physical therapy to learn to walk again. His BCVA OD was 20/20 and OS was LP in his superior field and CF in his inferior field. There was also a 4+ APD OS. Anterior segment was unremarkable OU. DFE showed 0.4rd OD and 0.5rd OS with 3+ pallor. Optic nerve head photos were performed. The patient returned for a Goldmann visual field which showed slight constriction nasally OD and severe constriction superiorly OS with only a small portion of his inferior field remaining. This patient was motivated to learn to drive again, so he returned for a vision therapy TBI evaluation as he will require driver training in the future. This poster will review traumatic optic neuropathy and Goldmann visual field interpretation. It will also discuss what is entailed with a TBI vision therapy evaluation and the proper management therein.jones_traumatic
Effect Of Otx-101, A Novel Nanomicellar Cyclosporine Formulation, On Corneal Fluorescein Staining In Patients With Keratoconjunctivitis Sicca: Results Of A Pooled AnalysisKarpeckiRanjan Malhotra, Doug Devries, Jodi Luchs, Alan G. Kabat, Barry Schechter, Bridgitte Shen Lee, Lee Shettle, Robert Smyth-Medina, Abayomi Ogundele, Jason Bacharach2019This pooled analysis evaluated total corneal fluorescein staining (CFS) in patients with keratoconjunctivitis sicca (KCS) receiving OTX-101 0.09% or vehicle in the randomized, double-masked, vehicle-controlled phase 2b/3 and phase 3 studies. Patients received 1 drop OTX-101 or vehicle in both eyes twice daily. CFS was performed at baseline and study days 28, 56, and 84/early discontinuation. Pooled safety assessments included adverse event (AE) monitoring. Mean baseline total CFS scores ± standard deviation for OTX 101 (n = 523) and vehicle (n = 525) groups were 4.2 ± 2.52 and 4.3 ± 2.64, respectively. For total CFS, the least squares mean changes from baseline ± standard error were −0.9 ± 0.08 vs −0.5 ± 0.08 (P = 0.0008) at day 28; −1.2 ± 0.08 vs −0.9 ± 0.08 (P = 0.0013) at day 56; and −1.4 ± 0.09 vs −0.9 ± 0.09 (P = 0.0002) at day 84 for OTX-101 and vehicle groups, respectively. Treatment-related AEs were mostly mild with instillation site pain reported by 21.8% vs 4.0% of patients in OTX-101 and vehicle group, respectively. Treatment with OTX-101 led to greater improvements vs vehicle in corneal surface staining as early as 4 weeks, with further improvements seen out to 12 weeks. OTX-101 was well tolerated in patients with KCS.karpecki_staining
When You See the Unforeseen…KhanSo-Yeon (Sharon) Lee O.D., F.A.A.O., Julie Rodman O.D., M.S., F.A.A.O.2019A 72 y/o BM presented for a diabetic exam with complaints of near vision blur OU. PMH included ‘under-control’ diabetes for the past 30 years with no reported complications. BCVA was 20/20 OD, OS. DFE revealed few dot blot hemorrhages and exudates (without thickening) in the macular area OU along with a suspicious net of thin vessels adjacent to the optic disc OS. Ancillary testing was performed to further evaluate the anomalous vasculature. OCT and OCT-Angiography (OCTA) confirmed NVD OS. OCTA is a non-invasive imaging modality that provides outstanding visualization of the peripapillary vasculature. Thus, it can be utilized to confirm or negate the presence of active neovascularization in microvascular disease.khan_unforeseen
Acquired Prosopagnosia With Left Superior Homonymous Hemianopsia Due To Acute Right Temporo-Occipital Lobe InfarctKimuraDr. Michael Sullivan-Mee O.D.2019A 77 year-old male presented to Optometry clinic with sudden painless bilateral visual field loss and difficulty recognizing familiar faces. Humphrey 30-2 VF revealed a left homonymous hemianopsia, much denser superiorly. Patient was sent immediately to the Emergency Department for a stroke work-up. Neuroimaging confirmed an infarct at the right temporo-occipital lobe junction. Acquired Prosopagnosia (facial blindness) can be separated into two forms. The first is apperceptive prosopagnosia which is the inability to accurately form facial perception. The second is associative prosopagnosia which is the inability to match facial perception to memory. Acquired prosopagnosia suggests damage to the temporo-occipital lobe region which helps control facial perception and memory.kimura_infarct
Much Ado About Jerks: When A Jerk Isn't A NystagmusKiserAriel Lenning, Bryan Metzger, Rachel Newland2019Unusual spastic, small angle saccadic intrusions were noted during a 49-year-old white female’s annual eye exam. Motions were not noted at the patients exam 1 year prior. The patient had no subjective awareness of motion nor did she have attendant facial twitching, blepharospasm, or ataxia. The patient was diagnosed with opsoclonus, a rare form of saccadic intrusion. It is typically a sequela of neoplastic disease, multiple sclerosis, or certain medications. This poster reviews the characteristics of the condition, it’s differential diagnoses, and its causes.kiser_jerk
Fright At First Sight: Utilization Of OCT-A In Long-Term Management Of Choroidal Rupture.KumarJulie Rodman, OD, MS, FAAO2019OCTA is an indispensable tool in screening for choroidal neovascularization (CNV) within choroidal rupture (CR). Our patient suffered blunt trauma OS 20+ years ago, resulting in CR. She presented with stable vision and no observed changes with dilation and fundus photography. It is with OCTA that early detection of CNV was possible. Risk factors of CNV after CR vary among literature. A study of 79 eyes by Secretan et al found CNV in 82% of eyes in the first year. They were seen in patients of older age, in ruptures of longer length, and closer macular proximity. Our patient was promptly referred to retina for further evaluation. OCTA is still in its infancy. Clinical studies highlighting its use were first published only in 2014. It is a non-invasive method for imaging choroidal/retinal microvasculature with shorter acquisition time than traditional, invasive techniques like fluorescein and indocyanine green angiography. In this case, OCTA was able to localize early CNV in an otherwise asymptomatic patient with no apparent changes within the long-standing CR on dilated exam. This technology afforded the patient time to be seen before suffering major ocular sequelae that has the potential to result in devastating vision loss.kumar_fright
Beyond the Triad: Treatment and Management of Macular Edema in the Setting of Retinitis PigmentosaLee2019Retinitis pigmentosa is the most common inherited retinal dystrophy and can often present with macular edema. Several mechanisms of the development of macular edema have been proposed but the pathogenesis has yet to be discovered. This report discusses a case of bilateral macular edema secondary to retinitis pigmentosa on topical carbonic anhydrase inhibitors. Various treatment modalities range from topical to surgical intervention; none to this date have been standardized. Quality and quantity of central vision is imperative because many of retinitis pigmentosa patients will lose peripheral vision as well. Management of central edema is crucial to visual prognosis.lee_rp
It Could Be Right Under Your Nose: A Rare Case of Vision Loss Secondary to Nasopharyngeal Squamous Cell CarcinomaLiMatthew Horton2019Squamous cell carcinoma (SCC) is an uncontrolled squamous cell proliferation that can be aggressively metastatic. Although SCC in optometry is overwhelmingly an eyelid finding, it is not limited to this locality. A 59- year-old male presented with a gray haze in the left eye with left facial tingling and numbness for five months. The patient had counting fingers acuity and a mild afferent pupillary defect in the left eye but otherwise unremarkable ocular health. Imaging confirmed stage 4 nasopharyngeal squamous cell carcinoma causing trigeminal nerve dysfunction and vision loss from compressive and infiltrative optic neuropathy. The purpose of this case is to introduce an overlooked differential for mass effect diagnoses.li_carcinoma
Contrast Enhancement in GlaucomaLinRebecca Marinoff, OD, FAAO2019A 92 year-old male was referred for a low vision evaluation with reduced vision secondary to advanced primary open angle glaucoma. He wanted to return to reading printed newspapers which was difficult using his current reading glasses. Best-corrected visual acuity was 20/100 OD, 20/160 OS, and the examination also revealed severely reduced contrast sensitivity and constricted visual fields. He reported significantly increased comfort and reading fluency with a stand magnifier with LED light and with electronic portable CCTV. Contrast sensitivity is a better predictor of visual function in everyday tasks than visual acuity; therefore clinicians must utilize magnification and contrast enhancement tools in their management of these cases.lin_contrast
Panuveitis Secondary to SyphilisMajeed2019This abstract describes the case of a 60-year-old Caucasian male presenting for a gradual decrease in vision OS>OD over three weeks. BCVA at initial presentation was 20/30 OD and CF@1f t OS. Upon examination, patient had panuveitis with retinal vasculitis, diffuse chorioretinitis, and cystoid macular edema OS>>OD. Extensive autoimmune workup and anterior chamber tap were performed. Serology was positive for HIV and syphilis. Treatments included IV penicillin for five days, HAART, and prednisone. After five days, the panuveitis was significantly improved OD with BCVA of 20/25. An exudative inferior retinal detachment ensued OS. Because FA revealed mild peripheral leakage in this eye, monitoring biweekly was preferred over surgical intervention.majeed_panuveitis
Persistent Dysthyroid Optic Neuropathy Following Total ThyroidectomyMathiesonSharon Bisighini, OD2019A 42-year old male presented with complaint of constant scotoma in central vision OS and pain with eye movements. Examination revealed engorgement of medial and lateral recti insertions, temporal optic nerve pallor OD, optic nerve edema OS, and choroidal folds OU. Visual field testing revealed inferior altitudinal defects OU. The patient had a history of hyperthyroidism with recent tachycardia and elevated thyroid function tests. Due to ocular and systemic complications, a total thyroidectomy was recommended. Dysthyroid optic neuropathy is a severe complication of Graves' ophthalmopathy. In patients with dysthyroid optic neuropathy visual field loss is rare. We present a unique case of Graves' ophthalmopathy which persisted even after total thyroidectomy.mathieson_dysthyroid
Clomiphene Citrate Induced Visual Palinopsia in Polycystic Ovary Syndrome CaseMcGheeWeston Acosta B.S., Toren Arnold B.S., Taylor Mabile B.S., Peyton Taylor B.S.2019Palinopsia is the occurrence of visual images after the stimulus has been removed. A 32 year old Caucasian female presented with symptoms of constant “trailing after images” in both eyes for two days duration. She denied any other associated symptoms. She revealed a prior medical history of polycystic ovary syndrome and initiated her monthly treatments of oral clomiphene citrate less than one week ago. Normal vision, ocular health, and ancillary tests OU, including a MRI. The patient was diagnosed with probable clomiphene citrate induced visual palinopsia. Two months after discontinued therapy, her palinoptic symptoms moderately improved but did not completely resolve. Drug induction should be a diagnosis of exclusion.mcghee_polycistic
Unilateral Vitreopapillary Traction Demonstrated By Optical Coherence Tomography Mistaken For Disc EdemaMiddleton2019A case report of a 73-year-old male with a prior diagnosis of disc edema, who is shown to have unilateral vitreopapillary traction rather than true optic disc swelling, confirmed by optical coherence tomography (OCT). OCT showed vitreous traction surrounding the optic discs of both eyes. Vitreopapillary traction can mimic other causes of optic disc edema, including increased intracranial pressure when it is bilateral. Thus, early diagnosis aided by OCT can help avoid unnecessary testing such as neuroimaging or lumbar puncture. Although the phenomenon of vitreopapillary traction is well reported, this case indicates that not all ophthalmologists recognize the condition.middleton_vitreopapillary
Binocular Diplopia Associated With Vestibular Dysfunction After Gentamicin TreatmentMitchellChung To, OD, FAAO2019A 55-year-old, Caucasian male presented with long-standing complaints of intermittent, binocular diplopia associated with head movement. History was remarkable for Meniere’s disease in which he reported diplopia after one dose of gentamicin injection. Examination revealed a consistent left head tilt with cogwheeling smooth pursuits and a right hyperphoria and esophoria in primary gaze. Voluntary head movements in any position resulted in immediate diplopia and nystagmus that dissipated over time. Given the history and clinical findings, a vestibular dysfunction was likely the culprit for the visual complaints. Vertical and horizontal prism were prescribed to stabilize the binocular system. Referral to vestibular and vision rehabilitation was initiated.mitchell_gentamicin
Ghost Cell Glaucoma: Who You Gonna Call?Mixon2019Ghost Cell Glaucoma: Who You Gonna Call? Author: Shundale Mixon Background: A patient presents to your clinic with increased IOP, decreased vision, no clear visualization of the optic nerve or fundus, but B-scan shows no retinal detachment. Who are you going to call? Case Report: A 53-year-old male presents with blurry vision secondary to hemorrhagic PVD OS. A b-scan was performed indicating no retinal detachment. A vitrectomy was performed to decrease the hemorrhage and improve vision. Shortly afterwards, IOP progressively increases and a microhyphema is present in the anterior chamber. Is the patient developing neovascular glaucoma or something else? Conclusion: This patient was diagnosed with ghost cell glaucoma due to various factors affecting adequate perfusion to the optic nerve. The patient is being carefully monitored and is stable with frequent anti-VEGF injections.mixon_ghost
The Role of Binasal Occlusion in Treating Vision Motion Sensitivity in Mild Traumatic Brain InjuryMooreTerri Zerilli, OD2019Vision motion sensitivity (VMS) is a common symptom reported in mild traumatic brain injury (mTBI) and is typically associated with prolonged recovery. VMS describes symptoms of dizziness/disequilibrium provoked by moving visual stimuli. VMS symptoms can be debilitating, compromising functional performance and even causing anxiety. Binasal occlusion (BNO) has been proposed as an effective treatment option to stabilize postural control in those with vision-related balance problems following a mTBI. Unfortunately, there is no standard protocol for fitting these patients due to limited publications. The case presented demonstrates the successful use of BNO to treat a mTBI with VMS. Diagnosis of VMS, along with BNO evaluation and fitting guidelines will be highlighted.moore_binasal
Successful Vision Therapy for a Veteran with Accommodative Infacility due to Blast-Related TBIMorrow2019This presentation follows the case of a 67 year-old white male through treatment of stage 3 conjunctival intraepithelial neoplasia (CIN) of the right eye. The patient was referred to our office for a suspicious “conjunctival mass”. Through excisional biopsy, a diagnosis of CIN was given and treatment with interferon alpha 2b injections was implemented. A complete resolution was seen with the alpha 2b injections. Interferon is an emerging treatment alternative to the gold standard of excision with cryotherapy. Prognosis for vision is very good.morrow_injectable
Successful Vision Therapy for a Veteran with Accommodative Infacility due to Blast-Related TBIMuesselMichelle Brown OD, JulieAnne Roper OD MS2019Traumatic brain injury (TBI) is becoming more prevalent in veteran populations as soldiers from Operation Iraqi Freedom and Operation Enduring Freedom are receiving health care after re-entering civilian life. It is critical to be able to treat these patients effectively in a primary care optometry setting as visual disturbances can occur in more than 65% of blast related and non-blast related TBIs. Our patient presented for a TBI evaluation caused by an IED blast in combat and was diagnosed with accommodative infacility after a full binocular vision workup. Vision therapy was initiated and after 8 weeks of in office and home therapy his symptoms were almost completely resolved. With this case we emphasize a practical way in which vision therapy can be incorporated and utilized in a primary care practice. We will review emerging research and guidelines for traumatic brain injury treatment and management in the primary care optometry setting.muessel_veteran
The Use of Electrodiagnostic Testing in Accounting for Visual Loss in a Patient with Cerebral PalsyNehmadHua Bi, OD, Swati Kumar, OD2019Background: We describe a case of cerebral palsy (CP) in which electrodiagnositic testing was implemented to account for reduced vision not explained by the eye exam. Case Report: A 29 y/o female with CP complained of centrally reduced vision OD of unknown etiology since childhood. BVA was 20/60 OD and 20/20 OS. Slit lamp and fundus exams were normal. Macular function measured by multifocal ERG was normal OU. Pattern ERG showed moderate ganglion cell response attenuation OU. Pattern VEP revealed significantly more attenuation and delay OD than OS indicating neuronal dysfunction beyond the retina and consistent with the reduced VA OD. Conclusion: Electrodiagnostic testing can be useful in explaining reduced vision due to visual pathway defects in patients with CP.nehmad_electrodiagnostic
Pupillary Abnormalities As An Indicator of Secondary GlaucomaNguyen2019ICE (Iridocorneal endothelial) syndrome is a rare iridocorneal condition characterized by an abnormal proliferation of corneal endothelial cells that expand into the iridocorneal angle and iris, causing progressive obstruction of the angle, iris atrophy, and peripheral anterior synechiae formation. Although it’s etiology is unclear, studies suggest that it is viral in origin. Common complications of ICE syndrome are corneal edema and secondary glaucoma, which can be difficult to manage. Presented are two cases of ICE syndrome that resulted in mild and severe manifestation of secondary glaucoma. These cases aim to discuss the three different variants of ICE as well as its diagnosis and treatment.nguyen_pupillary
Outer Retinal Tubulation, Pseudocysts and Age-Related Macular Degeneration: Using Advances in Spectral Domain Optical Coherence Tomography to Guide TreatmentNguyenTheresa Zerilli- Zavgorodni, OD, FAAO2019Advances in retinal imaging have led to the discovery of novel outer retinal morphologic changes. In particular, outer retinal tubulations, which are ovoid, hyporeflective spaces found in the outer nuclear layer. They are to be differentiated from retinal pseudocysts. Both entities have been identified in patients with age-related macular degeneration (AMD) and can simulate cystoid macular edema (CME). Therefore, it is important to be able to recognize these entities, differentiate them from CME, cystoid cavities and intraretinal exudates in order to properly treat, manage and prevent unnecessary interventions. This case report presents a patient with AMD and retinal pseudocysts. Differences in morphology, location, and findings on ancillary testing are highlighted.nguyen_tubulation
Neurotrophic Keratopathy Secondary to Ocular Manifestations of Pyoderma GangrenosumNoyesChantelle Mundy, OD, FAAO2019Pyoderma gangrenosum is a rare skin condition which results in necrosis and ulceration, typically of the extremities. In very rare cases, it can affect the ocular adnexa. The exact etiology of pyoderma gangrenosum is unknown, but is likely immunologic. It is thought to be a neutrophilic dermatosis-- an excess supply of neutrophils, which has been observed in biopsied tissue. It may have an association with other systemic autoimmune conditions such as rheumatoid arthritis. Corticosteroid therapy is the most prominent treatment method, but success of lesion healing is limited. In the handful of recorded ocular cases, ulceration/necrosis of the eyelid tends to result in lagophthalmos or peripheral ulcerative keratitis. This case reports using a scleral lens for the management of an exposure and neurotrophic keratopathy, secondary to cicatricial lagophthalmos following eyelid involvement of pyoderma gangrenosum.noyes_pyoderma
Polypoidal Choroidal VasculopathyNusgartMichael Belhumeur2019A 59 year old African American female presented to clinic for glaucoma suspect follow up. Dilated fundus exam that day was remarkable for a new large peripapillary pigment epithelial detachment with surrounding hemorrhage and exudate in the right eye. No recent trauma was reported, and the patient was asymptomatic. Patient was referred to the retina specialist. On follow up there, fluid started to encroach on the macula, causing reduced visual acuity. The patient was diagnosed with polypoidal choroidal vasculopathy and was treated with intravitreal Elyea, which was unsuccessful, and was switched to Avastin. With continued follow up visits, serial OCT imaging showed resolution of edema, though visual acuity has not returned to baseline.nusgart_polypoidal
Maculopathy, What Could it Be? PCV!ParadisSarah Wilson, OD2019Polypoidal choroidal vasculopathy (PCV) is rare vascular disease of the choroid causing serosanguineous maculopathy and subsequent fibrosis. PCV has an estimated prevalence of 0.30% and is often misdiagnosed as macular degeneration. This case covers the progression of PCV of the left eye in an African American female from 20/15 acuity in 2004 to hand motion acuity in 2018. The patient’s case is well-documented with chronological images of fluorescein angiography, indocyanine green angiography, OCT angiography, macular OCT and fundus photos showing her progression from a small juxtapapillary CNVM to an extensive disciform scar.paradis_maculopathy
A Rare Origin for a Choroidal MetastasisParasherRegina Portocarrero, O.D.2019A 69 year-old white male with history of sarcoidosis and metastatic prostate cancer presented with a new floater in the right eye. Fundus examination revealed a hypopigmented lesion highly suspicious for a choroidal metastasis, which was then confirmed by a retina specialist. Metastatic cancer most commonly presents in the choroid due to its rich vascular supply. The prostate accounts for only 2% of choroidal metastasis. However, prostate cancer is the most common cancer in American men, and on autopsy of prostate cancer patients, 8% presented with a choroidal lesion. While few case reports exist, optometrists must be vigilant for prostate choroidal metastasis in their differential diagnosis to enable early management.parasher_gravity
Ocular Melanocytosis and The Associated ComplicationsPerkins2019Ocular melanocytosis (melanosis oculi) is a form of congenital unilateral blue nevus. If the periocular skin is involved it is called oculodermal melanocytosis (nevus of ota). Both conditions can affect the deep episclera, sclera and uveal tract. An increased risk for the development of glaucoma and melanoma is associated with this condition. The patient outlined in this case presented with bluish discoloration of the left sclera, iris heterochromia, increased pigmentation of the trabecular meshwork, and darker fundus pigmentation in the affected eye. This presentation will review the ocular melanocytosis and oculodermal melanocytosis and the associated complications.perkins_ocular
LASIK Activated Herpes Simplex Viral KeratitisPetrik2019Herpes Simplex Virus (HSV) keratitis activation can occur following LASIK refractive surgery. This case follows a young patient who developed recurring episodes of HSV keratitis OD post Lasik OU. Atypical epithelial disruption and rippling was confined within the Lasik flap boundary in the absence of dendritic formation. Three separate episodes occurred within 10 months of Lasik surgery with no previous history of keratitis. Systemic history was positive for HSV Type 1. Presentation included eye pain, redness and significantly blurred vision OD. Complete resolution for each episode was achieved after one week when treated with oral Valacyclovir 1000mg tid and artificial tears only. Valacyclovir 500mg was prescribed indefinitely to prevent recurrence.petrik_lasik
Bilateral Cortical Blindness s/p Sequential Right MCA Stroke and Left Glioblastoma MultiformePhamMatthew Horton, OD FAAO2019Cortically-induced blindness is caused by damage to the primary visual cortex (V1) or its immediate afferents. Depending on the extent of damage to V1, loss of vision can vary from a small scotoma to a hemianopsia and in most cases, central vision is spared. However, the patient highlighted in this presentation illustrates a more severe case. A 68-year-old male presented with a history of cortical blindness due to a right middle cerebral artery stroke causing a left homonymous hemianopsia. Six months later, MRI testing revealed glioblastoma multiforme infiltrating the left occipital and temporal lobes, affecting the patient's initially spared right hemifield and causing severe, progressive vision loss.pham_cortical
Clinical Management Of Progressive, Late-Stage KaratoconusPicioreanu2019Keratoconus is a bilateral, progressive disease affecting approximately 0.05% of the population. Left uncontrolled, it can cause weakening and bulging of the central or paracentral cornea, resulting in irregular astigmatism and its trademark ‘cone’ shape. The disease tends to manifest during puberty, reaching stability 10-20 years following initial presentation. It is believed that the earlier the presentation of the disease, the more aggressive it tends to be. A 34-year old Native American male who has been followed by our clinic for the past 5 years for continued progression presents for a scleral lens progress check. On that day the lens was showing dramatic touch over the cone region in the left eye. Pentacam topographical imaging indicated possible steepening of the cone and thinning of both corneas, while OCT analysis displayed marked anatomical changes over the cone regions. This poster discusses how to properly manage aggressive keratoconus progression in late onset patients, OCT analysis and how it can be used to detect structural indicators of possible hydrops development, and candidacy for cross-linking in these types of patients.picioreanu_keratoconus
Successful Vision Therapy for a Veteran with Accommodative Infacility due to Blast-Related TBIRasekhi2019Profound systemic infections can produce septic shock due to an overwhelming inflammatory response. Most cases of septic shock are found in immunocompromised or elderly patients. A 26 year old otherwise healthy male developed septic shock, subsequent hypotension and bilateral ischemic optic neuropathy resulting in best corrected vision of light perception OD and 10/500 OS. Other causes of significant hypotension and ischemic optic neuropathy include hemodialysis and post-operative peripheral ischemia due to prolonged prone position. It is critical to study these cases and determine if preventative measures can be implemented. A collaborative effort between low vision optometrists, occupational therapists and primary care physicians is necessary to manage similar patients as there is no proven treatment.rasekhi_septic
Transneuronal Retrograde Degeneration Observed with the Retinal Ganglion Cell Analysis of a Patient with Right Homonymous Hemianopia Secondary to Cerebrovascular AccidentRhodes2019When a retrogeniculate pathway lesion occurs, the nerve fibers lose function in a process called axonal degeneration. Axonal degeneration can occur in two directions: anterograde (away from the presynaptic cell body) or retrograde (toward the presynaptic cell body). The human visual pathway exhibits retrograde transneuronal degeneration in a very characteristic way as demonstrated through the advent of new imaging studies such as magnetic resonance imaging (MRI) and spectral-domain optical coherence tomography (SD-OCT). This case study provides evidence of transneuronal retrograde degeneration through the pattern of loss of retinal ganglion cells in a patient with a right homonymous hemianopia secondary to cerebrovascular accident (CVA).rhodes_stroke
Non-Traditional Optometric Testing For Learning Related PatientsRitter2019When assessing patients with multiple learning related disabilities, optometric practitioners all too often depend solely on a traditional battery of tests. These tests appropriately test for conditions that can relate to classic academic lags in areas of reading, spelling, writing and mathematics. The practitioner must learn to go beyond the basics. This poster will explore areas that are essential to fully understanding the whole patient. It will discuss rationales for performing tests such as the GORT-5 (Gray Oral Reading Test), TOSWRF-2 (Test of Silent Word Reading Fluency), CONNERS-3, KBIT-2 (Kaufman Brief Intelligence Test) and RAN-RAS (Rapid Automatized Naming / Rapid Alternating Stimulus).ritter_testing
From Tiredness to Transfusions: Managing the Ocular Manifestations of AnemiaRoperRachel Muessel, OD2019As a hematological disorder, anemia can have both significant underlying systemic implications and simultaneous ocular complications, including anemic retinopathy in 28% of patients. We present a case of asymptomatic new unilateral retinal hemorrhages detected in a 84-year-old patient with generalized fatigue, confirmed with OCT and fundus photography. Due to unknown cause, a CBC was ordered, revealing normocytic anemia with extremely low hemoglobin of 6.8 g/dL. The patient was sent to the ER for stabilization, admission, and blood transfusions. Ocular findings improved with treatment of the underlying anemia. We will provide a comprehensive overview of anemia for the optometrist, including a diagnostic and multidisciplinary approach to managing patients with ophthalmic findings.roper_anemia
Horner's Syndrome Secondary to Metastatic Prostate CancerRoseJustin Cole, OD, FAAO2019Middle-aged black male presented to the eye clinic for new, painless, ptosis of the left eye, duration 2 weeks. Upon examination and record review, miosis of the left eye was evident along with a previous CT/MRI imaging revealing a necrotic left supra-clavicular lymph node. A thorough exam was performed along with Apraclonidine pupil testing and photo documentation. Left-side second-order Horner's Syndrome was diagnosed secondary to left necrotic supra-clavicular lymphadenopathy from metastatic prostate cancer.rose_horner
Multi-Modal Imaging of Hereditary Ocular AnomaliesRoussoRim Makhlouf OD FAAO, Julie Rodman OD FAAO2019Introduction Evaluation of retinal and ONH lesions requires a thorough assessment in order to rule out malignancy.  Diagnostic imaging modalities such as OCT/OCTA provide valuable information not otherwise seen during clinical examination.  OCT provides a structural analysis of the lesion whereby OCTA allows for visualization of microvasculature via segmentation of the anatomic layers allowing for delineation of abnormal vasculature and other malignant features.  We will present three cases: a case of congenital simple retinal hamartoma, a case of combined hamartoma of the retina and RPE and an optic nerve head melanocytoma. Each case presentation will highlight unique ophthalmoscopic findings with emphasis on the use of multi-modal imaging.    Discussion/Conclusion Differentiating between benign and malignant ocular anomalies can be challenging due to similar funduscopic appearances. Ancillary diagnostic modalities can provide valuable information about the intrinsic features of the lesion including blood flow, presence of CNV, subretinal fluid, or hemorrhages; all of which are rarely seen in benign, congenital lesions.rousso_hamartoma
Acute Optic NeuropathiesSan Miguel2019Acute optic neuropathies come in several different forms. This report reviews the diagnosis and management of a 38 year old black female who presented with optic neuritis, as well as the key clinical findings used to differentiate between other types of acute optic neuropathies. Making the correct diagnosis when it comes to these conditions is imperative in order to implement the correct treatment and management plan.sanmiguel_acute
Compressive Optic Neuropathy with Severe, Asymptomatic Vision LossSeidlerErin Draper, OD2019A 56 year old woman presented for a comprehensive exam; upon covering her left eye, she discovered her vision with her right eye was hand motion. Vision in the left eye was 20/20. A 1.8 log unit APD and a large central scotoma were noted in the right eye. The right eye was measured as 3mm more proptotic than the left. Fundus examination revealed diffuse pallor of the right optic nerve with mild elevation of the superior, inferior and nasal rim. Neuro-imaging revealed a complex right sphenoid wing meningioma with invasion into the cavernous sinus and orbital apex with compression of the right optic nerve. She was referred to neurosurgery and underwent debulking surgery with cyberknife.seidler_compressive
Effect of OTX-101, a novel nanomicellar cyclosporine formulation on tear production in patients with keratoconjunctivitis sicca: Results of a pooled analysisShen LeeDamien Goldberg; Barry Schechter; Charles Darby; Abayomi Ogundele; John Sheppard2019This pooled analysis evaluated the percent of eyes with clinically relevant improvement in tear production (increase ≥10 mm from baseline in Schirmer’s test) in patients with keratoconjunctivitis sicca (KCS) and baseline Schirmer’s test <10 mm, treated with OTX-101 vs vehicle in phase 2b/3 and phase 3 randomized, vehicle-controlled studies. Patients received 1 drop OTX-101 or vehicle in both eyes twice daily. Schirmer’s test was evaluated at baseline and day 84. Pooled safety assessments included adverse event (AE) monitoring. At baseline, 523/1046 eyes (50%) receiving OTX-101 vs 501/1050 eyes (47.7%) receiving vehicle had a Schirmer’s test <10 mm. Of these, 98 eyes (18.7%) receiving OTX-101 vs 51 eyes (10.2%) receiving vehicle had an increase ≥10 mm in Schirmer’s test (P = 0.0001) on day 84. The mean change from baseline ± standard deviation in Schirmer’s test at day 84 was 4.5 ± 7.4 vs 2.6 ± 6.4 for OTX-101 and vehicle, respectively (P <0.0001). Most treatment-related AEs were mild with instillation site pain reported by 21.8% vs 4.0% of patients in OTX-101 and vehicle groups, respectively. Treatment with OTX-101 significantly improved tear production at 84 days vs vehicle. OTX-101 was well tolerated in patients with KCS.shenlee_otx
Prevalence and Severity of Patients with Dry Eye Disease and Meibomian Gland Dysfunction: An Analysis of the AAO IRIS® RegistrySiffelCorey Joseph, Reza Dana2019This study used the American Academy of Ophthalmology (AAO) IRIS® Registry (Intelligent Research in Sight) data to assess the prevalence and severity of dry eye disease (DED) in patients with comorbid meibomian gland dysfunction (MGD). ICD-9, ICD-10, CPT and medication insurance claim codes were used to identify diagnoses of DED and MGD. DED prevalence and severity (mild, moderate or severe; based on a staged treatment algorithm of medications and procedures) of adult (≥18 yrs) patients with ≥1 eye care visit in 2017 were determined. Of 2.8 million patients identified with DED in 2017, 20.5% (n=576,101) were also diagnosed with MGD (67.7% women, 32.3% men). The prevalence of MGD was 19.4% among women, 23.0% among men, and increased from 18.4% (n= 10,454) among patients 18-29 years of age to 23.5% (n= 135,584) among patients 80+ years of age. Overall, 58.2% were untreated for their DED; 60.4% had mild DED, 29.0% had moderate DED, and 10.7% had severe DED. This analysis provides the most robust estimate of the prevalence and severity of comorbid DED and MGD in the US. The high prevalence of comorbid DED and MGD, the high proportion of patients without documented DED treatment, or with moderate and severe DED, warrants further study.siffel_dryeye
A Rare Case of Bilateral Corneal Edema Secondary to AmantadineSinghTim Luke OD2019Amantadine has been used as a prophylactic agent for the treatment of Influenza A in adults since 1966. A 49 yo female with a history of optic neuritis and MS reported blurry vision for 4 days and had been on amantadine for 8 months for increasing fatigue and difficulty walking. Ocular findings revealed endothelial folds and corneal edema in both eyes, which are rare ocular manifestations of amantadine. This case discusses a patient who developed a rare case of bilateral disciform keratitis secondary to amantadine treatment.singh_edema
Now You See Me, Now You Don’t: Fresnel Prism Drastically Increases Mobility PerformanceSmallKathryn Brogan, OD; Theresa Zerilli, OD, FAAO; Nancy Shenouda-Awad, OD, FAAO2019Severe peripheral visual field (VF) loss is a hallmark sign of advanced glaucoma. The mobility of these patients is particularly affected, increasing the risk for falls and injury. Fresnel prism can be an effective treatment option and works by displacing images from the non-seeing to the seeing field. This unique case presents a non-traditional Fresnel prism fit in a monocular patient with end-stage glaucoma having only 6 degrees of field remaining. Prism, coupled with orientation and mobility training, enhanced peripheral VF awareness significantly improving mobility skills. Clinical pearls of Fresnel prism including candidate criteria, fitting/placement, as well as the importance of prism training will be discussed.small_fresnel
7 Years Later? Unilateral Corneal And Macular Edema After Bilateral Cataract SurgerySmallKathryn Brogan, OD; Nancy Shenouda-Awad, OD, FAAO; Theresa Zerilli, OD, FAAO2019Macular and corneal edema has been shown to manifest weeks or even months post cataract extraction (CE). Many systemic risk factors, including diabetes, can play a role in ocular inflammation being more persistent post operatively. This case presents an atypical late-onset unilateral case of cystoid macular edema (CME) concurrent with pseudophakic bullous keratopathy (PBK) after a bilateral complicated cataract extraction in a patient with Type II diabetes mellitus. Proper management of CME and PBK post CE with an emphasis on topical versus surgical intervention will be discussed. Additionally, this poster will address the importance of proper diagnosis and pre-operative preparation for high-risk patients.small_edema
Conversations To Have in Conversion DisorderSmith201960-year-old female with history of Asperger’s syndrome, anxiety disorder, and concussion secondary to a recent motor vehicle accident presents complaining of gradual reduced vision in both eyes. She has several somatic symptoms including headaches, reduced mobility, and intermittent tingling in her extremities. Visual field testing shows tubular fields despite normal confrontational fields. Visual function appears generally reduced in both eyes with no discernable etiology found on comprehensive eye examination, OCT, or neuroimaging. Her symptoms fit criteria established in the DSM-V for non-organic vision loss secondary to conversion disorder that could relate to PTSD from motor vehicle accident. Treatment plan consists of evaluation by mental health professional and careful patient education.smith_conversion
The Impact of Ocular Surface Disease Signs and Symptoms on Optical RemakesSmithDr. Whitney Hauser, Dr. Michael Christensen2019Dry Eye Disease (DED) is a chronic, progressive condition which has been demonstrated to lead to reduced functional visual acuity. Patients complaining of reduced visual acuity with their spectacles may request an optical remake. DED may be the cause of the reduced visual acuity rather than the optical quality of the spectacles. A pilot study was conducted to determine if DED contributed to optical remakes. Compared to participants satisfied with their glasses, participants requesting optical remakes showed significantly worse tear breakup time (TBUT) OD, and worse TBUT OS (which approached significance). A larger sample size in future studies may shed more light on whether optical remakes are related to DED.smith_remake
nOT A Typical GlaucomaSoong2019Nevus of Ota, also known as congenital melanosis bulbi or oculodermal melanocytosis, is a rare hamartoma of dermal melanocytes. This presents as a unilateral blue-grey hyperpigmentation around the face and eye. Nevus of Ota may be associated with malignancies of the uveal tract and unilateral open angle glaucoma. This case reviews a 38 year old African American female referred for a glaucoma evaluation due to elevated intraocular pressure. This review will include ocular manifestations, differentials diagnoses, and management.soong_glaucoma
Successfully Increasing Visual Function and Independence by Incorporating a Multidisciplinary Approach to Low Vision RehabilitationSorberMargaret Elizabeth Moore, OD; Theresa Zerilli, OD, FAAO; Jonathan Hamilton, OD, FAAO; Nancy Shenouda-Awad, OD, FAAO2019End stage glaucoma can lead to concurrent central and peripheral vision loss making low vision rehabilitation challenging in these cases. For these patients, inter-professional management is crucial to help with their visual needs outside of what can be addressed in the low vision exam. Optimal management encompasses orientation and mobility training, manual skills training, computer assistance training, and assistance with living skills. Maintaining self-independence and preserving one’s quality of life necessitates lifestyle modifications including preparation for future visual degradation. This case discusses appropriate low vision device recommendations along with the importance of inter-professional management to both maximize remaining vision and potentially prepare for further functional compromise.sorber_independence
Intense Pulse Light Treatment for Lid DiseaseswartzNone2019Intense Pulse Light (IPL) is a thermotherapeutic treatment commonly used in dermatology for pigmentation and neovascularization. It is used to treat acne rosacea and has been found to be beneficial in the treatment of lid disease, including blepharitis and meibomian gland dysfunctions. A literature review will proceed cases illustrating the effect of IPL treatment on clinical signs and symptoms in dry eye patients. Treatment parameters and techniques will be discussed.swartz_ipl
"Crack"ing the CaseThomas2019This presentation discusses the clinical presentation of a patient with a history of cocaine abuse leading to cocaine retinopathy. The patient presented with numerous cotton wool spots and a few scattered dot and blot hemorrhages; the patient also had diabetes but his blood sugar levels were controlled and diabetes alone could not account for the amount of ischemia seen in the retina. Ocular side affects of cocaine have been documented, ranging from anterior to posterior segment findings. Cocaine retinopathy presents as an ischemic retina which correlates with the mechanism of action of cocaine as it blocks reuptake of various neurotransmitters and leads to an exaggerated sympathomimetic response.thomas_cracking
Like Mother Like DaughterToomey2019This presents a case of mother and daughter with bilateral optic nerve dysplasia and associated maculopathy in the setting of recent genetic testing resultant for heterozygosity for the p.R270H Variant in the PAX2 Gene. The family history is notable for Chronic Kidney Disease and severe blindness going back several generations. The clinical presentations and associations within the PAX-2 related disorder spectrum will be discussed as well as the impact of genetic testing on clinical and surgical treatment plans.toomey_dysplasia
What A Pain! Central Serous Chorioretinopathy Following Dental SurgeryTylerAlexandra M. Espejo, OD, FAAO2019A 37 year-old black male presented with complaints of blurry vision OD for approximately one week. The patient reported an image like a "dime" over his vision, with symptoms of flashing and floaters in the superior field during the same time period. Systemic history was pertinent only for a dental procedure one week prior with a steroid injection to treat "headaches" following a root canal on the right side of his mouth. Clinical examination revealed an elevated retinal lesion just inferior to the macula that was evaluated with OCT imaging and fundus photography confirming central serous chorioretinopathy. The patient was monitored with dilation and serial OCT assessments over a six week period with resolution of signs and symptoms. While the association with central serous chorioretinopathy and steroids has been reported and established in the literature, the unique aspect of this case presentation is the association between the ocular findings and the dental procedure. Serial OCT images will be presented and a review of current literature for CSC presented.tyler_serous
History Mystery: A case of HSV1 uveitis masquerading as traumaTylerBeata I. Lewandowska, OD2019A 39-year-old man presented with a recent ocular trauma of concrete debris to both eyes, approximately 1.5 weeks prior. The patient had been initially examined elsewhere and treated with prophylactic Tobramycin but his ocular symptoms were persistent with mild photophobia and blur OS>OD. Upon examination, anterior chamber cells and KP were noted initially OS. A diagnosis of anterior uveitis OS was made and the patient was treated with Durezol and Cyclopentolate 1% TID. Upon return to clinic, the patient noted improvement in symptoms with topical therapy but the uveitis persisted over several weeks and at future exams cells and flare were also noted OD. During the follow-up period additional systemic symptoms including swelling of various lymph nodes and a rash occurred - as well as a spike in intraocular pressure. Serology was ordered for a number of systemic conditions with the only positive result occurring for Herpes Simple Virus (HSV) 1 IgG type specific Ab (normal <.90, pt results of 46.7) while the HSV1 IgM was negative. Based on the lab results, the patient was started on Valacyclovir and resolution of all systemic and ocular symptoms occurred. The case demonstrates the variable nature of HSV1 presentations.tyler_hsv
Prosthetic Color Contact Lens in the Management of Globe Rupture ComplicationsVadapalli2019A forty-eight year old male was referred to the specialty contact lens clinic at a VA Hospital. He was referred for debilitating issues with light sensitivity. The patient’s ocular history was remarkable for a left ruptured globe injury, resulting in secondary traumatic aniridia and aphakia. Additionally, the patient reported sympathetic ophthalmia in the fellow eye. Management of complications related to the patient’s ocular trauma was ultimately addressed with a prosthetic color contact lens. Successful fitting of this type of lens relies on a number of factors including patient education, proper lens selection, patient’s visual expectations, and cosmetic goalsvadapalli_prosthetic
Filaments on Transplants: Management of Filamentary Keratitis following Penetrating KeratoplastyWangDaniel Fuller, OD, Diplomate FAAO, FSLS201959-year-old white male status-post penetrating keratoplasty (PKP) presented with severe filamentary keratitis. Filamentary keratitis is associated with multiple ocular surface diseases and can be found in 27% of patients after PKP. Beyond redness and irritation, corneal filaments, if left untreated, can induce epithelial defect, corneal vascularization and promote graft rejection. The patient was managed according to conventional treatments of mechanical removal of filaments, soft bandage contact lens, acetylcysteine, and cyclosporin prior to scleral lens fitting. A recent case report shows scleral lens wear to be a viable treatment option for filaments keratitis following PKP and can be considered for first-line therapy or maintenance therapy.wang_filaments
Terson's Syndrome: An Ocular Manifestation of a Life-Threatening ConditionWard2019This case report details a 59-year-old male presenting with extensive bilateral preretinal, intraretinal, and subretinal hemorrhages secondary to a ruptured aneurysm of the right-middle-cerebral artery, causing a subarachnoid hemorrhage (SAH). This case includes retinal imaging, OCT progressions, visual fields, and cranial computed tomography. The presentation will review the clinical presentation of Terson’s Syndrome, relevant neuro-anatomy, pathophysiology, recommended workup, and treatment of the condition. Also included will be a discussion of the nomenclature used to grade SAH in order to better communicate with co-managing practitioners. While rare, Terson’s Syndrome is associated with a five times increased risk of death in a patient with SAH, and timely diagnosis can help to direct life-saving care.ward_terson
Successful Treatment of a Viral Papilloma with Topical InterferonWatson2019This report highlights a case of a viral conjunctival papilloma that was successfully treated with topical interferon therapy. A 74 year-old male was referred to our clinic to be evaluated for an orbital mass in his left eye. Ocular exam revealed a large, painless, vascular, elevated lesion on the temporal bulbar conjunctiva. Topical interferon therapy and oral cimetidine therapy was initiated. The lesion responded excellently to therapy and the patient was left with only a pinguecula pending biopsy. Biopsy excision was performed to confirm the diagnosis of viral papilloma. This presentation will include photo-documentation of the papilloma on initial presentation, during treatment and after resolution.watson_papilloma
Management of a Patient with a Traumatic Cataract and Irregular Pupil with the Use of a Prosthetic Tinted LensWilliams2019Traumatic injuries to the eye can lead to a cascade of symptoms that can be debilitating to patients. This case report discusses the use of a prosthetic tinted lens to improve the symptoms of a patient with a traumatic cataract and an irregular pupil after suffering an eye injury. A 69-year-old white male presented with the complaints of glare, photophobia, lack of depth perception, and decreased vision in the left eye. The patient’s past ocular history was positive for a traumatic injury to the left eye thirty years prior. A Nissel Natural tinted lens with a 4.5mm clear pupil was placed on the patient’s left eye to achieve a more regular pupil appearance, decrease excess light entering the eye, and increase the patient’s depth of focus. The patient reported an immediate decrease in photophobia and a slight improvement in depth perception after lens insertion. The use of prosthetic tinted lenses has been shown to improve photophobia and cosmesis in patients with irregular irides and traumatic cataracts. Chronic sequalae of traumatic eye injuries can be devastating. However, with proper management, patients can experience symptomatic relief.williams_traumatic
Clinical Presentation and Management of X-Linked Retinoschisis in Non-Twin BrothersYanaseDaniel Smith, OD2019Juvenile macular dystrophies often present in early childhood and result in variable visual outcomes. X-linked retinoschisis is the leading cause of juvenile macular degeneration in males, and involves splitting of the retinal layers throughout the fovea and peripheral retinae. The clinical phenotype of X-linked retinoschisis may vary, but is most commonly represented by the spoke-wheel parafoveal pattern. This case demonstrates clinical features consistent with X-linked retinoschisis in non-twin biological brothers, as well as, explores genetic testing and management strategies.yanase_xlrs
New Onset Floaters Leading to a Diagnosis of SyphilisYeePaula Johns, OD, MPH, FAAO2019A 63 year-old female presented to our clinic with a complaint of new floaters and blurred vision. Her medical history was unremarkable. DFE was significant for bilateral vitritis. Labwork revealed an active infection of syphilis with an RPR titer of 1:128. Syphilis is the great masquerader and should be considered in all cases of unexplained ocular inflammation. Ocular manifestations of syphilis may occur at any stage of the disease; therefore, optometrists play a key role in initiating the work-up for syphilis. Early detection and treatment of syphilis is important in order to limit the spread and prevent progression into later stages of the disease.yee_syphilis
Yoked Prism: An Effective Treatment for Reading with Homonymous HemianopsiaZerilliTam Nguyen O.D., F.A.A.O, M.S.2019Homonymous hemianopic (HH) visual field (VF) loss following stroke can impact one’s ability to perform activities of day living (ADL) including mobility, driving and reading. Reading is an important ADL that can be significantly affected in these patients. The degree in which reading ability is compromised can be influenced by the characteristics of the VF loss, notably the side of the HH deficit and whether fixation is spared or split. This case demonstrates a successful fit with yoked prism in a patient with HH VF loss and macular splitting. Factors influencing the potential for success with yoked prism and clinical guidance relating to evaluation and fitting recommendations will be provided.zerilli_yoked
Utilizing Scleral Mapping Technology To Design Custom Scleral LensesZhangJudith Perrigin, OD, FAAO2019A keratoconic, corneal transplant patient, presented to clinic at risk of losing employment due to poor vision. He was unaided and reported dissatisfaction with a variety of lens modalities including scleral lenses in the past. Due the patient’s complex corneal irregularity and scleral toricity, sMap-3D technology was utilized to design and successfully fit the patient in customized Europa multi-meridian scleral lenses. New scleral mapping technology is a useful tool to understand a patient’s scleral anatomy and may optimize success and patient satisfaction with scleral lenses as well as reduce chair time in the fitting process.zhang_mapping
Bungee Cords and Tree Branches: A Case of Ocular Complications from Blunt TraumaZimmerman2019Blunt trauma can have long term devastating effects on vision, and 90% of eye injuries are preventable with eye protection. This case follows a patient that sustained a bungee cord injury across the face followed by a subsequent injury by a tree branch OU hours later during military training. He was not wearing eye protection for either incident. The patient presented to clinic with commotio retinae, corneal abrasions, and traumatic acute anterior uveitis. This case serves to demonstrate proper utilization of up-to-date technologies, prompt evaluation, and through follow-up and treatment to preserve vision and improve patient comfort.zimmerman_trauma
Recurrent Corneal Macroerosion: A Case of Immediate and Long-term TreatmentsZimmerman2019This case report follows the treatment of a recurrent corneal macroerosion with the combination of a large diameter Kontur Precision bandage contact lens with the incorporation of topical Pred Forte to treat and prevent re-occurrence. The Kontur bandage lens was left in place without removal for over 2 weeks. The 7mm x 7mm nondystrophic corneal macroerosion was also treated with conservative long term and short term methods. Proper immediate and long-term treatment not only relieves pain, but can also aid in the recovery and reattachment of the corneal epithelium to the underlying basement membrane preventing future erosion. This patient has been erosion free for over 9 months.zimmerman_macroerosion
From Back to BlackAnguita2018Introduction Shock induced anterior ischemic optic neuropathy following spinal stenosis surgery leads to ocular complications, irreversible vision loss. Case 69-year-old white male with central field loss OD and superior field loss OS awakening from lumbar surgery. BCVA was CF OD and 20/25 OS. Funduscopic exam revealed bilateral optic nerve swelling and splinter hemorrhages. Diagnosis of SIAION, secondary to blood loss, increased orbital venous pressure from the prone position with multiple comorbidities. Conclusion Prevalence of SIAION is low in America, yet it can be devastating to one’s quality of life. Consider risk factors and a different surgical approach.anguita_black
Supraclinoid Aneurysm: A Proposed Mechanism for Increased Unilateral Intraocular Pressure (IOP)ArrieteKathleen Komornik, OD, Alexis Rodriguez, OD2018Unilateral glaucoma is commonly associated with a traumatic etiology. The following two case reports are of patients previously diagnosed with unilateral glaucoma in the absence of trauma where neither patient responded to pressure-lowering eye drop therapy. After both patients developed a progressive ptosis ipsilateral to the side with the higher pressure, further investigation and imaging revealed supraclinoid aneurysms. The case reports are followed by a proposed mechanism that unilaterally increased IOPs without classic uniocular glaucoma presentation could be a potential manifestation of an aneurysm.arriete_aneurysm
Bilateral Retinal Lesions in the Setting of Suspected Metastatic Breast CancerArteagaAlina C. Balasa OD2018Sarcoidosis is a multisystem, inflammatory, granulomatous disease which can affect the eyes in 25% of patients. A 55-year-old African-American female with a history of primary open angle glaucoma presents for an eye exam. Medical history is significant for breast cancer, bipolar disorder, and chronic kidney disease. Entering vision is 20/20 OD, OS. Dilated eye exam reveals C/D 0.95 OD, 0.75 OS. Bilateral 3DDx3DD creamy, elevated, retinal lesions are noted nasal to the optic nerve. This case will highlight the importance of ruling out metastatic breast cancer in a high-risk patient with retinal pathology. We will discuss presumed sarcoid peripapillary choroidal lesions and how to rule out other pathology. Our case will be supported by sequential OCTs, fluorescein angiography, MRI, biopsy and lab results.arteaga_bilateral
Early Onset Epiretinal Membrane in a Young AdultAworunse2018The incidence of epimacular membranes diagnosed in children and adolescents is exceptionally rare. A 24-year-old male presented for an emergency eye exam with complaints of decreased vision and increased metamorphopsia in his left eye. Exam findings revealed a dense epiretinal membrane with significant traction. Patient noted he had longstanding decreased acuity in the left eye. Patient underwent pars plana vitrectomy with membrane peel without complication. Although limited, published studies on the management of ERM in young patients have demonstrated that vitrectomy with membrane peel can be performed to improve visual acuity. ERM as an amblyogenic factor should be considered in individuals that present with dense ERM in the affected eye.aworunse_epiretinal
Eyelid Neurofibroma Masquerading as ChalazionAworunse2018This report highlights a case of an eyelid neurofibroma resembling a painful chalazion leading to diagnosis of neurofibromatosis. 38-year-old male presented for an emergency exam due to a longstanding, painful lid lesion. Patient reported no resolution with warm compresses or oral antibiotics. Ocular and physical exam revealed Lisch modules, elevated skin lesions and café au lait spots on his extremities. Patient had no known history of NF. Patient was referred to ophthalmology for excision. Surgeon indicated that lesion was likely a neurofibroma and patient was referred for physical examination. Amongst numerous differentials for chalazia and hordeola, neurofibromas should be considered in individuals with or without a known history of NF.aworunse_eyelid
Use of OCT-A in the Detection of an Occult Peripapillary Choroidal Neovascular MembraneBalasaRigoberto Arteaga OD2018Optical Coherence Tomography Angiography (OCT-A), is a novel, non-invasive instrument which can be utilized to diagnose various ocular pathology. We present a case of a 72 year old white male who presents for routine eye care. Medical history is pertinent for hypertension, prostate cancer, and hepatitis B. Best corrected vision is 20/25 OD, OS. Dilated eye exam OD reveals an area of subretinal fluid extending from the optic nerve head inferiorly towards the fovea. HD 5 Line Raster shows an area of suspicion for choroidal neovascularization. OCT-A was performed at follow up and confirms choroidal neovascular membrane near the disc. OCT-A has emerged as a powerful in vivo tool in the diagnosis and management of retinal and choroidal pathology. We highlight the role of OCT-A in patients with suspected choroidal neovascularization and discuss treatment options.balasa_oct
New onset upbeat nystagmus in a patient with chronic alcoholismBelhumeurAmy Jill Quan2018A 55 year old white male presents for new onset blur. He admits to trouble walking without assistance due to vision, stating he cannot focus on things clearly. Best corrected acuity is 20/40 in each eye with no improvement on refraction. An upbeat nystagmus is found on external testing with, intraretinal hemorrhages in each fundus. Lab work was reviewed and CT scan ordered, along with urgent referral to neurology. The nystagmus with unsteady gait was attributed to Wernicke-Korsakoff syndrome due to chronic alcoholism. At follow up, patient had received two IM thiamine injections. Nystagmus and gait issues had mostly resolved, with acuities returning to pre-nystagmus levels.belhumeur_upbeat
Why Differential Diagnoses Matter: A Game of ShadowsBouras2018A 33-year old female presented to our clinic as a walk-in/ocular emergency with the complaint of a dark shadow over her superior, peripheral vision in the left eye. An APD OS on pupil testing and pain on EOMs were noted. After a careful dilated fundus examination yielded normal findings and ruled out any retinal detachment, a visual field was ordered. A superior altitudinal defect was present and a diagnosis of optic neuritis was made. Patient was immediately sent for an MRI and consult to neurology for treatment. The consult confirmed retrobulbar optic neuritis and the MRI results are currently pending in order to rule out the implications of Multiple Sclerosis.bouras_shadows
Ocular Toxicity Secondary to Asclepias tuberosaChangCarrie Ho, OD, FAAO2018Introduction The latex of Asclepias tuberosa, a milkweed plant, contains cardiac glycosides which are toxic to the corneal epithelium and endothelium to cause corneal edema. Case Report A 69-year-old Caucasian male presented with corneal edema after handling Asclepias tuberosa. The corneal edema was treated with ciprofloxacin, prednisolone acetate, and a 5% hypertonic sodium chloride ophthalmic solution and resolved in 10 days. Conclusion There are only a few reported cases of corneal toxicity secondary to exposure to the Asclepias species. In cases of acute corneal toxicity with uncertain etiology, further questioning is warranted and exposure to the latex of Asclepias plants should be considered.chang_toxicity
Assessing Dry Eye symptoms and Meibomian Gland function before and after Lipiflow treatment.Chester2018This quality assurance project assessed eye dryness data and Meibomian gland function before and after Lipiflow treatment. A Standardized Patient Evaluation of Eye Dryness (SPEED) Questionnaire was answered by 65 affected patients to record the severity and frequency of their symptoms. In addition to the SPEED Questionnaire, each patient’s Meibomian gland function for both eyes was recorded. These procedures were completed before and approximately 8 weeks after bilateral Lipiflow treatment. The patients’ average Meibomian gland function improved by about 122% after Lipiflow treatment. Patients’ severity and frequency averages of eye dryness symptoms decreased by about-30% and by -33% respectively, after the use of Lipiflow.chester_lipiflow
Novel Treatment For Graft Rejection and KeratitisConnolly2018A 24 year old female presented with a history of keratitis and stabilized graft rejection. Ocular history included alkaline chemical burn, DALK, cataract surgery, and PKP with prior graft rejection. Prior treatment options included: artificial tears, cyclosporine 0.05%, lifitegrast 5%, amniotic membranes, and steroid pulses. She was on 3 topical medications for IOP control due to steroid induced IOP spike from controlling latest rejection. Slit lamp showed multiple confluent punctate epithelial defects OS, neovascularization and edema. Since the patient had tried multiple traditional treatment options with adverse effects, she agreed to try a relatively new treatment for chronic inflammatory ophthalmic conditions: an FDA- approved repository corticotropin injection (Acthar). This case study presents another treatment option for recalcitrant corneal keratitis and graft rejection.connolly_graft
Olopatadine 0.7% and Rhinitis, What a CoincidenceDe PazAgustin Gonzalez2018Drainage of topically applied medications via naso-lacrimal system has been documented as a potential way of systemic toxicity. This case presents a rather uncommon ocular complication of chronic nasal steroid use and a coincidentally beneficial nasolacrimal drainage side effect secondary to the management of allergic symptoms by the use of topical olopatadine 0.7% ophthalmic solution (Pazeo, Alcon).. 24 year old healthy F with signs and symptoms of allergic conjunctivitis and mildly elevated IOP after 1 year treatment of allergic rhinitis with Fluticanose Propionate (Flonase) experienced relief of allergic rhinitis and conjunctivitis after 6 weeks of treatment with olopatadine 0.7% solution. The patient was currently treated with Flonase for allergic rhinitis QD but reported sometimes TID for 1 year. The clinical exam was normal with VA of 20/20 and IOP's of 24 OD and 26 OS. After 6 weeks of treatment with olopatadine 0.7% ophthalmic solution and discontinuation of Flonase, IOP measurements were 18 OD and 19 OS. Coincidentally, patient reported relief of allergic rhinitis symptoms after treatment with olopatadine 0.7% ophthalmic solutiondepaz_rhinitis
Peripheral Age-related Macular Degeneration - Really?DemerittSamantha Kayser, OD, Deborah Jessurun, BS2018Peripheral Age-Related Macular Degeneration – Really? Introduction Peripheral exudate hemorrhagic chorioretinopathy (PEHCR) is an uncommon, but symmetrical peripheral retinal degeneration that affects elderly patients. The clinical findings of PEHCR vary from peripheral retinal pigment epithelial mottling, subretinal fluid or hemorrhages, subretinal exudation, pigment epithelial detachments to vitreous hemorrhages. We report a case of PEHCR in a primary care eye clinic. Case Report An 89-year old white female presented with complaints of reading up close and seeing faces at intermediate and far distances. BVA was 4/16 OD, OS. DFE revealed macula geographic atrophy and isolated, midperipheral dot and blot hemorrhages OU. DFE of the periphery revealed a subretinal hemorrhage and scar due to a resolved subretinal hemorrhage OD and pre-retinal hemorrhage and scar due to a resolved subretinal hemorrhage OS. Conclusion Despite the low prevalence of PEHCR, primary eye care practitioners should be aware of this rare condition, its relationship with macular degeneration and polypoidal choroidal vasculopathy, and its unique clinical presentation.demerritt_macular
Peripheral Exudative Hemorrhagic Chorioretinopathy: A Clinical MasqueraderDesaiJennifer Krech OD, Charles Haskes OD MS FAAO2018Peripheral Exudative Hemorrhagic Chorioretinopathy (PEHCR) is a rare chorioretinal degeneration in which limited case reports exist. The literature suggests that PEHCR is a peripheral variant of age related macular degeneration. Clinical features of the disease make PEHCR a mimicker of more ominous conditions such as uveal melanoma, and a diagnostic dilemma persists upon initial presentation. Supplementary testing such as fluorescein angiography, ultrasound (A-scan and B-scan), and optical coherence tomography (OCT) are fundamental in establishing the diagnosis of PEHCR. This case demonstrates the use of imaging techniques to confirm the diagnosis and determine appropriate management. Clinical features, differential diagnoses, treatment, and management will be discussed.desai_exudative
Managing Fungal Keratitis: PaecilomycesDevitt2018Fungal Keratitis is relatively rare in developed countries, it is difficult to diagnose, visually devastating, and is most commonly associated with contact lens wear, trauma, chronic eye disease or systemic disease. The purpose of this case report is to publish a documented case of Paecilomyces filamentary fungal keratitis management and outcome in an otherwise healthy non-contact lens wearing 60 year old male. There are limited publications on this specific ocular fungal infection and it is resistant to multiple fungicidal agents. Early diagnosis of fungal keratitis is often impossible unless there is a specific history of vegetative trauma ,and is not correctly diagnosed until the keratitis is proven refractory to antibiotic treatmentdevitt_fungal
The Price of BeautyDillinger2018A 32 year old female presents with Blurry vision and referral for Glaucoma evaluation following bilateral Iris implants in Colombia. Over the course of 6 months, the patient experienced progressive vision loss caused by bilateral UGH syndrome due to the Artificial Iris implants. The patient was referred to Ophthalmology for removal of the implants. This lecture intends to provide background for artificial iris implants, potential devastating consequences and management of UGH syndrome.dillinger_beauty
Venous Stasis Retinopathy: Urgent or Emergent?Duty2018A 60-year-old white male presents with a 3-month history of occasional tunnel vision OS eye lasting several minutes. He has a pertinent medical history of hypertension, diabetes mellitus and is status/post left femoral endarterectomy. He reports a 50-year history of smoking 2 packs of cigarettes daily and admits to occasional numbness in his left foot. A dilated fundus exam shows normal ocular health OD and multiple dot and blot hemorrhages and cotton wool spots in the mid-periphery OS. A carotid doppler and follow-on computed tomography angiography of the neck are abnormal, showing significant carotid occlusive disease. This case reviews proper management and referral protocols pertinent to Venous Stasis Retinopathy.duty_stasis
A Double Helping of DiplopiaDzurinko2018Sudden onset diplopia can be challenging for both the patient and clinician. It is important to differentiate the etiology in order to determine the appropriate intervention. A 70 year old male presents with a recent onset vertical diplopia. Clinical examination reveals a reversing hypertropia on left and right head tilts, with relief of symptoms in upgaze. Tentative diagnosis of bilateral cranial nerve IV palsy was made. This case presentation will discuss the characteristics and etiologies of a bilateral cranial nerve IV palsy, as well as the relevant differential diagnoses, necessary ancillary testing, and prognosis for visual recovery.dzurinko_diplopia
A Good Fit: Soft Lens Use After Corneal Cross-linking on a Keratoconus PatientElumeluRobert M. Kelly, O.D2018Corneal cross-linking, which has only been FDA approved since 2016, is quickly becoming the premier treatment for combatting the corneal and visual degradation caused in progressive kerataconous. However, the question remains: what lens options should optometrists consider when looking for a good fit for cross-linking patients? This case goes through the process of fitting a 19-year old, Hispanic, kerataconous patient after undergoing corneal cross-linking on both eyes. After a thorough examination and corneal topography were performed, Rose K2 soft lenses were chosen for this patient in hopes of providing both comfort and the option of repeated lens use as the patients corneas continued to stabilize after treatment.elumelu_crosslinking
Rod – Cone Dystrophy: Diagnosis and Low Vision Management to Improve Quality of LifeEspejoNicole Patterson, OD, FAAO; Lindsay Howse, OD2018Rod-Cone dystrophy is a condition where the genetic code for rhodopsin is damaged causing progressive loss of photoreceptors, it affects over 1.5 million world-wide. A case report of a 37 year old female who presented to clinic experiencing photophobia, nyctalopia, and visual field loss will be presented. Electrodiagnostic testing confirmed involvement of both rods and cones. Visual fields confirmed constricted visual fields with central vision loss. OCT macular thickness was reduced in both eyes. This patient was referred to low vision. Devices for nyctalopia and filters for photophobia were prescribed. The role of low vision and improvement in quality of life will be discussed.espejo_dystrophy
A Rare Case of Exercise-Band Induced Commotio RetinaeFergusonSarah R. Wilson, OD2018We will present a textbook example of a rare ocular condition resultant from a seemingly benign exercise activity. A patient presented with significant eye pain, lid and orbital ecchymosis, and blurred vision OS after an exercise band snapped backwards into the patient’s eye one day prior. Fundus examination revealed a large paramacular area of retinal whitening and macular thickening approximately 20 disc diameters in size. The blanched retinal area was confluent and the overlying retinal vessels were intact. BCVA was 20/30-2 in the involved eye. The poster will include excellent wide-field fundus photos with Optomap, Cirrus HD-OCT images of the macula demonstrating Berlin’s edema, a detailed discussion of pathophysiology as well as explanation of differential diagnoses, treatment and management.ferguson_commotio
RAM: The Role of AntiVegF on Visual RecoveryFogleman2018A case of a retinal arterial macroaneurysm followed with spectral domain optical coherence tomography and treated with Avastin. A 78 year old Caucasian female initially presented with decreased vision OD secondary to intraretinal and subretinal hemorrhage. A retinal arterial macroaneurysm with resultant macular edema was revealed with fluorescein angiography. Two Avastain injections showed a resolution of macular edema and significantly improved visual acuity from CF to 20/40. This case demonstrates the potential treatment effects of anti–vascular endothelial growth factor therapy versus observation for a symptomatic retinal arterial macroaneurysm.fogleman_ram
Multifocal Pattern Dystrophy Previously Diagnosed as Familial (Dominant) DrusenFrantz2018A 59 year old African American male presents for routine eye exam with a previous diagnosis of familial (dominant) drusen that was found to be multifocal pattern dystrophy. This case will explore the benefits of multimodal imaging on making a definitive diagnosis, the classic clinical presentation of the condition, and the current standard of care management.frantz_multifocal
Appearance of Optic Nerve Head Drusen with Optical Coherence Tomography: A Case SeriesFurtadoNicole C. Stout, OD, FAAO, Derek Y. Ho, MD, PhD2018Background. Optic nerve head drusen (ONHD) are retained hyaline bodies located in the anterior portion of the optic nerve. ONHD may result in irregular or indistinct disc margins, a presentation similar to what is seen with acquired disc edema, a condition which may result in severe ocular morbidity if untreated. ONHD formation is a slow, degenerative process. The underlying pathophysiology accounts for the varying sizes and composition of ONHD, as well as their intrinsic ability to autofluoresce. Case Report. A case series of three patients illustrating the variable appearance of ONHD visualized with spectral domain-OCT. Cross-sectional OCT scans of the optic nerve head are used to demonstrate that ONHD appear as: (i) hyporeflective cystic spaces with hyperreflective walls, (ii) small hyperreflective deposits within the optic nerve, or (iii) subretinal hyperreflective focal masses. Fundus autofluorescence images are shown for comparative analysis.furtado_optic
Pituitary macroadenoma presenting with decreased contrast sensitivity and central visual field defectFurtado2018Case Report. A 40-year-old female presented complaining of a progressively increasing brownish hue to the vision OD for the past few months. She also described recent short-term memory difficulties and a possible increase in hand and foot size over the past few years. Visual acuity was 20/15 in each eye. Pupils were normal. Contrast sensitivity testing with Pelli-Robson was 1.45 OD and 1.75 OS. Color vision assessment was normal in each eye, but a 20% desaturation was noted OD versus OS with red cap testing. DFE was unremarkable. Humphrey SITA standard 24-2 perimetry testing showed a central defect OD and scattered overall depression OS. MRI of the head revealed a 2cm x 2cm lesion on the pituitary gland with mass effect on the optic chiasm and extension bilaterally into the cavernous sinus. Discussion. Although the characteristic visual defect associated with a pituitary macroadenoma is bitemporal field loss, a variety of other visual field defect patterns are possible. This poster examines the spectrum of visual field defects observed with pituitary macroadenomas, as well as investigates other forms of visual dysfunction which may be present with this condition.furtado_pituitary
A novel use of multifocal scleral lenses for myopia control in the setting of corneal scarringGongPam Satjawatcharaphong, OD, FAAO, FSLS2018A 12-year-old male with degenerative myopia and corneal scarring secondary to severe entropion was fit into multifocal scleral lenses. Scleral lenses optically neutralize corneal irregularities and provide a protective mechanical barrier. Additionally, the stability of scleral lenses potentially allows for steady presentation of peripheral myopic defocus on the retina when utilizing multifocal optics. Studies have reported on the use of scleral lenses in children with ocular surface disorders, but there have been no reported cases on employing scleral lenses for myopia control. Given the benefits of comfort and centration, multifocal scleral lenses should be considered as a treatment modality for myopia control in the setting of corneal irregularities.gong_novel
Getting Under Your Skin: A Rare Presentation of ScabiesGraingerShephali Patel, Michelle Rountree2018A 68 year old African American male presented with complaints that he felt like something was crawling underneath his skin, which awoke him from sleep and non-resolving bumps around his eyes for past 3 months. Ocular history was remarkable for advanced glaucoma and cataracts. Slit lamp examination revealed multiple flesh colored lesions with no bleeding, crusting, or ulcerations, which did not improve with treatment by erythromycin. Consult with oculoplastics lead to diagnosis of scabies, a rare parasite which traditionally spares the face and head, and he was treated with Permethrin 5% dermal cream, used off-label for ocular adnexa. The lesions began to disappear within two weeks after treatment.grainger_scabies
The Management of Hemangiomas in ChildrenHarris2018Infantile capillary hemangiomas are common benign vascular tumors that can affect the orbit. Typically, rapid progression is observed over the first year of life, followed by spontaneous resolution before the age of seven. Hemangiomas may be superficial or deep and can cause ocular complications depending on the location. Optometrists provide a vital role in monitoring and providing treatment for these patients, as disruption of vision is common in the forms of deprivation, amblyopia, strabismus and anisometropia. Several cases of hemangiomas are evaluated in this presentation, including different locations, pre- and post-pharmacologic treatment, and amblyopia management.harris_hemangiomas
Diagnosis and Management of Patient with Epimacular Membrane and Proliferative Sickle Cell RetinopathyHaynesMohammad Rafieetary2018The majority of epimacular membranes are resultant from vitreoretinal interface interactions in a normal eye through age related processes. However, patients who have proliferative retinal disease are at increased risk to develop epimacular membranes. This case report details the management of a patient who developed epimacular membrane at a the age of 46 due to proliferative sickle cell retinopathy. The patient was initially referred for diagnosis of epimacular membrane, but subsequently was found to have peripheral neovascularization. The patient had panretinal photocoagulation, followed by vitrectomy, forceps membrane peel, and ILM peel. In atypical presentations of epimacular membrane, careful retinal evaluation with consideration of proliferative retinal disease should be performed.haynes_epimacular
Progression of Vitelliform Lesion and Formation of Geographic Atrophy as Shown by Optical Coherence Tomograophy and Fundus Autofluorescence: A Case ReportHaynesMohammad Rafieetary2018Vitelliform lesions, often mistaken for choroidal neovascular membranes, are an accumulation of lipofuscin associated with several disease entities including Best's disease, adult-onset foveomacular vitelliform Dystrophy , age-related macular degeneration, pattern dystrophies, and others. These lesions may cause mild loss of vision and visual distortions, but do not tend to cause significant vision loss. However, over time lesions can be re-absorbed, often with subsequent formation of geograhic atrophy causing substantial loss of central vision. These lesions have characteristic OCT and FAF findings. This case demonstrates the progression of a vitelliform lesion with eventual formation of geographic atrophy as shown by OCT and FAF.haynes_vitelliform
Prism Application for Strabismus, Brain Injury, & Low VisionHo2018Prisms bend light toward its base and image towards its apex. This tool transforms space through magnifying and minifying images seen through its apex and its base, respectively, which leads a viewer to perceive both spatial expansion and compression within a single plane dependent on the prism’s orientation. The following cases highlight various application of prisms: to reduce visual confusion associated with diplopia; to enhance field awareness in the context of visual field loss; and to compensate for shifts in egocentric localization as a result of retinal problems. Case 1: A prism prescription improves fusion for a patient with non-commitant strabismus resulting from pituitary tumor removal and contralateral Bell’s Palsy. Case 2: A prism prescription enhances spatial awareness and mobility for a post-stroke patient with incomplete inferior-dense left hemianopsia. Case 3: A prism prescription compensates for a maladapted reading posture and poor eye-hand coordination for a low vision patient with inferior field loss in his better seeing eye. Conclusion: Prisms are unique, indispensable, and readily available optical tools with multiple applications in all fields of optometric care.ho_prism
Navigating Unusual Findings in Optic NeuritisHynesC. Lisa Prokopich, OD MSc, Sandip Randhawa OD MSc, Sarah MacIver OD FAAO2018A 41 year old white woman bus driver presented with pain on eye movement OS>OD. Clinical findings included normal VA (20/15 OD, OS), but OS desaturation, RAPD, trace color defects, reduced contrast, and superior temporal visual field loss (30-2). Retrobulbar optic neuritis OS was diagnosed; however, treatment was delayed as neurology was uncertain about the diagnosis due to both the excellent acuity and shifting field loss on repeat measures. MRI and blood work were non-contributory, but trypanophobia limited ready access to an enhanced MRI, further complicating the diagnosis. Consideration for diagnosis in atypical optic neuritis will be emphasized, as well as MRI under general anesthesia.hynes_neuritis
"A tale of recurrent central serous chorioretinopathy"IsaacAndre Stanberry, OD, Dipl ABO2018A 38-year-old woman was evaluated and diagnosed with acute central serous chorioretinopathy (CSCR). Over 17 months, 4 unique episodes of CSCR were observed and documented with OCT and fundus photography. Each episode persisted for approximately 3-4 months. Her medical history was unremarkable but she reported a stressful home-life. Both acute and recurrent cases of CSCR are less frequently observed in women. The risk of permanent vision loss is higher with frequent recurrences, multiple hyperreflective foci and the presence of pigment epithelial detachments. This is a case of recurrent CSCR without a common underlying systemic cause in a woman with high risk retinal characteristics.isaac_recurrent
Things That Make You Go Bump in the Night: A Case of Night BlindnessJohnson2018A 56 year old male presented with the complaint of not being able to see at night for two to three months. Medical history was remarkable for alcoholic liver disease. Prior, the patient had not been regularly followed with eye exams. BCVA was 20/20 OD and 20/25 OS with no APD, mild nuclear cataracts, significant dry eye, and scattered patchy retinal atrophy. Based on exam findings, vitamin A deficiency was suspected as the cause of reduced night vision. Vitamin A labs were obtained and found to be at undetectable levels. The main causes of vitamin A deficiency include malnutrition, malabsorption due to systemic causes, inadequate storage, and rarely diet pills.johnson_bump
unilateral Optic Disc Edema as a Clinical Manifestion of Whipple's DiseaseKanikunnelMichelle Nguyen OD2018Whipple’s disease is a chronic systemic bacterial infection that affects the small intestines, but can also affect any organs of the body. The condition is rare, but can be life-threatening when untreated due to CNS involvement: ocular, oculo-masticatory and meningeal manifestation. This case is a rare presentation of unilateral optic disc edema as an early clinical manifestation of Whipple’s disease. Dilated eye examination of our patient revealed unilateral optic nerve edema of the right eye. MRI of the brain and orbits were unremarkable. The results from the EGD, GI biopsy and histological studies confirmed Whipple’s disease. The optic nerve edema improved in 3 weeks after initiating oral antibiotics treatment.kanikunnel_whipples
Goldenhar syndrome: A case report of limbal dermoid removal and ocular sequalaekim201829 year old female presents with burning and itching in the left eye. She presents with a history of intermittent exotropia, proptosis, and lagophthalmos in the left eye. Her medical history is positive for Goldenhar Syndrome. History of limbal dermoid removal on the right eye. She presented with cranio facial deformities which involved the orbit, attributing to her ocular diagnoses. Anterior segment evaluation revealed minimal scarring from her surgery. Fundus evaluation was unremarkable. This case demonstrates some of the ocular features of patients with Goldenhar syndrome which is part of the oculo-auriculo-vertebral spectrum. Ocular signs can vary among patients and treatment is tailored for each patient.kim_goldenhar
Degenerative Retinoschisis and Potential Progression to Retinal DetachmentKomornikRuth Hyatt, OD, FAAO2018Degenerative retinoschisis is the splitting of the retinal layers between the outer plexiform and inner nuclear layers. It is an acquired condition that typically remains stable; however, in certain cases, degenerative retinoschisis may progress towards the macula and rarely can convert to a similarly-looking retinal detachment. Being familiar with the differing clinical appearances of schisis and detachment as well as understanding risk factors for and signs of progression is imperative in appropriate management.komornik_retinoschisis
Imaging Technologies and their Role in Differentiating Amelanotic Posterior Segment LesionsKomornikRuth Hyatt, OD, FAAO2018Choroidal lesions such as amelanotic nevus, amelanotic melanoma, osteoma, and hemangioma may apprear strikingly similar to eachother; appropriate management necessitates accurate differentiation. Circumscribed choroidal hemangioma (CCH) is a benign vascular lesion occupying one quadrant of the choroid. The following is a case report of CCH including a review of diagnostic imaging modalities that allow for accurate management of amelanotic lesions of the posterior segment.komornik_imaging
Accelerated Progression of Diabetic RetinopathyLamPaula Johns, OD2018A case of accelerated progression of diabetic retinopathy from mild to proliferative in a woman diagnosed with chronic myeloid leukemia. This rare complication likely resulted from the secondary development of anemia from CML. Due to the nature of leukemia, an increase in peripheral non-perfusion and ischemia occurs throughout the entire body. In isolation diabetics with anemia are reported as 2.4x more likely to develop DR than diabetics without. This is due to the direct relationship between hemoglobin levels and the development and progression of PDR. With ischemic events compounding together from leukemia and anemia an accelerated the progression of pre-existing diabetic retinopathy is created.lam_diabetic
Transient unilateral hemianopia associated with atypical ocular migraineLappCharles N. Davis, OD2018Clinical findings for unilateral hemianopia is a serious concern. Differential diagnoses include infection, tumor, stroke, or migraines. This case presents a 45-year-old female with field loss, afferent pupil defect, and severe pain around the OS. She has a family history for migraines and is treated for POAG. Visual field results reveal a progressive left hemianopia OS. An extensive work up included laboratory testing, CNS imaging, cardiovascular and neuro-ophthalmology consult. The laboratory and imaging results were unremarkable. The neuro-ophthalmology evaluation excluded an intra-cranial tumor. Treatment was initiated for chronic migraines. This most interesting case revealed resolution of the migraine symptoms accompanied by resolution of the hemianopia OS.lapp_hemianopia
CHARGE Syndrome: Ophthalmic ManifestationsLeach2018A 14 year-old Hispanic girl presented to clinic to gain information about her visual function and potential recommendations for learning materials. Although not reported as a confirmed diagnosis, the patient had many features reflecting CHARGE syndrome, including ocular colobomas, hearing abnormalities, and to a lesser extent, microphthalmos and a cleft palate. Her nystagmus, mild cataracts, retinochoroidal colobomas, and visual field loss all appear to contribute to the severe level of low vision in her left eye, while microphthalmia accounts for the legal blindness in the right. Educational recommendations were provided to achieve better learning in the classroom setting, as well as a referral to the low vision clinic was placed.leach_charge
Under Pressure: A Case of Bilateral Hypotony Secondary to Systemic DehydrationLomaxJulieAnne M. Roper, O.D., M.S.2018While uncommonly encountered, ocular hypotony may result from both ocular and systemic causes and have serious complications including permanent vision loss and phthisis bulbi. We will present a unique case of bilateral hypotony in a 53 year old patient with significantly decreased intraocular pressure that had not yet impacted vision or function, as evidenced by optical coherence tomography and fundus photography. Thorough systemic review elicited symptoms of systemic dehydration, and both the hypotony and symptoms completely resolved upon rehydration. In addition to reviewing the ocular manifestations of systemic dehydration, we will provide a comprehensive overview of both bilateral and unilateral hypotony management, including pathophysiology, pertinent diagnostic testing, and treatment strategies.lomax_pressure
Chiari Malformation Type 1: A Case When Headaches and Optic Atrophy Lead to a Diagnosis of Cerebellar AbnormalityLomax2018Chiari malformation type 1 (CM1) can have ocular complications such as double vision, nystagmus, and optic atrophy. Headache and vertigo are common symptoms of CM1 that may present in an ocular examination. It is important to consider this cerebellar anomaly as a differential in patients presenting with headaches or unexplained optic nerve pallor. Proper imaging can reveal this often missed diagnosis.lomax_chiari
What are you losin' with this drusen?Luft2018Reticular pseudodrusen (RPD) are yellowish deposits affecting the inner RPE and IS/OS interface which follows a pattern or network “reticular” appearance. They have been described in recent literature as having implications for, but not diagnostic criteria of, the development of advanced macular degeneration. RPD can easily be overlooked with standard dilated fundus examinations and basic color fundus photography. This case highlights a 57-year-old female misdiagnosed and treated as AMD AREDS category III, then properly diagnosed with RPD after fundus auto-fluorescence and SD-OCT evaluation. In this case, the clinical pearls of detecting reticular pseudodrusen are highlighted, as well as its pathophysiology, prognosis, and the overall impact on patient management.luft_drusen
Dead Things Don't SwellLypkaJoseph Sowka, OD, FAAO, Diplomate, Eulogio Besada, OD, MS, FAAO2018Elevated blood pressure can lead to malignant hypertension and is a significant risk factor for the development of retinal artery occlusions. A patient presented with malignant hypertension along with a branch retinal artery occlusion in the right and a suspected previous central retinal artery occlusion in the left eye, evidenced by a history of sudden, painless vision loss, an atrophic retina, attenuated sclerotic arterioles and optic nerve head pallor. New management guidelines indicate that patients with transient ischemic attacks, including transient monocular vision loss, and retinal artery occlusions should be urgently referred to a specialized stroke unit for proper assessment, including a diffusion-weighted MRI.lypka_dead
A Curious Case of a Concerning ChoroidMesenburg2018A 74 year old black male with a recent diagnosis of lung cancer presented to clinic with a chief complaint of progressive vision loss over three days in his right eye. Examination revealed BCVA 5/200 OD, 20/25 OS, and a suspicious appearing lesion in his right choroid. Sub retinal fluid under the macula in his right eye was confirmed with OCT testing. His left eye was unremarkable for pathology. This poster will illustrate the ophthalmic presentation, management and treatment of a patient with a choroidal neoplasm as well as the importance of identifying and ruling out any underlying systemic etiologies.mesenburg_choroid
More than Meets the Eye: Multiple Benefits with Multifocal Scleral LensesMickles2018The use of scleral lenses has grown tremendously with indications that now go beyond visual rehabilitation of irregular astigmatism. Scleral lenses can also benefit patients with regular astigmatism, presbyopia, and dry eye disease. Optimizing vision with soft contact lenses for astigmatic and presbyopic patients can be challenging. Herein I report on a 55 year old oblique astigmatic presbyope with concomitant dry eye disease who achieved maximum vision and ocular surface restoration with multifocal scleral lenses. Multifocal scleral lenses which provide comfortable, stable vision are a viable option for patients struggling with dry eye disease and visual compromise with soft contact lenses.mickles_multifocal
Undiagnosed Demodicosis: A Case of Unnecessary Antibiotic and Steroid UseMiller2018Demodicosis often presents with signs and symptoms that mimic that of blepharitis, Dry Eye Syndrome, and Meibomian Glandular Dysfunction. Misdiagnosis in this case lead to years of antibiotic/steroid combination ointment which culminated in a toxic keratitits. Considering and treating Demodex as a source of recalcitrant lid inflation and ocular irritation can reduce antibiotic resistance and the over prescribing of prescription medications.miller_demodicosis
Granulomatous Uveitis in a TB Positive FemaleMitchell2018An 82 year-old Native American female presents with eye pain and photophobia OS. Anterior segment examination revealed large greasy mutton-fat keratic precipitates on the endothelium and 4+ cells in the anterior chamber OS. She was diagnosed with granulomatous anterior uveitis and started on atropine BID and Pred Forte Q1Hr. Lab workup revealed a positive TB test. At 1 week follow-up 3/4 of iris was zippered to the anterior lens capsule with minimal improvement to cells and KP’s. Pred Forte was replaced by Durezol 5x/day, and chest x-ray was ordered to rule out active tuberculosis. The chest specialist began treatment for latent TB after x-ray was negative for active lesions. Differential diagnoses for granulomatous uveitis include tuberculosis, Vogt-Koyanagi-Harada syndrome, sarcoidosis, and syphilis. VKH has an increased prevalence in Native American populations. Discussion will include diagnosis, treatment, and potential outcomes for this patient.mitchell_uveitis
Unique Use of an Amniotic Membrane in the Treatment of Limbal Stem Cell Dysfunction status post LASIKMolina2018In the setting of limbal stem cell dysfunction (LSCD), human amniotic membranes have been shown to help repair and promote the growth of limbal stem cells (LSCs). In a case of a 23-year-old female with contact lens induced LSCD exacerbated after LASIK and no relief from traditional topical treatments, a Prokera Clear was applied to the right eye. After four days, treatment was a success with clinical signs of LSCD diminished. Although its mechanism is unclear, amniotic membranes contain anti-inflammatory properties that aid in the restoration of functioning LSCs. Amniotic membranes should be considered as a treatment option when traditional methods do not provide relief.molina_amniotic
Headlights in a FogMorrow2018Sudden painless visual acuity loss in young adults is rare. Differential diagnoses include retinal detachment, vitreous hemorrhage, optic neuritis, toxic optic neuropathy, and central serous retinopathy to name a few. A differential that may not come to many clinician’s minds is a marked vitritis secondary to a toxoplasmis infection. The purpose of this presentation is to discuss the parasitic etiology of toxoplasmis, the prevalence of systemic and ocular manifestations of the parasite, the unique clinical findings associated with this infection, and the testing and treatment that should be considered as I review a recent clinical case I encountered.morrow_fog
Silent Sinus SyndromeMullenRuth Hyatt O.D.2018Silent Sinus Syndrome (SSS) is a chronic condition of the maxillary sinus with multiple ophthalmic findings of significance. In SSS, maxillary sinus blockage leads to negative pressure buildup and eventual collapse of the sinus, which precipitates orbital floor downward bowing. This change in orbital anatomy induces unilateral hypoglobus and enophthalmos. This case report discusses a 67-year-old white male with recent onset of vertical diplopia and eventual diagnosis of SSS through MRI. Optical correction of this patient’s diplopia was resolved with vertical prism. Surgical intervention of the sinus and/or orbit can be done to correct both hypoglobus and enophthalmos, which often relieves diplopia.mullen_sinus
The Changing Clinical Spectrum of Macular Pattern DystrophyNguyenTheresa Zerilli Zavgorodni2018A 79 year-old male presented with complaints of blurry vision at near. He reported longstanding symptoms which started 10 years ago and have gradually progressed. Dilated fundus examination showed mild geographic atrophy, pigment migration OU with a round area of yellow elevation OD. Macular optical coherence tomography and fundus autoflourescence confirmed the diagnosis of adult-onset foveomacular vitelliform dystrophy (AFVD) and reticular pattern dystrophy. Pattern dystrophies refer to a group of autosomal- dominately inherited group of macular diseases sharing a common phenotype which affects the retinal pigment epithelium. We present a unique case of overlapping pattern dystrophies, illustrating how one form can evolve and morph into another within a single patient.nguyen_spectrum
Do You Believe in Scleral Miracles?NguyenZoeanne Schinas2018Radial keratotomy (RK), a refractive surgery performed in the 1970’s and 1980’s, consists of making corneal incisions for the correction of myopia and /or astigmatism. A refractive shift towards hyperopia and progressive astigmatism, along with fluctuations in vision due to low corneal rigidity are a common occurrence after the procedure. In most cases, this is considered an undesirable postoperative complication. However, this is a unique case in which a post RK patient experienced a sudden refractive shift and improved unaided visual acuity immediately after scleral lens wear which lasted for several days.nguyen_scleral
Internuclear ophthalmoplegia secondary to basilar artery stenosisNhouyvanisvong2018This case outlines the management of a middle-aged Native American male who presented to our walk-in Urgent Eye clinic with complaints of red, irritated eyes, and was incidentally found to have new-onset internuclear ophthalmoplegia. This case is focused on the discovery of the internuclear ophthalmoplegia, further complicated by the patient’s limited communication due to aphasia, and a complex medical history including multiple brainstem strokes, uncontrolled diabetes and subsequent retinopathy, and other vascular risk factors. The internuclear ophthalmoplegia was ultimately determined to be secondary to recent basilar artery stenosis causing pontine infarction.nhouyvanisvong_internuclear
An assumed case of toxocariasisPatel2018Toxocariasis is a parasitic infection, characterized by presentation of a round, raised white retinal lesion, which sometimes has fibrotic bands radiating from the lesion causing traction. The lesions can be in periphery or posterior pole. Our 17-year-old Hispanic patient had similar findings as well as choroidal folds temporal to optic nerve. Findings were classic of toxocariasis. However, she was diagnosed with toxoplasmosis by an ophthalmologist. This case illustrates the subtle differentiation of pathology. When in doubt regarding a lesion, it's important to get a second opinion. If this was an active toxoplasmosis and not seen by an ophthalmologist, the end results could have been detrimental to her vision.patel_toxo
There is more to macula than AMD: Differential Diagnosis of AMD Look a likesRafieetaryRoya Attar, OD, MBA2018There are a group of conditions that have similarities to age related macular degeneration (AMD) and often misdiagnosed as AMD. These conditions include; adult vitelliform macular dystrophy, polypoidal choroidal vasculopathy, macular telangiectasia (Mac Tel type 2), pattern macular dystrophy, central areolar choroidal atrophy, and Stargardt macular dystrophy. This Poster will review the clinical as well as the diagnostic imaging such as OCT, fundus autofluorescence and angiographic characteristics of these masquerades to AMD.rafieetary_amd
Vitreomacular Traction: Know When to Hold Them and When to Fix ThemRafieetaryJessica Haynes, OD2018Vitreomacular traction (VMT) is a common condition diagnosed by optometrists, many times during regular examination of unsuspecting patients. This poster will review and demonstrate the clinical course of VMT particularly by actual case examples. The criterion and characteristics for when it is appropriate to monitor the patient as opposed to those who will benefit from surgical intervention is discussed as well.refieetary_traction
Choroidal Melanoma: Side Effects of I-125 BrachytherapyRappach2018Introduction: Choroidal melanoma is the most common primary malignant ocular tumor in adults affecting 6 per 1 million in the United States. I-125 brachytherapy is a common treatment modality with a good prognosis; however, keeping the eye does not mean you always keep vision.  Case: 69-year-old white male with gradual vision loss following I-125 brachytherapy treatment for choroidal melanoma. Dilated examination revealed extensive damage secondary to radiation therapy. Conclusion: The main goal of treatment is to prevent metastasis, but potential side effects are well-documented and need to be discussed thoroughly with the patient. This patient was able to keep the eye without metastasis, but functional vision is gone.rappach_melanoma
The Alphabet Soup of Federal Mandated Laws to Help the DisabledRitter2018This poster will describe the federal and state mandated programs that the optometrist can take advantage of to help learning disabled patients achieve their life goals. These programs were developed to help enable both younger and older patients navigate through the educational system to rise above their perceived limitations. Discussion will include programs the practitioner should have working knowledge of to help support their patient’s with specialized educational and social needs. Included will be the more commonly utilized resources such as FAPE: Fair, Appropriate Public Education including section 504; IDEA: Individuals with disabilities in education act and ADA: Americans with Disabilities act. Other directives will be mentioned as well.ritter_alphabet
Sudden onset aneurysm: incidence, physiology and rehabilitationRitter2018This poster describes the diagnosis and treatment of a 61 year old who suffered an aneurysm resulting in a subsequent craniotomy 5 years prior. Initial symptoms included severe neck pain leading to dizziness, loss of vision, hearing and unconsciousness. After hospitalization and follow-up therapy, changes were not noted until beginning a program of vision rehabilitation. Discussion covers the conditions and anatomy that can lead to cerebral aneurysms, the signs, symptoms and differential diagnoses. Proper, timely referrals will be emphasized followed by a brief discussion of the successful vision rehabilitation performed. With over 6.6 million Americans with un-ruptured aneurysms and 30,000 with ruptured aneurysms, this information is critical to serving our active and aging populations.ritter_aneurysm
The Complexities of the Ganglion Cell Complex: A Case Series Exploring the Visual Impact of Retrochiasmal LesionsRoper2018In addition to visual field loss, lesions of the retrochiasmal visual pathway have been shown to have correlating retrograde thinning of the spectral domain optical coherence tomography (SD-OCT) ganglion cell complex (GCC). We will explore these variable structural and functional manifestations in a case series of patients with increasing complexity and management demonstrating the correlation between neuro-imaging, visual fields, and SD-OCT. We will compare and review the management strategies for the resultant visual field loss. Our cases will include a right superior homonymous quadrantanopia due to a stroke, a left homonymous hemianopsia due to a stroke, and a right homonymous hemianopsia due to a traumatic brain injury.roper_ganglion
Prolonged management of herpes simplex keratitis due to corneal toxicity caused by ViropticSan Miguel2018The preferred treatment option for herpes simplex keratitis is often Zirgan, but many times is not used due to cost or lack of availability at many pharmacies. Viroptic is an alternative treatment option, and although it is effective in treating the viral infection, it can cause extreme corneal toxicity that can take weeks to resolve. This report reviews the management approach of a 61-year-old male with herpes simplex keratitis successfully treated with Viroptic, however severe corneal toxicity occurred and required additional treatment.sanmiguel_herpes
PUK Handling: Not Just for the NHL. A Case Report on Peripheral Ulcerative KeratitisSchaeffer2018A 71-year old male was referred for painful corneal thinning. Diagnosis of Peripheral Ulcerative Keratitis (PUK) was made based on clinical findings, slit lamp photography and anterior segment OCT was obtained. Blood work was gathered to investigate possible systemic causes. Treatment with oral and topical steroids was initiated, and patient improved. PUK is a rare condition of painful progressive peripheral corneal thinning often due to a serious underlying systemic etiology. PUK can result in permanent vision loss if left untreated. According to the American Academy of Ophthalmology, there are only 3 cases per million per year; however, due to the severity of morbidity and possible mortality surrounding this condition, it is important to be able to recognize and manage it appropriately.schaeffer_puk
Bilateral Recurrent Anterior Uveitis as an Uncommon Adverse Event with Ipilimumab Treatment for MelanomaShoemakerDavid Johnson, O.D.2018A 65-year-old white male presented acutely with symptoms of bilateral pain and reduced visual acuity that began upon awakening. The patient’s recent medical history is remarkable for cutaneous melanoma and treated with ipilimumab, a monoclonal antibody that has significantly improved survival rates in malignant melanoma cases. Ocular adverse effects from this treatment have been documented in less than 1% of patients. The patient was diagnosed with bilateral anterior uveitis which became recurrent with repeated infusions. Typical uveitis work-up proved to be unremarkable. This case presentation follows the treatment and management of recurrent anterior uveitis as well as the proposed pathophysiology of ipilimumab-induced ocular inflammation.shoemaker_recurrent
From NLP to “I Can See” – Successful Rehabilitation in a Complex Case of Concurrent Functional and Organic Vision LossSimoncelliTheresa Zerilli O.D., F.A.A.O2018Functional, or non-organic visual loss (NOVL), may present with a variety of manifestations, ranging from mild unilateral vision loss to visual field disturbances and total blindness. Furthermore, NOVL can coexist with organic pathology complicating the clinical picture and diagnosis. Prognosis may be guarded in the presence of psychiatric comorbidities. This unique case presents a monocular patient with recurrent episodes of NOVL complicated by a history of PTSD and advanced ocular disease including end-stage pigmentary glaucoma and bilateral retinal detachments. Low vision rehabilitation emphasized reassurance, and close monitoring lead to a significant improvement in vision from NLP to 20/30. Clinical characteristics, diagnosis, and management of NOVL in the presence of concurrent ocular pathology will be discussed.simoncelli_nlp
Diagnosis and Management of a Fungal Corneal UlcerSoong2018Fungal corneal ulcers are notoriously difficult to manage due to signs and symptoms that masquerade as other infectious ulcers, limited options in treatment, stubborn resistance to treatments, a slow healing period, and deep penetration into the layers of the cornea. If not properly managed, this infection can lead to severe vision loss and other devastating effects on the eye. This case reviews a 48 year old made referred for a central corneal ulcer that was not responding to topical antibiotic treatment. This review will include differential diagnoses, when to consider altering treatment and the approach in management of fungal keratitis.soong_fungal
Post-RK Complications: Management of Higher-Order Aberrations and Corneal HazeSoryaChris Wroten, O.D.2018A 68-YOWM c/o constant monocular diplopia and “ghosting” OS that are longstanding and present with or without correction. Patient has previous history of radial keratotomy OU x1990, with secondary cut in OS. He wears correction OS infrequently, due to discomfort OS>OD with current hybrid lens OD and RGP OS (BVA 20/30 and 20/80 respectively). Exam revealed 8-cut RK OU resulting in irregular, flat, corneas on topography and central corneal haze OS. Patient returned for a successful scleral lens fit with ZenLens 16.0mm oblate design SCLs, reporting great satisfaction with vision, comfort, and resolution of diplopia (BVA 20/20 OD, 20/50+2 OS). SLE photos, topography, and anterior segment OCT will be presented, as well as a discussion on management options for post-RK complications.sorya_postrk
Solar Retinopathy Confounds Pituitary Tumor Diagnosis: A Case Report & Literature ReviewSoryaChris Wroten, O.D.2018A 66-YOWF presented for initial exam reporting history of pituitary tumor resection in 2003 and past sun gazing. Exam revealed macular solar retinopathy with BVA of 20/30 OD, OS, but was otherwise unremarkable. Visual fields showed marked left homonymous hemianopsia with significant progression versus prior fields done elsewhere, so MRI of the brain was ordered. A review of symptoms, findings, and management options for this confounding case of solar retinopathy with concurrent space-occupying lesion will be discussed, including hormone therapy, resection, and radiotherapy, in addition to presenting color optic nerve photos, OCT results, radiologic images, and 10 years worth of visual fields.sorya_solar
Whooshing in the fog: A case of fibromuscular dysplasiaSteiner2018A patient presents with eyestrain, is diagnosed with convergence insufficiency, and begins vision therapy. She makes steady gains but still has concerning symptoms of slow reading, mental fogginess, and intermittent whooshing in her ears. After consultation with multiple specialists, could it be that her optometrist holds the key to her diagnosis? Fibromuscular dysplasia, a life-threatening thickening and aneurysmal condition of medium-sized arteries, can go undiagnosed for years. Symptoms such as blurred vision, transient loss of vision, dizziness and headache will being these patients into the optometrist’s office. Proper testing, education, and management prolongs life and restores function. Etiology, symptomatology, differential diagnosis, and management will be presented.steiner_dysplasia
Adults with strabismus: Know when to hold ‘em, know when to fold ‘emSteiner2018Strabismus can be a challenging condition in any patient, and many doctors have limited experience managing it. Because of recent writings on neural plasticity, more adult patients are presenting with the desire to better understand their condition and options for possible treatment. How best to triage these patients without overlooking serious health concerns, tying up office resources, or feeling at a loss? This poster presents mini-cases, each of which will highlight important aspects of the care of the adult with strabismus. Emphasis will be placed on streamlined testing that allows doctors to efficiently determine whether referral for therapy, surgery, imaging, or medical co-management seems most urgent.steiner_strabismus
Ocular Syphilis: A Case Study and Review.Sterling2018This poster features a 67-year-old man that presented to the clinic after getting “flea killer” in his eye earlier that day. He was diagnosed with an iritis and treated traditionally. When he failed to respond to the treatment, labs were ordered and diagnosis of ocular syphilis was made. This poster will review the ocular manifestations of syphilis, the necessary lab work, differential diagnosis, and treatment options.sterling_syphilis
Expect the UnexpectedStottlemyer2018Syphilis is a sexually transmitted disease, caused by Treponema Pallidum, that is on the rise in the US and left untreated can lead to devastating vision loss. . Clinical findings associated with ocular syphilis include anterior uveitis, posterior uveitis, vitritis, chorioretinitis and optic neuritis. Additionally, somatic symptoms of syphilis range from early flu-like symptoms to neurologic complications in late stage neurosyphilis. Here I present a case of a 40 year old heterosexual, immunocompetent, while male with normal vision but new onset of photopsia and dizziness. Clinical exam revealed mild anterior vitritis with two snowballs in the far retinal periphery and mild disc edema. Laboratory testing was diagnostic for neurosyphilis, the treatment of which provided relief of photopsia and reduction of ocular inflammation. This case serves as a reminder to “expect the unexpected”; subtle ocular presentations can be associated with significant systemic pathologies that demand prompt treatment to reduce risk of long-term physical and visual impairment.stottlemyer_unexpected
Multifocal Choroiditis and PanuveitisTautges2018Multifocal Choroiditis and Panuveitis (MCP) and Punctate Inner Choroidopathy (PIC) are White Dot Syndromes that constitute inflammatory chorioretinopathies of unknown etiologies. These pathologies typically present with whitish lesions in the retina or choroid that often lead to atrophic scarring. Their inflammatory nature can generate choroidal neovascular membranes, retinal edema, and subretinal fluid, leading to blur and metamorphopsia when found in the macula. This poster exhibits a case study exploring these two differentials by displaying a patient’s progression of symptoms, signs, and treatment over 8 years of clinical care. It also presents the images (OCT, fundus photos, FA) which monitor the evolution of the lesions found in the condition.tautges_choroiditis
Dacryocystitis: When to Consider Surgical InterventionThompson2018Patient presents for evaluation of redness and swelling of the left lower lid, which has been occurring intermittently over the past year. On examination, the patient is diagnosed with a chronic dacryocystitis OS. She is started on oral Augmentin and scheduled for incision, drainage, and culture the following day. The patient is re-evaluated post-incision and drainage with improvement in presentation and symptoms. Culture has confirmed growth of Proteus Mirabilis. At follow-up two weeks later, she has developed a recurrence of infection. Patient is re-started on Augmentin and scheduled for a dacryocystorhinostomy procedure, due to the chronic, recurrent nature of her condition. The patient is doing well post-operatively without recurrence.thompson_dacryo
Comparison of Keratoconic Soft and Corneal Gas Permeable Designs in a Keratoconic PatientTomiyamaJudith A. Perrigin, OD2018A keratoconic patient, with complaints of mild dryness and frequent lens breakage, presented wearing standard spherical gas permeable lenses. She was successfully fit in both soft and a keratoconic specific design of rigid lenses. ComfortKone multicurve rigid lenses offer a posterior aspheric periphery to help control edge lift and midperipheral alignment. Kerasoft IC is a custom-lathed soft silicone hydrogel lens with customized selection of the central and peripheral regions. The different lens designs were compared in their objective and subjective performance. While practitioners may be hesitant to “rock the boat” (i.e.change lens design or parameters) if the current modality is satisfying the patient, offering the patient the latest technology may optimize vision, comfort, and eye health.tomiyama_keratoconic
A positive response to expansion prisms for low vision rehabilitation following strokeWang2018For homonymous hemianopsia and neglect, expansion prisms may help increase awareness of objects in the affected periphery by increasing binocular visual field. The use of expansion prisms may aid patients in safe mobility and object collision risk. A 73-year-old male presented with a left homonymous hemianopsia and left spatial neglect. He felt anxious in public settings, bumped into objects, and performed poorly on neglect testing. After two weeks of expansion prism wear, the patient conveyed positive response with increased awareness of his left field and increased comfort navigating unfamiliar environments. Repeat neglect testing also yielded significant improvement. He held himself with more confidence and reported a greater level of safety.wang_prisms
When Two Eyes Aren’t Better Than One: A Rare Case of Simultaneous Bilateral Non-Arteritic Ischemic Optic NeuropathyWardRichard Gardner, OD2018This report details a 76-year-old male presenting with simultaneous bilateral disc edema secondary to non-arteritic ischemic optic neuropathy (NAION). The presentation will include serial visual fields and excellent OCT images. This case will review the clinical presentation of NAION including relevant anatomy, recommended work-up, systemic associations and risk factors, and differential diagnoses. Anterior ischemic optic neuropathy (AION) is important clinically as it is one of the most common manifestations of acute optic neuropathy in older patients. NAION constitutes up to 95% of all AION cases and can have a profound impact on visual function.ward_twoeyes
Hemodialysis and Effect on Intraocular Pressure: A Case ReportWiedemann2018A link between hemodialysis and elevation of intraocular pressure has long been suggested, but presents certain challenges for the clinician to identify and manage. Several methods for the rise in intraocular pressure are suggested including increase in aqueous humor production or a decrease in blood osmolality causing more fluid transfer. This is a case of a patient with end stage kidney disease and hemodialysis treatments weekly, with progression of glaucoma despite controlled intraocular pressure with in office measurements. Close management, aggressive treatment, and co-management with nephrology helped to prevent further vision loss in this patient.wiedemann_hemo
Tilted Disc Syndrome: A Congenital ConundrumWilliams2018Tilted disc syndrome is a congenital anomaly characterized by inferior ectatic conus, situs inversus, and anomalous disc shape. Associated clinical findings can mimic serious neurological disease, both sight and life threatening. Visual field defects most commonly involve the temporal and superior temporal field, imitating tumors of the anterior visual pathway. Sequelae of tilted disc syndrome including choroidal neovascularization and macular serous detachments can lead to severe vision loss. A case of tilted disc syndrome in a patient with history of pituitary adenoma will be presented. This poster will also highlight clinical findings and associated complications that aid in appropriate management and prompt differentiation in cases of congenital optic nerve head anomalies.williams_tilted
A rare clinical manifestation of Bechet’s DiseaseWuCarl Jacobsen, O.D., F.A.A.O.2018A 58-year-old Hispanic male reported to clinic having recently noted a crescent-shaped scotoma and decreased vision in his right eye. His medical history was significant for Type II diabetes, hypertension, and hepatitis C. Upon examination, a white-creamy yellow crescent shaped lesion was found temporal to the fovea spanning the length of the arcades in the affected eye. Through subsequent visits, the lesion disappeared and signs of retinal vasculitis appeared. Further case history revealed genital and oral aphthous ulcers suggesting a diagnosis of Bechet’s Disease. Although typically associated with anterior uveitis, Bechet’s Disease can present as a retinal vasculitis.wu_bechets
Role of low vision rehabilitation in expanding functional visual fields with stabilization of binocularityZerilliTam Nguyen O.D., F.A.A.O, M.S.2018Advanced Glaucoma is typically characterized by marked peripheral visual field (VF) loss that can be debilitating. Low Vision Rehabilitation often emphasizes enhancing peripheral field awareness for safe travel. Some patients, however, may also have binocular instability secondary to loss of peripheral fusion locks. In select cases, correction for binocular instability can provide a functional increase in VF. This unique case presents a patient with one eye having central vision loss and other with severe peripheral VF loss. A dramatic increase in reading speed secondary to a functional increase in VF was achieved by stabilizing binocularity. Techniques employed for binocular testing and functional field assessment will be emphasized.zerilli_lowvision
A Case of Multiple Cranial Nerve Palsies Associated with LymphoepitheliomaAlvarezDr. Shephali Patel2016Lymphoma is a cancer involving the immune cells of the body and has been implicated in many ocular conditions, including cranial nerve palsies. This case report discusses a 50-year-old African American male who has a history of lymphoma with multiple cranial nerve involvement. He successfully underwent chemotherapy and radiation treatment for his condition yet had a residual cranial nerve six palsy and was symptomatic for diplopia.alvarez_palsies
Outer Retinal Tubulation: What it is and How Does it Affect the Management of ARMD PatientsAtchersonDr. James Willamson, OD; Dr. Andrew Rixon, OD2016Outer retinal tubulations are loculated pockets of hypofluorescence with surrounding hyperfluorescent rings that could appear to the uniformed practitioner as new areas of intraretinal or subretinal fluid. Two cases of patients with a history of CNV with subretinal fibrosis from wet ARMD will be presented. Both patients had macular OCTs showing the presence of Outer Retinal Tubulation. This poster will discuss the pathophysiology of this phenomenon and how the emergence of spectral domain-optical coherence tomography has aided the practitioner in the appropriate diagnosis and as a result more appropriate management to avoid unnecessary subspecialty care.atcherson_tubules
Displaced: A case of ectopia lentis et pupillaeAuJulie Rodman, OD2016Ectopia lentis et pupillae is a bilateral congenital disorder characterized by lenticular and pupillary ectopia caused by mechanical tethering of the pupil and zonular disruption. There is often great variability in the manifestations between the two eyes and a wide range of complications that can arise with significant impact to vision. This presentation details the management of a serous retinal detachment resulting from phacoanaphylactic (lens-induced) uveitis as a complication of ectopia lentis et
Adaptation to spectacle wear; differences between children and adolescents with Autism Spectrum Disorder and typically developing controlsBadeRachel Anastasia Coulter, OD, Yin Tea, OD, Pamela R. Oliver, OD, MS, Erin Jenewein OD, MS, Jacqueline Rodena, OD, Sandra Dunbar, DPA, OTR/L, Nicole Quint, OT, MOTR/L, Bin Zhang, MD, PhD, G. Lynn Mitchell, MAS2016Children with Autism Spectrum Disorder (ASD) often have a higher incidence of tactile defensiveness, making adaption to wearing eyeglasses difficult. 22 ASD or Typically Developing (TD) subjects aged 9 to 17 years old were enrolled from subjects recruited in another study. Parents completed telephone surveys at 1, 2, 4, 8, 12, and 16 weeks after each child received their glasses. The survey asked questions about wearing time, willingness to wear glasses and amount of prompting required. Most of the ASD patients (13 of 15) had not worn glasses previously, however this did not significantly impact wearing time or frequency. No significant difference was found between ASD and TD wearing time.bade_adaptation
Rehabilitation of an Acquired Brain Injury Patient with Neglect and HemianopsiaBakotaDr. Sandra Fox, OD2016Acquired brain injury (ABI) occurs from a non-traumatic event such as anoxia, aneurysm, or stroke. Damage can be focal, diffuse, or both. A person who has suffered an ABI may experience a hemianopsia, loss of half of their visual field, right or left. Neglect, the inattention to or lack of awareness of visual space on either their right or left side, is often associated with a hemianopsia. Rehabilitation of an ABI takes an interdisciplinary team approach to help the patient return to his/her highest functional level of health and independence. This case highlights vision rehabilitation of an ABI patient with neglect and hemianopsia.bakota_rehabilitation
Uncovering myasthenia gravis following bilateral ptosis repairBhalooDavid Chen, MD2016An 83-year old Caucasian male presented to oculoplastics with ptosis OS > OD. Bilateral ptosis repair was performed without incident. At one month post-op, patient began complaining of intermittent diplopia and having fallen 3 times in the previous 2 weeks. 9-gaze Maddox rod testing performed 3 times in 5 minutes produced an array of results. Drooping of the left upper lid was noticed during testing. When lab results returned positive results to confirm diagnosis of myasthenia gravis, patient was referred for further testing to determine if it was systemic or ocular. The patient was started on 60 mg pyridostigmine qid and all symptoms resolved. Continued follow-up care is ongoing.bhallo_myasthenia
Bull’s Eye Maculopathy in a Jamaican PatientBlack2016A 56 year old Jamaican female presented for decreased vision. Medical history was significant for hypertension, type 2 diabetes mellitus and systemic lupus erythematosus. Previous medical treatment for her SLE included chloroquine. Preliminary testing was unremarkable. The patient was correctable to 20/40 OD and 20/25 OS. Slit lamp findings were remarkable for mild corneal staining, cortical spoking and trace posterior subcapsular cataracts OD, OS. Dilated fundus examination was significant for large cup to disk ratio, epiretinal membrane and bull’s eye maculopathy. The case will be presented including ancillary testing and a literature review of bull’s eye maculopathy. Choloquine use in immigrant populations will also be discussed.black_bullseye
A Curious Case of Pontine Infarction: The Nine SyndromeBorgmanAlex Jackson2016A 59 year old AAF with a history of brainstem stroke 2 months prior presented with an ocular motility disturbance of Fisher's one-and-a-half syndrome, along with an ipsilateral facial nerve palsy, and contralateral hemiparesis/hypesthesia. As predicted based on clinical exam, MRI confirmed ischemic lesion in the dorsal tegmentum of the caudal pons. A thorough understanding of neuroanatomy can help localize lesions causing abnormal ocular findings.borgman_nine
Retinal Pigment Epithelial Detachment (PED): A Proposed Manifestation of Tamoxifen RetinopathyBrophyCasey Hamm, OD, and Julie Rodman, OD, FAAO2016It has been well documented that tamoxifen, an estrogen receptor antagonist used to treat breast cancer, can result in ocular toxicity including cataract, vortex keratopathy, and retinopathy. A 50-year-old African American female with a history of chronic tamoxifen use was referred for ocular examination. Although correctable to 20/20 OD and OS, fundoscopy revealed a juxtafoveal round, serous lesion in the left eye. Spectral domain OCT confirmed the presence of a shallow retinal pigment epithelial detachment (PED). While PED has not previously been associated with tamoxifen use, tamoxifen-associated retinal toxicity is believed to occur at the level of the RPE. Thus, PED could be a potential manifestation of tamoxifen toxicity.brophy_tamoxifen
Rhegmatogenous retinal detachment secondary to cytomegalovirus retinitis in immunocompromised patient with previous retinal detachment repairCairnie2016Cytomegalovirus in immunocompromised individuals commonly results in multiple systemic complications, with frequent ocular findings of chorioretinitis. This is a case of a 60-year old female presenting with peripheral retinal hemorrhages, sectoral necrosis, and concomitant rhegmatogenous retinal detachment involving the macula. The patient reported previous retinal detachment repair in the affected eye and use of immunosuppressants for recent kidney transplant. Additional medical history revealed diabetes and hypertension. The patient urgently received a pars plana vitrectomy with silicone oil and scleral buckle. A vitreous specimen confirmed active infection by cytomegalovirus. This case demonstrates the importance of a thorough case history and accurate diagnosis of retinal findings in determining the proper treatment.cairnie_cytomegalovirus
Optical Coherence Tomography, Humphrey Visual Field, MRI and Other Clinic Findings in a Patient with Septo-Optic DysplasiaCappelliTiffany Tucker, OD, FAAO2016Septo-optic dysplasia (SOD) is a congenital disorder consisting of a triad of optic nerve hypoplasia, pituitary hormone abnormalities and midbrain defects. Patients may have a multitude of ocular complications including reduced vision, visual field defects, strabismus, and coloboma. This poster will examine OCT results, clinical findings, and evaluation of a patient with SOD. In this case, the OCT results indicated a bilateral optic nerve abnormality which was supported by the clinical exam, visual field and MRI results. Continued monitoring for hormonal insufficiencies is indicated. The presence of optic atrophy should prompt further investigation to determine the etiology and ensure proper treatment, as indicated.cappelli_septo
Diagnosis and management of syphilitic uveitisChocky2016This case will discuss diagnosis and treatment of syphilis, a condition that can have a variety of sight threatening manifestations. A 27 year old African American male presented to the New Jersey VA Medical Center complaining of blurry vision in the left eye and floaters for the past three weeks. Best corrected visual acuities were 20/25 OD and 20/200 OS. Pertinent ocular findings included iris nodules, severe anterior chamber inflammation, and vitritis in both eyes. After laboratory testing, the patient was diagnosed with syphilis and admitted to the hospital for intravenous antibiotic therapy. The patient had full visual recovery after treatment.chocky_syphilitic
Unilateral Peripapillary Schisis with Advanced GlaucomaChoiKevin Corcoran OD, FAAO2016Peripapillary schisis has previously been reported with congenital optic nerve anomalies such as optic disc pits and colobomas. Recent studies have identified this finding in patients with angle closure, narrow angle and open angle glaucoma. One study reported a 5.9% rate of occurrence in open angle glaucoma patients. Subclinical peripapillary schisis associated with glaucoma may be underreported. This case report describes an incidental finding of unilateral peripapillary schisis with macular involvement in a patient with advanced glaucoma.choi_peripapillary
Intraosseous Meningioma: A Cause of Unilateral ProptosisDauDipti Singh, OD, MPH2016Meningioma is the most common benign primary CNS tumor that arises from meningothelial cells attached to the dura mater. It occurs more in women and incidence increases with age. A 50 y.o female complains of increased size of the OD over several years without decrease vision or diplopia. Hertel exophthalmometer revealed proptosis OD. MRI and CT scan revealed a sclerotic lesion of the right sphenoid wing and lateral orbit without generating any mass effect on the optic nerve and orbit. Neurology was consulted due to concern for intraosseous meningioma. About 92% of meningiomas are asymptomatic and require no treatment other than periodic observations. Surgical resection biopsy is warranted to confirm diagnosis.dau_meningioma
Subretinal Macular Fluid: That’s the Pits!EngstromChristian W. Jordan, OD, FAAO2016An optic disc pit is a rare (1:11,000) congenital abnormality caused by incomplete closure of the fetal fissure during embryogenesis. I present a case of a 9 year-old Caucasian female referred to Palmetto Health Ophthalmology for evaluation of her right eye due to an irregular red reflex on physical exam. Dilated fundus examination revealed an optic disc pit with associated subretinal fluid within the macula, RPE pigmentary changes, and a decreased foveal light reflex in the right eye. I will present fundus photos and high–resolution OCT imaging, as well as discuss key differentials every clinician should consider for appropriate diagnosis and management. This case presents a rare presentation of visually insignificant macular fluid associated with an optic disc pit in a child.engstrom_optic
Grapefruit-sized Mucocele Inducing Narrow Angle GlaucomaFergusonBrad Sutton, OD, FAAO, Julie Torbit OD, FAAO2016A 74 year old man presented with a red, swollen shut right eye. The patient complained of the right side of his nose running and a headache located on his right temple. IOP was elevated and anterior chamber angles were very narrow along with mild proptosis OD. CT and MRI scans of the orbits revealed a large mucocele occupying the entirety of the frontal sinuses, displacing the right globe inferiorly, pressing on the right superior rectus muscle, extending through the right and left frontoethmoidal recesses into the right side of the nasal cavity, and inducing narrow angle glaucoma.ferguson_mucocele
Neovascularization of the Angle in a Patient with Uveitis Glaucoma Hyphema Syndrome: A Case StudyGravelineLeonard Oshinskie, OD2016Uveitis Glaucoma Hyphema (UGH) Syndrome is an exceedingly rare complication of cataract surgery, which occurs in less than one percent of cases. 82 yo male presents five years after cataract extraction with inflammation, uncontrolled IOP, and hyphema in the angle. He was treated with multiple topical medications for glaucoma and rebound inflammation for over two months. Due to the persistent inflammation, subsequent neovascularization of the angle (NVA) developed independent of neovascularization elsewhere in the eye. Moderate transillumination defects of the iris confirmed a mal-positioned posterior chamber IOL. The patient was referred to Ophthalmology for an IOL exchange and anti-VEGF injections. It is important that eye care providers are aware of potential NVA development in UGH patients, and routine gonioscopy should be performed.graveline_hyphema
Clinical Management of Post-Traumatic DiplopiaGreenSurbhi Bansal OD, FAAO, FCOVD2016A literature review reveals that extra ocular motility surgery is the preferred treatment of strabismus and diplopia following orbital reconstruction in maxillofacial trauma. This case follows a 45-year old Caucasian male who presented for evaluation of diplopia secondary to orbital trauma. He had been in a boating accident 2 months prior where he sustained subdural, epidural and subarachnoid hemorrhages as well as superior and lateral orbital wall fractures with subsequent strabismus from mechanical damage to his right inferior oblique muscle. This presentation highlights non-surgical diplopia treatment modalities including occlusion, prism, and vision therapy to help patients obtain single vision following orbital trauma.green_posttraumatic
Progressive Bilateral Panuveitis in the Setting of Presumed Neuro-SarcoidosisHammondThomas Albini, MD2016Sarcoidosis is a granulomatous systemic disorder of unknown etiology often seen in young adults with significant ocular and neuro-ophthalmologic manifestations. Our patient is a 30-year-old African-American female with progressive, bilateral vision loss from panuveitis and optic disc involvement. She was diagnosed with sarcoidosis due to a positive gallium scan and initially responded well to oral prednisone, though her vision has significantly declined in the following years to 20/200 and hand-motion in the right and left eyes, respectively. This case illustrates the varied and occasionally unrelenting course of sarcoidosis despite maximum immunosuppressive therapy.hammond_neuro
The Red Eye Disease: Hereditary Benign Intraepithelial Dyskeratosis (HBID)HannaCrystal Victor, OD2016Hereditary Benign Intraepithelial Dyskeratosis (HBID) is a rare, benign disease of the ocular and oral mucosa. Ocularly, it is characterized by bilateral, elevated epithelial plaques on the temporal and nasal bulbar conjunctiva, sometimes extending to the cornea. Due to the associated conjunctival hyperemia, HBID is sometimes referred to as the “red eye” disease. HBID is an autosomal dominant inherited disease, almost exclusively found in the Haliwa-Saponi Indian tribe of northeastern North Carolina. Symptomatic ocular plaques require topical treatment, whereas more severe cases that involve the cornea and affect vision may warrant excision.hanna_redeye
Demodex Infestation as a Source of Ocular Irritation and Contact Lens Intolerance in Young PatientsHauserRachel Grant, OD; Alan G. Kabat, OD, FAAO2016The recognition of Demodex as a factor in ocular surface disease has grown in recent years. These parasitic mites infest the pilosebaceous unit of hair follicles in humans, including the eyelashes. While the prevalence of Demodex has been estimated at approximately 90% in those over 50 years of age, symptomatic infestation remains possible in younger individuals. In this report, we describe three cases of recalcitrant ocular discomfort and contact lens intolerance in young (22- to 26-year-old) patients that were ultimately attributed to eyelid infestation by Demodex. Additionally, we provide a review of published prevalence studies, recognized associations and contributory factors, clinical images, video microscopy and treatment options for Demodex.hauser_demodex
Homatropine-Induced Acute Progression of Pigment Dispersion Syndrome in a Case of Concurrent Bilateral Anterior UveitisHawkinsKaitlin Mayo, OD, Meghan Elkins, OD2016Treatment for bilateral anterior uveitis is traditionally homatropine and a topical steroid. In patients with pigment dispersion syndrome, homatropine may be a risk factor and exacerbate this condition. In the case of a 66 year old white male being treated for uveitis, homatropine usage likely precipitated increased midperipheral iridolenticular touch, as seen on gonioscopy. This resulted in an accelerated pigment release, large iris transillumination defects, heavy pigment accumulation in the trabecular meshwork, and a significant IOP increase. The patient now requires baseline testing and regular follow-ups to determine if this process has led to any glaucomatous manifestations. Other diagnoses to consider include uveitis-glaucoma-hyphema (UGH) syndrome and steroid-induced glaucoma.hawkins_bait
Function of mfERGs in Plaquenil ScreeningHenneyBeth Norris, OD2016Hydroxychloroquine (plaquenil) has been used as antirheumatic drug therapy for years despite its risk of retinal toxicity. Historically, patients have been monitored using subjective measures such as visual field testing and objective findings during fundus examination often leading to diagnosis of late stages of toxicity. SD-OCT and fundus autofluorescence (FAF) have given a more objective measure for monitoring patients. However, evidence suggests that electrophysiological changes occur prior to structural changes identified on SD-OCT and FAF indicating a need for earlier testing for high-risk patients. Multifocal ERG testing has been suggested as an adjunct test according to the 2011 AAO Guidelines. It has been suggested as a future solitary screening tool.henney_hcq
A Case on Bilateral Diabetic Papillopathy and Talc Retinopathy: Diagnosis and ManagementHoRussell Jew, O.D.2016Diabetic papillopathy is a diagnosis of exclusion for optic disc edema in patients with diabetes. A 56-year-old male presented with bilateral hyperemic optic disc swelling and disc hemorrhages. Patient had uncontrolled diabetes and secondary syphilis treated with penicillin. Patient had normal visual acuity, pupils, and MRI result was unremarkable. Lumbar puncture showed normal opening pressure and CSF cytology showed elevated glucose and non-reactive VDRL. Optic disc edema resolved over time and resulted in optic atrophy with corresponding loss of nerve fiber evident on optical coherence tomography and visual field defects. The patient’s long history of IV drug use and presence of fine retinal refractile bodies are consistent with talc retinopathy.ho_diabetic
Neurological impact of Wallenberg Syndrome on the Visual-Vestibular SystemsHueskeChung To, OD.2016A 50-year-old male presents for consultation following a left lateral medullary infarct occlusion of the left vertebral artery (Wallenberg syndrome) with complaints of intermittent binocular diplopia, vertigo, and oscillopsia. Assessment revealed an intermittent central nystagmus, a right skew deviation, and a left Horner’s syndrome. Video recordings of the nystagmus and ocular motor responses were documented. This case discusses the neurological impact of Wallenberg syndrome on the visual-vestibular system and provides a clinical pathologic correlation between neuro-anatomic involvements with the manifesting symptoms.hueske_wallenberg
Myopic Foveoschisis with Macular HoleJohns2016Myopic foveoschisis is a devastating ocular complication that can occur in progressive myopia and posterior staphyloma. Prior to widespread OCT use myopic foveoschisis was difficult to diagnose and manage, as the retina often looks relatively normal on examination. The inner and outer layers of the retina will split in myopic foveoschisis, which can progress to a macular hole. A 61 year old female patient presented to our clinic for an overdue diabetic eye exam. Her medical history was remarkable for uncontrolled diabetes and progressive myopia. Best corrected vision was 20/80+ in the right eye and 20/40+ in the left eye. The fundus appeared grossly normal on slit lamp exam, but macular OCT showed a myopic foveoschisis with macular hole in the right eye.johns_myopic
“Challenges of a Specialty Contact Lens Fitting on an Irregular Cornea with Concomitant Multiple Surgeries and Endothelial Decompensation”KhanAndrea M. Janoff, O.D., F.A.A.O.2016This case highlights the challenges of specialty contact lens fitting for post penetrating keratoplasty (PKP) in a patient with an ocular history of pseudophakia, failed trabeculectomy with significant conjunctival elevation, glaucoma tube shunt surgery and endothelial compromise. A 57-year-old female was referred from a tertiary care center for contact lenses to improve vision. Len options considered included a large corneal gas permeable (GP) with and without reverse geometry, an oblate hybrid design and a semi-scleral with peripheral notching or microvault. Ultimately, the patient was fit into an Intralimbal GP lens. Various treatments were incorporated to address complications as they presented, namely punctate epithelial erosions, intermittent stromal edema and peripheral bullae.khan_specialty
Management of BIlateral Central Bacterial Corneal Ulcers in a Pregnant PatientKruthoff2016This case study reviews a 38 year old female with bilateral central corneal ulcers stemming from contact lens overwear and negligence. This case was complicated not only by patient non-compliance with treatment and follow ups, but also by the patient being pregnant, thus changing and limiting the standard treatment plan. This review will discuss how this difficult case was approached, with focus on handling patient noncompliance and management of these sight threatening ulcers with special caution due to the patient’s health history.kruthoff_ulcer
"Seeing Red" Diagnosing and Co-managing ScleritisLane2016Scleritis is a painful condition with poorly understood pathogenic mechanisms. Without proper treatment this disease can lead to severe ocular complications and often indicates a more serious underlying systemic disease. Scleritis has even been linked to increased mortality in patients with rheumatoid arthritis. This case reviews a 65 year old rheumatoid arthritis patient whom we diagnosed with scleritis and then co-managed with her rheumatologist. Included in this presentation are pictures of the patient's sclera with characteristic bluish hue post inflammatory episode, anterior segment OCT scans to investigated scleral thinning and a summary of the patient's care. Also provided is a review of scleritis types, treatments, prognosis and a discussion of the use of anterior segment OCT to monitor scleral thinning and aid in scleritis diagnosis.lane_scleritis
A Case of Corneal Endotheliitis: Its Presentation, Diagnosis and TreatmentLanham2016A case presentation consisting of multiple visits for a single patient referred in for a non-healing, unilateral epithelial defect with underlying stromal haze. Symptoms included mild photophobia and general discomfort. The case will outline the steps taken to control patient symptoms, adjust treatment after changes in ocular findings as well as how to determine the underlying cause of the condition, found to be HSV 1. Emphasis will be put on using ocular findings to navigate differentials, how to obtain a sample to then test for these differentials and proper follow up visits throughout the diagnostic process and long term.lanham_endothelitis
Alport Syndrome Explains Patient History and Chief ComplaintLavalleJason Duncan, OD FAAO2016Alport syndrome is a hereditary disorder involving gene mutations coding for the biosynthesis of type IV collagen that leads to kidney disease, sensorineural hearing loss, and ocular degenerations. Ocular Manifestations can include dot and fleck maculopathy, anterior lenticonus, cataracts, and posterior polymorphous dystrophy. A 46 year old African American male presented with blur and monocular diplopia in the left eye. The patient also had hearing loss, a history of kidney transplant, and a strong family history of endocrine disease. He had phacoemulsification in the right eye in 2005. Slit lamp evaluation revealed anterior lenticonus in the left eye. This poster reviews the ocular manifestations and management associated with Alport syndrome.lavelle_alport
Snoozing Optic nerve: A Case Report on Obstructive Sleep Apnea and Ischemic Optic NeuropathyLeShephali Patel O.D.2016Non-arteritic anterior ischemic optic neuropathy (NAION) is a stroke of the optic nerve, which leads to sudden vision loss. This case covers the unique risk factor of obstructive sleep apnea (OSA) that led to a bilateral sequential NAION in 46 year old white male. This presentation will review the patient history, risk factors, and examine how OSA and complications from the CPAP triggered an ischemic event.le_snoozing
An Undiagnosed Case of Stickler SyndromeLeeDiana Shechtman, OD, FAAO2016Intro: Stickler syndrome is one of the most common inherited connective tissue disorders. It is due to genetic mutation affecting craniofacial, auditory, musculoskeletal, and ocular systems. Characteristic ocular manifestations include high myopia, early onset cataracts, membranous or beaded vitreous degeneration, retinal breaks and detachments Case: 19 yo female presented with a history of a superior visual field defect OS. Best-corrected visual acuity was 20/200 OS. Medical history revealed joint hypermobility, hearing loss, arthritis & a strong family history of retinal detachment. Facial features associated with Stickler syndrome were noted. Dilated fundus exam revealed a membranous vitreous anomalies OU, and a large inferior retinal detachment with associated proliferative vitreoretinopathy OS. She was referred for retinal detachment repair and is currently in post-op care. Conclusion: Ocular exam findings is essential in diagnosis, putting optometrists at the forefront in identifying and managing patients with stickler syndrome. It is important to diagnose these patients at an early age in order to avoid sight-threatening complications and help guide multidisciplinary co-management approach.lee_stickler
Raloxifene Crystalline RetinopathyLevy2016Raloxifene is a medication commonly used for lowering the risk for breast cancer in post-menopausal women and treating osteoporosis. In this case, a 61 year old female presented with bilateral crystalline deposits in the parafoveal region. The patient’s medical history was unremarkable other than her 60mg P.O. of Raloxifene and Lexapro. Her ocular history was WNL other than her long standing C/D asymmetry which is being monitored. Her VA had remained stable at 20/20 OU. This case demonstrates that there should be a similar level of caution used when monitoring patients using Raloxifene due to the fact that it can have a presentation similar to Tamoxifen Retinopathy.levy_crystalline
Oral spironolactone as a novel treatment approach for central serous chorioretinopathyLiuDavid Mietzner, OD, FAAO and Theresa Chong Fernandez, OD, FAAO2016Central Serous Chorioretinopathy (CSR) is an idiopathic serous retinal detachment at the macula region occurring in approximately one out of every 10,000 people. The disease is more common in young men between the ages of 20-50 years of age. Men are six times more likely than women to be affected. CSR is typically associated with any corticosteroid use, type A personality, stress, pregnancy, and systemic hypertension. Bilateral involvement has been reported to occur in up to 40% of cases. Historically, cases of CSR are treated with laser therapy. The following case demonstrates the use of a novel treatment approach for CSR, oral spironolactone, a mineralocorticoid receptor antagonist.liu_spironolactone
Ocular Surface Squamous NeoplasiaLuskLeslie A. Phillips, OD; T. Peter Lindquist, MD2016Ocular surface squamous neoplasia (OSSN), or more specifically carcinoma in-situ, is a relatively uncommon corneal finding. We present a case involving a 63 year old white male presenting with a flat, gray, epithelial plaque-like opacity extending approximately 270 degrees across the limbus in the right eye. Our initial diagnosis of ocular surface squamous neoplasia (OSSN) was confirmed by a corneal specialist within our practice who initiated treatment. This presentation discusses the characteristic ocular signs and histologic features of OSSN, its clinical course, medical and surgical therapies and differential diagnosis of OSSN. The need for biopsy versus empirical-based treatment will also be discussed.lusk_ossn
Stargardt's Disease (Fundus Flavimaculatus)MadriagaDr. Brian Kawasaki2016Stargardt disease is the most common juvenile macular dystrophy and is typically inherited in an autosomal recessive manner. A mutation in the ABCA4 gene causes lipofuscin to accumulate in the retinal pigment epithelium (RPE) resulting in photoreceptor death. However, a milder form with a slower visual deterioration and later onset can occur known as fundus flavimaculatus. A 44 year-old Middle Eastern female presents to the eye clinic at the VA Southern Nevada Healthcare System complaining about a gradual decrease in vision starting around 2006. Utilizing electrodiagnostic testing, fluorescein angiography, optical coherence tomography, and fundus autofluorescence testing, the patient is diagnosed with fundus flavimaculatus. Genetic testing results are pending.madriaga_stargardts
FIRST POSTER SUBMISSION FOR 2016Mayo2016Lorem ipsum dolor sit amet, consectetur adipiscing elit. In sed felis tortor. Etiam ornare ante ut nibh viverra tincidunt. Phasellus ut magna sapien. Sed feugiat accumsan nunc sit amet bibendum. Curabitur eu augue porta massa sodales scelerisque ut in nisi. Cras ultricies velit nec ex pretium, eget ornare diam lacinia. Vestibulum non nisi non lorem tristique posuere. Duis ornare tellus a quam molestie, porttitor blandit metus dapibus. In euismod, turpis non consequat lacinia, nulla nisl maximus ipsum, vel sollicitudin ipsum mauris a elit. Maecenas ultricies magna at ullamcorper consectetur. In et arcu eget lectus egestas maximus. Suspendisse tempor pharetra ipsum, viverra dictum nulla hendrerit volutpat. Sed interdum urna quis ipsum convallis ullamcorper. Phasellus velit sem, gravida in fermentum a, mattis quis sem. Maecenas vitae pulvinar felis, ac semper nisl. Etiam mattis volutpat purus sit amet sodales.
The Clinical Application of Fundus AutofluorescenceMercadoAmber Louprasong, OD2016Fundus autofluorescence (FAF) is an imaging tool that allows clinicians to detect and monitor a variety of retinal disease. FAF provides a non-invasive view of certain disease processes from a metabolic perspective. It has been shown to be effective in the early detection of retinal disease and their potential predictive makers for progression. The images provided by FAF are often dramatic compared to standard fundus photography and this poster will review and discuss how FAF works and demonstrate how FAF can be used as an effective clinical tool in everyday optometry practice.mercado_faf
Looking Through a New lens: Scleral Lenses for AphakiaMicklesChristopher R. Choat, OD, FAAO, Dipl. Low Vision2016Gas permeable contact lenses can play a key role in providing visual rehabilitation for aphakic patients. While corneal gas permeable contact lenses often provide positive outcomes for aphakic patients, the resurgence of scleral contact lenses has created an opportunity to restore visual function for aphakic patients with irregular corneas who are intolerant to corneal gas permeable lenses. Herein we report on a 28-year-old traumatic unilateral aphakic patient with an irregular cornea and retinal detachment who achieved maximum vision and comfort with a mini-scleral lens. Mini-scleral lenses, which provide comfortable and stable vision, hold promise for becoming a preferred visual rehabilitative option for aphakic patients.mickles_scleral
Purtscher's-Like Retinopathy Secondary to Acute PancreatitisMiriello2016A 35 year old white male with a recent history of acute pancreatitis presented with sudden bilateral visual acuity loss. The patient’s presenting uncorrected distance vision was 20/40 OD and 20/400 OS. Pinhole acuity did not improve OD but improved to 20/70 OS. Dilated fundus examination revealed cotton wool spots of the posterior pole greater OS than OD. The patient’s history, along with his clinical presentation, lead to a diagnosis of Purtscher’s-like retinopathy OU. Classically, Purtscher’s and Purtscher’s-like retinopathy are treated with intravenous mega-dose steroid therapy. The patient refused, however, and was treated with oral prednisone and local steroid OS in the form of Ozurdex injection.miriello_purtschers
Clinical Presentation and Management of Choroidal OsteomaMoharJames Esposito, OD, FAAO, Nicholas Chan, OD2016Choroidal Osetoma is a rare ossifying tumor of the choroid commonly found in young women in their second to third decade of life. It is extremely important to differentiate this typically benign tumor from other more catastrophic metastatic neoplasms. Although this condition presents no immediate threat to vision, choroidal neovascularization has been found to occur in one-third of cases, in which case fluorescein angiography is useful to evaluate need for treatment. On occasion, when a choroidal neovascular membrane is present, laser photocoagulation or anti-vascular endothelial growth factor agents can be administered to preserve vision.mohar_choroidal
Scleral Lenses Help a Professional Football Player with Keratoconus SCORENguyen2016Athletes with keratoconus can be more challenging to fit with contact lenses due to their activity level and environment. A 23 year old rookie cornerback in the National Football League presented for a routine comprehensive eye examination. Examination and corneal topography revealed early keratoconus. Scleral gas permeable contact lenses were chosen for this professional football player to allow for the most stable vision, durability, handling and comfort in times of extreme eye movements and physical activity. Visual acuity is not the only factor that needs to be addressed for athletes. Proper lens selection for keratoconic athletes affects their vision, but can make a difference in their performance on the field and their professional longevity.nguyen_scleral
Chorioretinitis: an uncommon case of acute unilateral posterior uveitis in a non-immunocompromised older patientNguyen2016Purpose: To discuss an uncommon case of acute unilateral posterior uveitis with minimal anterior segment findings and no ocular pain in an older patient. Background: Toxoplasmosis is the most common cause of infectious posterior uveitis in non-immunocompromised individuals. Depending on the ocular structure(s) affected, chorioretinitis is a form of posterior uveitis involving inflammation of the choroid and retina. Case Presentation: A 66 year-old diabetic white male complained of decreased vision in his right eye without ocular pain for two weeks. Entering acuities were hand motion OD and 20/20 OS. Anterior segment revealed trace cells OD and clear OS without keratic precipitates in either eye. Posterior segment was significant for hazy views of focal subretinal lesions and significant vascular shealthing with dense vitreous veils OD and mild signs of non-proliferative diabetic retinopathy OS. Conclusion: Severe vitreous inflammation is almost always present in ocular toxoplasmosis with possible mild anterior segment inflammation. This can aid the examiner to differentiate toxoplasmosis from other infectious diseases associated with chorioretinitis such as Herpes Simplex, histoplasmosis, sarcoidosis, syphilis, and tuberculosis.nguyen_chorioretinitis
The Expanded Role of MRI in the Diagnosis of Idiopathic Intracranial HypertensionNguyenAnsu Abraham O.D. and Shephali Patel M.S., O.D., F.A.A.O2016Idiopathic intracranial hypertension (IIH) is typically a diagnosis of exclusion characterized by papilledema due to increased intracranial pressure. Traditionally, it has been considered a disease devoid of MRI findings, but newer research shows an association of an empty sella and peri-optic fluid collection on MRI with patients with IIH. This case investigates the etiology of an atypical case of bilateral papilledema with hemorrhages in a 32-year-old African American female, with a differential diagnosis of multiple sclerosis. Multidisciplinary management was necessary to confirm the diagnosis of IIH and treatment for this disease.nguyen_idiopathic
A Rocky Situation: A Case Report on Acute Dacryocystic Retention SyndromePalmerWendy McGonigal, O.D., F.A.A.O; Shephali Patel O.D., M.S., F.A.A.O.2016Acute dacryocystic retention syndrome is a condition where dacryoliths or stones develop in the lacrimal sac and cause recurrent bouts of dacryocystitis. These stones are similar in composition to gall stones and are usually removed during dacrycystorhinostomy. This case presents an 83 year-old African American male with recurrent dacryocystitis due to the development of dacryoliths within the lacrimal sac, which were removed in office through the nasolacrimal duct. In cases of recurrent dacryocystitis, it is important to investigate the etiology of the condition for dacryoliths as well as more threatening conditions including lacrimal neoplasms.palmer_rocky
A Clotting Crisis: Ocular Manifestations of Polycythemia VeraRoperAshley Tessier, BS2016As a rare chronic myeloproliferative neoplasm, polycythemia vera (PV) has not only insidious underlying systemic implications but also significant ocular vascular complications due to hyperviscosity, including retinal hemorrhages, vascular occlusions, amaurosis fugax, and neuro-ophthalmologic manifestations such as papilledema and diplopia. We will present a case of asymptomatic bilateral retinal hemorrhages in a 50-year-old patient with known PV, complicated with thrombocytopenia from treatment with Jakafi (ruxolitinib) and co-monitored by oncology/hematology. We will provide a comprehensive overview of PV for the optometrist, including a diagnostic and multidisciplinary approach to managing patients with ophthalmic findings, with emphasis on the significant role that optometrists can have in early detection of this life-threatening disease.roper_polycythemia
Pediatric Ptosis SurpriseRunyon2016Idiopathic Orbital Inflammatory Syndrome (IOIS) is the third most common orbital disorder in adults. Pediatric IOIS cases represent between 6% and 17% of all orbital inflammatory disorders. According to the literature, this condition is extremely rare and usually bilateral in children. This unique case documents the diagnosis, treatment, and co-management of a case of unilateral orbital inflammatory myositis in a healthy 9 year old female patient who initially presented with an acquired ptosis and abnormal pupillary response.runyon_pseudotumor
Boldly Braving Blindness: A Case Report of Acute, Bilateral Radiation Induced Optic NeuropathySawickiGuadalupe Mejia O.D.2016Acute, bilateral optic neuropathy is a rare clinical finding. An 82 year-old male presented with a report of gradually reduced vision in his left eye over the course of one month. Entering acuities were significantly decreased from baseline at 20/80 OD, count fingers OS with newly appreciated optic nerve pallor OS greater than OD. Over the next three weeks the patient’s acuity would continue to deteriorate to count fingers OD, hand motion OS. The patient’s medical history of sinus cancer and radiation treatment would offer a pathway toward the diagnosis of exclusion radiation induced optic neuropathy. This unique case will follow the course of sudden vision loss from diagnosis to treatment and finally through blind rehabilitation.sawicki_radiation
“Spot on”- Optic Nerve Head Melanocytoma in a Young PatientSchinasJulie A. Tyler, OD, FAAO2016Background: Optic nerve head (ONH) Melanocytoma is a benign pigmented tumor that is most commonly located on or adjacent to the optic disc. Over time, melanocytomas may grow in size and/or affect vision, but rarely do they become malignant. Report: A 20 year-old black female was referred for evaluation of ONH pigmentation in the left eye. Her personal and family ocular/medical history was non-contributory. Best corrected DVA was 20/20 in each eye. Dilated fundus exam revealed a ¼ disc diameter area of flat pigmentation located within the cup and rim tissue of the temporal ONH, OS. Baseline photos were taken at the initial visit. In addition, the patient returned for HVF 30-2 SITA standard and SD-OCT testing at 2 weeks and 3 months. Images and additional test results will be presented. Conclusion: Baseline and serial photography, in addition to visual field and OCT testing, are important tools in both the assessment and monitoring of ONH Melanocytoma. Differential diagnosis for the condition will also be reviewed.schinas_spot
Idiopathic Juxtafoveolar Telangiectasia: An Atypical ResolutionShahLisa Steele M.S., O.D., Nancy Shenouda-Awad, O.D., F.A.A.O., Theresa Zerilli-Zavgorodni, O.D., F.A.A.O.2016Idiopathic Juxtafoveolar Retinal Telangiectasia (IJFT) is characterized by alterations of the juxtafoveolar capillary network in one or both eyes. According to Gass and Oyakawa, IJFT can be divided into three groups. Group I is a unilateral condition with visible telangiectasias occurring in males and causing vision loss due to macular edema. Group II is bilateral occurring in middle-aged men and women with telangiectasias that is difficult to detect on biomicroscopy examination. Group III is very rare and characterized by progressive obliteration of perifoveal capillary network occurring in a medical or neurologic disease. Treatment options for IJFT include laser photocoagulation, intravitreal injections of steroids, or anti-vascular endothelial growth factor (VEGF) agents; while photocoagulation being typically the preferred treatment. This case discusses a patient with type I IJFT accompanied by chronic macular edema. The poster will highlight this case as unique due to the macular edema resolving spontaneously without any medical intervention. IJFT clinical features, differential diagnoses and management will be discussed.shah_idiopathic
A Medical Chameleon? Amelanotic Choroidal Nevus Masquerading as Choroidal OsteomaSharrardAkilia Hang Nguyen, OD, Nancy Shenouda-Awad, OD, FAAO, Theresa Zerilli, OD, FAAO2016Choroidal nevi are relatively common and benign, while amelanotic nevi are a less common finding to encounter. Differential diagnoses for a choroidal amelanotic nevus include malignant melanoma, cavernous hemangioma of the choroid, metastatic cancer to the choroid, posterior scleritis, idiopathic sclerochoroidal calcification, choroidal osteoma, and hypopigmented congenital hypertrophy of the retinal pigment epithelium. Given some of these being detrimental differentials, it is extremely essential to rule out each one of them before coming to the final diagnosis of a benign lesion. This presentation will explore a rare case where an amelanotic nevus had all clinical features of a choroidal osteoma, and where the use of technology was critical in helping with the final diagnosis. Clinical features, differential diagnoses, the use of technology as an aid, management and treatment will be discussed.sharrard_nevus
The Many Faces of Zoster Ophthalmicus - An Atypical PresentationSmithBabita Gounden, OD2016Herpes zoster ophthalmicus (HZO) is a reactivation of latent varicella-zoster virus in the ophthalmic branch of the trigeminal nerve. It represents approximately 20 percent of herpes zoster cases, and presentations are highly variable. In rare cases, cranial nerve palsies have occurred secondary to HZO. A 75 year old white male presents with right sided periorbital pain and facial lesions. Ocular examination reveals an edematous cornea with dendritic lesions and reduced acuity in the right eye. Acyclovir and gabapentin therapy improved facial and corneal lesions. Interestingly a right exotropia and lagophthalmos subsequently developed, highlighted by video documentation. The patient was diagnosed with herpes zoster ophthalmicus resulting in a secondary incomplete cranial nerve three palsy. This case outlines multifaceted management needed for HZO patients, including management of uncommon sequelae such as cranial nerve palsies.smith_zoster
Isolated white retinal elevation in association with choroidal nevi: A careful look at the differentialsSteeleNettie Hines2016Isolated and well-circumscribed yellow-white elevations of the retina and choroid comprise a diverse group of benign and vision-threatening lesions. Differential diagnoses include retinal astrocytic hamartoma, retinocytoma, granuloma, unifocal helioid choroiditis, presumed solitary circumscribed retinal astrocytic proliferation (PSCRAP), retinoblastoma and amelanotic melanoma. Early diagnosis can be crucial, depending on the lesion, however clinical features distinguishing one from another are often subtle. In many cases, as this one demonstrates, the use of OCT may provide clear differentiation. FAF, IVFA and ultrasound are also often useful. In the following presentation, the key clinical and diagnostic features as well as treatment strategies is reviewed for the major differentials.steele_retinal
Serial anterior segment OCT imaging in autoimmune bilateral peripheral ulcerative keratitisSteenJulie Rodman OD, FAAO2016Introduction: Peripheral ulcerative keratitis (PUK) secondary to untreated Sjögren’s syndrome may be exacerbated by topical steroid therapy. Oral doxycycline may be an effective therapy prior to initiation of systemic immunomodulators. Anterior segment OCT serial imaging allows visualization of stromal remodeling and corneal re-epithelialization following treatment initiation which has not been previously reported. Case: A 61 year old white female with untreated Sjögren’s syndrome developed bilateral PUK while on topical fluorometholone for severe dry eye. After steroid discontinuation and introduction of oral doxycycline without other treatment alteration, she showed significant improvement in visual acuity, comfort and clinical appearance. The bilateral corneal ulcerative lesions were serially imaged with anterior segment OCT over the course of the disease process. Conclusion: The case presented elucidates the role of the optometrist in management of ophthalmic disease secondary to systemic autoimmune collagen vascular disease. This case also introduces the use of anterior segment OCT to demonstrate structural corneal remodeling in autoimmune PUK.steen_puk
Double Trouble: Triage of a patient with multiple cranial nerve palsiesSteiner2016Patients can present with double vision stemming from a number of etiologies, one of which might be a dysfunction of the third, fourth, or sixth cranial nerves. Teasing out the best remediation of the diplopia is challenging, as is the decision-making required to determine whether your patient has an underlying health concern. When the patient presents with multiple nerve palsies the difficulty grows exponentially. This poster will give practitioners a quick reference of the most common less- and more- urgent nerve palsy etiologies and methods for dealing with their visual sequelae. Professional referral and communication will be emphasized.steiner_double
OCT characteristics of combined hamartoma of the retina and RPEUbhiRim Makhlouf, OD, FAAO2016A combined hamartoma of the retina and RPE is a presumed congenital benign tumor, usually in the juxtapapillary area. Optical coherence tomography (OCT) has emerged as a useful tool in its differential diagnosis from malignant lesions, such as choroidal melanomas and retinoblastomas. We discuss a pediatric case that shows typical OCT characteristics, including prominent epiretinal membrane with vitreomacular traction resulting in retinal “mini-peaks” and “maxi-peaks,” as well as choroidal thinning. These vitreoretinal disturbances are thought to be the cause of vision loss in extrafoveal hamartomas, which provides insight into treatment strategies for preventing or possibly improving vision.ubhi_harmartoma
A Rare Case of Stage 4, Type 2 Idiopathic Juxtafoveal Retinal TelangiectasisVan AlstineSarah R. Wilson BA; Zachary L. Olsen OD2016We will present an excellent teaching case of an often misdiagnosed yet visually significant macular pathology. A patient presented with significant gradual decrease in vision OU. Fundus exam revealed RPE clumping and superficial retinal crystalline deposits in an annular pattern around the fovea OU. SD OCT revealed foveal atrophy OU. FA showed punctate hyperfluorescent spots around the maculae in the early phases and diffuse leakage throughout the maculae in the late phases OU. A diagnosis of stage 4, type 2 idiopathic juxtafoveal retinal telangectasis (IJXT) was made. The poster will include excellent fundus photos, OCT images, FA images, and a detailed discussion of the staging, pathophysiology, and treatment for IJXT.valstine_justafoveal
A clinical approach to evaluating nystagmus in the pediatric patientVickers2016Although nystagmus is relatively uncommon in the pediatric population (affecting approximately 0.35% of young children), it is important for optometrists to know how to properly manage this condition. Nystagmus can be a relatively benign, congenital condition compatible with good vision. However, nystagmus may be the presenting sign for visually significant ocular abnormalities or neurologic conditions. Using a variety of case reports, this interactive poster presentation will help decode nystagmus and its various clinical presentations in the pediatric patient.vickers_pediatric
Non-Hodgkin's lymphoma metastasis to the right lateral rectusVollmerRichard Gardner, OD, FAAO2016A 56 year-old Caucasian male with a history of non-Hodgkin’s lymphoma presented to the ER with a proptotic, red and painful right eye. Further testing revealed a cranial nerve VI palsy and proptosis was confirmed with exophthalmometry. Imaging revealed an ovoid lateral right intraconal mass mildly displacing the globe and contiguous with the optic nerve arising in the region of the right lateral rectus muscle. He was sent to oncology and was started on chemotherapy and IV dexamethasone to reduce the size of intraconal mass. This case will detail how a recurring lymphoma can show an initial ocular presentation and selected treatment options.vollmer_nonhodgkins
Efficacy and Safety of Lifitegrast Ophthalmic Solution 5.0% in Three Randomized Controlled Trials (RCTs) for Dry Eye DiseaseWhitleyEdward J Holland, Kenneth Sall, Stephen Lane, Aparna Raychaudhuri, Steven Zhang, Amir Shojaei2016Purpose: Report efficacy and safety across three RCTs of lifitegrast ophthalmic solution 5.0% for dry eye disease (DED). Methods: Lifitegrast studied in three 12-week trials: Phase 2 (lifitegrast n=54, placebo=55), OPUS-1 (lifitegrast=293, placebo=294), OPUS-2 (lifitegrast=358, placebo=360). Change from baseline in inferior corneal staining (ICSS) and eye dryness (EDS) analyzed. Results: Lifitegrast improved ICSS vs placebo in Phase 2 (treatment effect, 0.35; P=0.0209) and OPUS-1 (effect, 0.24; P=0.0007). Among more symptomatic subjects (baseline EDS ≥40, prior artificial tear use), lifitegrast improved EDS vs placebo in OPUS-1 (post hoc; lifitegrast=63, placebo=67; effect, 13.34; nominal P=0.0178) and OPUS-2 (effect, 12.61; P<0.0001). Lifitegrast appears well tolerated. Conclusion: Lifitegrast improves signs and symptoms of DED.whitley_efficacy
The importance of anterior segment imagingWilliams2016A 70 YOWM was referred for YAG capsulotomy in both eyes. Best corrected visual acuities were 20/25 in both eyes. Slit lamp examination revealed iris elevation at 10 o'clock in the right eye and no abnormalities in the left eye. Intraocular pressure was 16 mmHg in the right eye and 17 mmHg in the left eye. After dilation, posterior capsular opacification and mild non-proliferative diabetic retinopathy without clinically significant macular edema was found in both eyes. The most concerning finding was a black ciliary body mass in the right eye. Ultrasound biomicroscopy was key to determining whether the mass was a ciliary body cyst or melanoma.williams_imaging
“Pulling Apart” an Atypical Presentation of Peripapillary RetinoschisisZubkouskyJulie Tyler OD2016This case report illustrates a patient with peripapillary retinoschisis secondary to vitreoretinal traction. An asymptomatic 92-year-old HF presented for an annual comprehensive eye exam. Fundoscopy showed retinal elevation superior to the optic nerve head OD without hemorrhaging. SD-OCT revealed the presence of outer and inner layer retinoschisis with concurrent peripapillary vitreoretinal traction. The literature describes several cases of peripapillary retinoschisis, however, typically in the setting of optic nerve congenital anomalies, high myopia or glaucomatous optic neuropathy - all absent in this particular case. This case illustrates an atypical presentation of vitreoretinal interaction following an incomplete posterior vitreous detachment and will include a review of several images and differential diagnoses.zubkousky_peripapillary
Branded by the Sun: Solar Retinopathy Evident 40 Years After Watching Solar EclipseAbdou2015Solar retinopathy is a condition that occurs from prolonged viewing of the sun, causing destruction of macular photoreceptors via photochemical mechanisms. Reduced acuity ranges from minimal to severe vision loss, not correlating to the amount of time of sun exposure. A 48 year old Caucasian male presented with decreased vision and a central scotoma OD, stable over the past 40+ years. Acuities are 20/25 OD and 20/20 OS with normal external and slit lamp evaluation. Dilated fundus examination revealed a small, well circumscribed, red lesion directly in the fovea with no foveal reflex in the right eye. Upon further investigation of the patient’s history, patient revealed extended viewing of the solar eclipse at age 6, which he recalled viewing with one eye open. The presentation reviews representative photos and OCT of solar retinopathy along with proper management strategies and possible complications.abdou_solar
The Many Faces of Polypoidal Choroidal VasculopathyAbrahamShephali Patel O.D.2015Polypoidal choroidal vasculopathy (PCV) is a rare vasculopathy, which usually occurs bilaterally in the macula and is often confused with macular degeneration or central serous chorioretinopathy. A 55-year-old African American male with ocular history of a retinal hamartoma, presented with hemorrhagic changes. Upon review, the patient was diagnosed with PCV and followed by a retinal specialist. This presentation will also review suspected etiology, diagnosis, and current evidence-based management for PCV.abraham_polypoidal
Can You See Me Now? Smart Phone Applications for the Visually ImpairedAngloNicole Patterson, OD, MS, FAAO2015Living with visual impairment is an ongoing challenge that affects several aspects of everyday life. Today’s generation of low vision patients is fortunate that innovative technology continues to be developed. However, many low vision devices are expensive, bulky, heavy and/or not portable. Unlike most electronic magnifiers, phones are lightweight, mobile, convenient appliances that people always have on hand. Smart phone applications have the potential to revolutionize the lives of the visually impaired, providing the independence for which they’ve been yearning. In this poster, I discuss specific iPhone applications that I believe would be most beneficial for low vision patients.anglo_smart
Visual Impairment Secondary to Stroke in a Pediatric PatientAnglo2015A 9-year-old female with congenital hydrocephalus suffered visual impairment secondary to mini-strokes following a ventriculoperitoneal shunt malfunction. She was diagnosed with left facial nerve palsy with consequential exposure keratopathy OS, left homonymous hemianopia OU, acquired nystagmus OU, acquired esotropia and hypertropia OS, suppression OS, and deficits in visual perception. We managed the patient with yoked base-down prism because the null point of her nystagmus was superior. She is currently enrolled in vision therapy to enhance her balance, coordination, visual scanning, and visual processing skills. This case report demonstrates some of the common visual consequences following a stroke and the significance of optometry in the management of patients with brain injury.anglo_stroke
A Case of Spontaneous RPE Rip A Closer Evaluation with OCT ImagingAu2015A 68 year old white male presented with new floaters in the left eye for four days with no other associated symptoms. This patient had been previously diagnosed with a disciform scar in the right eye secondary to macular degeneration. His best corrected visual acuities were 20/400 OD and 20/200 OS. Upon funduscopic examination of the left eye, a large vascularized pigmented epithelial detachment (vPED) was present, and the assumption of an active choroidal neovascular membrane (CNVM) was presumed. The classic sub-RPE hemorrhage takes on a uniform, circumferential or spherical shape. This particular patient presented with a unique geometrical vPED form that was consistent with an RPE rip or tear measuring approximately one disk diameter. Ancillary testing included serial OCT images and color fundus photos. When an RPE tear occurs, the RPE is scrolled up leaving the adjacent bruch’s membrane naked, and this results in an overlying sensory retinal detachment. Of particular interest, the OCT imaging revealed a leading edge of the tear; moreover, Gass reports that this leading edge of the RPE tear may only be seen within the first twenty four hours of the event before being retracted. Many of the RPE rips reported in the literaturau_rpe
Wow! Is this what 3D looks like?!!BansalDeborah Amster, OD, FAAO, FCOVD2015The recommended treatment for severe anisometropic refractive amblyopia is refractive compensation along with monocular penalization of the better seeing eye for at least six hours daily, either through patching, atropine, or a Bangerter filter. One hour of near work with the amblyopic eye is advocated during the occlusion process. Recent evidence supports a binocular treatment of amblyopia to take advantage of our cortical plasticity. Improved visual acuity, stereopsis, and decreased suppression have resulted through this binocular approach. This case report will follow an 11 year-old white female who presented with anisometropic hyperopic refractive amblyopia and initial visual acuities of 20/20 OD and 20/200 OS. Binocular activities employed during therapy, changes to her visual acuity, contrast sensitivity, accommodation, and perception of depth will be presented.bansal_3d
Fix something, Break something: Postoperative Optic Neuropathy CaseBeardElaime Hernandez OD, Jonathan Hamilton OD, Theresa Zerilli-Zavgorodni, OD, FAAO, Nancy Shenouda-Awad, OD, FAAO2015Optic neuropathies can be caused by a large array of etiologies. Postoperative optic neuropathy is an important, but uncommon differential to consider when a patient presents with optic neuropathy or atrophy and a history of significant blood loss in conjunction with recent surgery. Anemia, hypotension, and hypovolemia predispose a patient to ischemic optic neuropathy after a major surgical procedure. This case discusses a postoperative optic neuropathy whose onset was four days after a femoral artery bypass performed secondary to deep vein thrombosis. It also highlights the preoperative and postoperative risk factors which will dictate the appropriate work up and management plan for postoperative optic neuropathy.beard_fix
A confounding case of pseudopapilledema: Solving the puzzle of bilateral disc edemaBeauregardTak Chau OD, Ashley Deemer OD2015A 44 year-old obese African American female presented with blurred vision, a vague complaint of diplopia and headaches. When clinical examination revealed bilateral disc elevation, she was referred for an urgent neurology work-up. MRI findings included enlarged empty sella, tortuous optic nerves with sheath enlargement and posterior pole flattening, all of which are consistent with idiopathic intracranial hypertension. Treatment with Diamox was initiated until lumbar puncture could be performed. When the opening pressure (13 cm H2O) and CSF cytology was unremarkable, Diamox was discontinued. It remained unchanged on repeat opening pressure and she was diagnosed with pseudopapilledema, or anomalous disc elevation. This case highlights the complexity of IIH by discussing its pathophysiology, diagnosis and management. The approach to differential diagnosis in determining papilledema from pseudopapilledema is emphasized.beauregard_pseudo
Idiopathic Multiple Pigment Epithelial Detachments: A Report of Two CasesBedwellBrad Sutton, OD, FAAO2015A pigment epithelial detachment (PED) represents a separation between the basement membrane of the retinal pigment epithelium and Bruch’s membrane. On OCT, serous PEDs appear as optically empty, dome-shaped elevations of the RPE layer. Two cases of multiple, idiopathic PEDs are presented. In each case, the patients were relatively healthy middle-aged, Caucasian females. Both presented with no visual complaints and had excellent visual acuity. Each patient had greater than 20 small, serous PEDs in the posterior pole in each eye. Their presence was confirmed with SD-OCT. These two cases represent an uncommon presentation of multiple PEDs that has rarely been reported in the literature. It has been suggested that multiple, small, bilateral PEDs in healthy people may be a variant of idiopathic central serous chorioretinopathy.bedwell_ped
Leber's Hereditary Optic Neuropathy Case Report and ManagementBennettNicole Patterson, OD2015Leber’s hereditary optic neuropathy (LHON) is disease inherited from maternal mitochondrial DNA that causes sudden, painless, severe vision loss in one eye with involvement of the other eye within weeks. The average acuity of a patient with LHON is 20/200 or worse. It is unlikely vision will improve. LHON prevalence is approximately 1/40,000. The disease is monitored using OCT. The current treatment for LHON is supportive, but there has been promising research in stem cell therapy. Patients can greatly benefit from low vision services. This case report reviews the management of LHON and discusses clinical findings and treatment options.bennet_lebers
TO PROTECT AND CORRECT: SCLERAL LENSES FOR EXPOSURE KERATOPATHY IN CROUZON SYDROME WITH KERATOCONUSBerke-SilvaAndrea M. Janoff, OD, FAAO2015Crouzon syndrome is a genetic disorder causing premature fusion of the craniofacial bones (craniosynostosis). Documented ocular complications include hypertelorism, exophthalmos, exposure keratopathy, strabismus, amblyopia and optic atrophy. A 17 year old male with Crouzon syndrome presented for a contact lens fitting OS. He had a history of keratoconus confirmed with corneal topography and pachymetry OU, exposure keratopathy due to lagophthalmos OU, and irreversible vision loss of unknown etiology OD. A successful contact lens fit was achieved with a Custom Stable TM (Valley Contax, Inc.) gas permeable (GP) scleral lens OS. Visual acuity was 20/20- with the contact lens and polycarbonate over-spectacles, providing safety as well as a correction for residual astigmatism. Keratoconus, although not considered a common associated ophthalmic finding, has been documented in the literature in patients with Crouzon syndrome. Since GP lenses are often required to mask irregular astigmatism, scleral lenses are an ideal option for these patients. Not only do they provide vision correction, they serve as a protective barrier preventing further complications from ocular surface exposure.berkesilva_protect
Comparative Tomography of Central Serous Chorioretinopathy.BesadaBarry J Frauens OD, Rim Makhlouf OD,Diana Shechtman OD2015Purpose: To compare spectral domain optical coherence tomography (SDOCT) of sub-retinal fibrin leakage and concomitant central serous chorioretinopathy (CSC) morphology in four cases with others documented. Case Reports: Four cases of acute onset CSC exhibiting serous neurosensory and retinal pigment epithelium detachment (PED) associated with a hyper-reflective pattern in the sub-retinal space emanating from the PED are described. All cases showed photoreceptor outer segment (POS) thickening, zones where the inner segment-outer segment junction line (IS/OS) was not visible and an outer retinal “dipping appearance. POS thinning with an increase of granular deposits on the posterior surface of the detached retina was observed at follow-up. As the CSC resolved, the IS/OS junction line became visible and the granular deposits diminished. Conclusion: SDOCT imaging of a hyper-reflective pattern at the sub-retinal space proximal to a PED in CSD may reflect resonance detection of fluid turbulences and density distribution disparities. The size of the leakage defect in the PED may determine the outline of the hyper-reflective pattern while the location may influence the spatial orientation. The hydrostatic and fibrin particle pressure flowing from a PED on a swollen POS may contribute to the apparent outer “dipping” imaged on optical coherence tomography.besada_tomography
Complicated Anterior Scleritis Secondary to Rheumatoid ArthritisBlackJulie Tyler, OD2015A 54 year old Hispanic female with complicated Rheumatoid Arthritis is diagnosed with diffuse anterior scleritis. The patient presented with the characteristic violet-bluish hue with left eye affected more than the right eye and poor general health. The case required co-management with her rheumatologist to manage her recent flare. Scleritis is the inflammation of the sclera and is secondary to an underlying condition in up to 50% of cases. Patients with mild to moderate, non-necrotizing scleritis have a good prognosis but the condition may continue for months to years. The case as well as a literature review will be presented.black_scleritis
Horner Syndrome Secondary to Internal Carotid Artery Dissection After A Short-Distance Endurance RunBorgman2015Oculosympathetic paresis, historically known as Horner sydrome, classically results in a triad of ptosis, miosis, and anhydrosis on the affected side. Any interruption or insult to any part of the sympathetic pathway to the eye can result in these classic findings. There are many possible etiologies along the three-neuron pathway, however, a few potentially life threatening causes must always be ruled out, especially in acute presentations. One life threatening etiology, in particular, to rule out is of internal carotid artery dissection (ICAD). A 38-year-old white female was referred to our clinic for a second opinion by her primary care physician for a sudden onset headache, ptosis, and miosis of the left side following a short endurance race 24–48h prior. Entering visual acuities were 20/20 in the right eye (OD) and 20/20 in the left eye (OS). Emergent magnetic resonance imaging (MRI) and magnetic resonance angiography (MRA) revealed a severe left ICAD. The patient was started on oral anticoagulants and oral steroids. Spontaneous resolution occurred three months later upon confirmation with repeat MRI/MRA. This case report reviews the clinical findings, diagnoses, treatment, and management of patients with Horner syndromes secondary to ICAD.borgman_horner
Multifactorial Pseudotumor CerebriBoucher2015Pseudotumor cerebri is a sight threatening condition that is made by a diagnosis of exclusion from neuroimaging and additional testing. This is a case of a young American Indiana female presenting with severe papilledema, a unilateral cranial nerve six palsy, and a recent diagnosis of rocky mountain spotted fever that was treated with doxycycline. The patient was referred to urgent care for CT scans as well as neuro-ophthalmology where a lumbar puncture was performed as well as bilateral optic nerve sheath decompression surgery and a ventriculoperitonal shut put in place. This case emphazies the importance of early recognition, correct diagnosis and intervention in preserving vision.boucher_pseudo
Clival Chordoma: A Case Report by Dr. Roxanne BuffanoBuffano2015Chordomas are rare slow growing-primary malignant tumors of the bones. These tumors develop from remnants of the embryonic notochord along the spine. They can be found anywhere from the base of the skull to the coccyx. These tumors account for only one percent of intracranial tumors. Clival chordoma is an uncommon tumor that is characterized by slow growth and insidious onset of symptoms related to compression of cranial nerves and adjacent brainstem structures. Patients usually present with longstanding symptoms. The most common presenting symptoms were headache, diplopia secondary to cranial nerve VI paresis and visual changes, such as blurred vision and occasionally total loss of vision. Computed tomography proves adequate for tumor identification and localization. Magnetic resonance imaging and angiography are used to localize the tumors, define vascular supply, and proximity to vascular structures. Despite their benign histologic features clival chordomas have historically been a neurosurgical enigma due to their difficult location and propensity to recur despite extensive resection. Untreated, the natural history of clival chordoma is bleak with a life expectancy of less than 10 years after diagnosis. We will review the etiologies, clinical presentations, diagnosis and management of this group of patients.buffano_clival
Differentiating amiodarone-associated optic neuropathy from non-artertic anterior ischemic optic neuropathy in a patient with unilateral optic disc edemaCrist2015A 64-year-old male treated with amiodarone for atrial fibrillation presented with new onset floaters and visual distortions revealing unilateral optic disc edema, is discussed alongside evidence for amiodarone associated optic neuropathy (AAON) being a clinically separate entity from non-artertic anterior ischemic optic neuropathy (NAION). Amiodarone, the most commonly prescribed anti-arrhythmic drug worldwide is limited in usage due to numerous side effects. Ocular effects of amiodarone toxicity range from corneal micro-deposits to optic neuropathy. Both AAON and NAION share a similar initial appearance of optic disc edema, yet AAON differs with a more insidious onset of vision loss, a longer duration of disc edema and more commonly bilateral, than NAION.crist_amiodarone
Double TroubleDemerittAnna-Kaye Logan, BS, Julie Rodman, OD, MS, FAAO, Nataliya Yakovleva2015Double Trouble Background: Hypertension results in a myriad of ocular complications and is a risk factor for the development of retinal vascular disease such as retinal occlusions and non-arteritic ischemic optic neuropathy. Case: A 79 y/o BM presented for evaluation of reduced vision. Ocular history was unremarkable. Medical history was positive for DM, HTN and CVA. BCVA was 20/30 OD & 20/50 OS. There was evidence of a trace APD OS. Funduscopy revealed an HRVO OD and NAION OS with significant hypertensive vascular changes OU. Conclusion: Due to the pathophysiology of hypertension, these conditions have been reported to occur concomitantly in the same eye. However, occurrence of each event in different eyes of the same individual has not been reported.demeritt_double
Flip me upside down and I will detachDemerittAnna-Kaye Logan, BS, Julie Rodman, OD, MS, FAAO and Andrew Kaper, BS2015Introduction Inversion tables are popular among fitness fanatics and are proven to release back pain and improve circulation. However, inversion tables carry potentially serious health problems including ocular ones. Inversion results in an increase in intraocular pressure, fluid accumulation within and around the eye and conjunctival hemorrhaging. We report a case of rhegmatogenous retinal detachment following daily repetitive use of an inversion table. Case A 64 y/o WM presented with complaints of a “foggy blob” in the inferior nasal quadrant OS occurring 4 days prior. He reported using an inversion table several times during that time period. BCVA 20/20 OD, CF @1 ft OS with limitation in vision peripherally. There was a +RAPD OS. DFE revealed pigmented anterior vitreous cells, 3 retinal holes and a large, bullous retinal elevation that extended to the macula OS. Conclusion Despite the positive osteopathic benefits associated with inversion tables, practitioners need to be aware of the potential ocular morbidities linked with inversion as well.demeritt_detach
When do you OVERMINUS your patient?DinhKara Collier, O.D. and Erin Jenewein, O.D., M.S., FAAO2015This case report highlights the use of overminus lenses for exotropia. A ten-year-old black male presented with large angle CAXT and symptoms of fatigue when reading and double vision. The patient had a history of large angle IAXT, and was unable to undergo vision therapy or surgery to help control his deviation. We prescribed overminus lens therapy, and follow up visit revealed moderate IAXT in the distance and large exophoria at near with no symptoms. The use of overcorrecting lenses has the advantage of achieving binocular control of exo deviations while wearing the lenses, which promotes good binocular asymptomatic control of the deviation (1).dinh_overminus
A Pigmented Vitreous Cyst in an Adolescent African American FemaleDitmetaroj2015Posterior vitreous cysts are rare ocular findings with only a limited number of documented cases since their discovery by Tansley in 1899. While many theories have been suggested to explain their etiology, studies have yet to provide a universal answer to their development. Vitreous cysts are typically classified into acquired or congenital forms, with most theories suggesting they arise from trauma. Appearances can vary in regards to size, shape, and pigmentation. Most cases remain asymptomatic and require monitoring while some symptomatic patients have undergone laser cystotomy or pars plana vitrectomy to alleviate the visual disturbances. Although some regard them to have little clinical importance, other sources believe that vitreous cysts may be linked to ciliary body melanomas and thus warrant further studies to help identify a patient’s prognosis.ditmetaroj_cyst
Surgical Treatment of Herpetic Keratitis Resistant to Conventional Topical TherapyDoRichard Lehrer M.D.2015Herpes Simplex Virus is a common viral infection that may lead to ocular disease. Herpes Simplex Type I or II may cause a myriad of ocular conditions which include but are not limited to blepharoconjunctivitis, epithelial keratitis, stromal keratitis, and iridocyclitis. This poster summarizes a clinical case regarding a 57 white male who is being treated for an ongong herpetic keratitis in his left eye that has been found to be resistant to conventional pharamcological therapy. The patient’s previous treatment plan included Viroptic, Vira A, Valcyclovir, Famvir, Vira A, and Idoxuridine 1%. Upon exhaustion of topical therapy, a superficial keratectomy and an amniotic Membrane graft was done. This patient is currently monitored for corneal post operative care.do_amniotic
Myopic Macular Schisis: an unusual diagnosis for sudden onset of floatersDuncan2015Myopic macular schisis, also termed foveoschsis, is a rare splitting of the retinal layers due to high myopia. This foveal separation occurs with anterior tractional forces along an epiretinal membrane that has formed secondary to posterior staphyloma. A 48 year-old African American female presented with sudden onset of floaters with BCVA 20/25 OD,OS. No flashes of light were reported. Past ocular history consisted of high myopia with LASIK correction 3 years prior. Posterior segment evaluation showed faint stellate strain of the macula OU. OCT confirmed bilateral infero/temporal retinoschisis involving the macula. This case report will include Optical Coherence Tomography findings and an explanation of the surgical procedures performed to aid resolution. A discussion of differential diagnoses will include epiretinal membranes, vitreo-macular traction, optic/scleral pits, advanced glaucomatous etiologies and genetic abnormalities associated with retinoschisis.duncan_schisis
Sunny Side UpEberle2015A 65-year-old white male with diabetes presents for a comprehensive eye exam with the complaint of blur at distance and near which corrects to 20/20 by manifest refraction. Examination reveals bilateral, round, subfoveal lesions diagnosed as adult onset vitelliform macular dystrophy. This rare disorder exhibits an autosomal dominant inheritance pattern in about 25-30% of patients, but the cause remains unknown in the remaining affected. Mutations in genes BEST1 and PRPH2 have long been known as responsible. Recent research advancement has uncovered other causal genes; IMPG1 and IMPG2. Clinical trials are currently underway to further study affected tissues and pluripotent stem cells.eberle_sunny
Bilateral Disc Edema Secondary to Intracranial Meningioma: A Case That Is More Than Meets the EyeEngstrom2015Meningiomas are the most common type of intracranial neoplasm. A 77 year-old white male presents to the Greenville VA Eye Clinic for routine eye care without visual complaints but family members note recent onset of poor memory and declining cognitive skills. Subjective findings show slightly reduced Snellen acuity and decreased color vision. Severe bilateral optic disc edema is viewed upon dilated fundus examination. MRI and CT Imaging reveal a large mass with associated edema and midbrain compression. This case reveals an atypically large and life-threatening primary intracranial lesion discovered during routine eye examination. Included are diagnostic testing, differentials, management and treatment of an insidious intracranial meningioma with ocular manifestations.engstrom_meningioma
Fundus Autofluorescence (FAF) Lights the Way to Stargardt Disease: The Utilization of FAF Imaging in the Differential Diagnosis of Retinal Maculopathies.FlahertyJarrett Mazzarella, OD, FAAO2015Stargardt disease is a macular degenerative condition which eventually results in decreased central vision. Lipofuscin and related compounds accumulate in the retina at an accelerated rate which ultimately induces retina and retinal pigment epithelial (RPE) cell death. Typical presentation includes scattered yellow flecks throughout the posterior pole with atrophy of both retina and RPE tissue. Historically, fluorescein angiography (FA) has been used for diagnosis, with a silent choroid as the hallmark finding. Newer approaches for differential diagnosis include spectral domain- optical coherence tomography (SD-OCT) imaging and fundus autofluorescence (FAF). This case focuses on the diagnosis of Stargardt disease based on key FAF findings with a unique finding of foveal sparing.flaherty_stargardt
When PVDs Go Awry: Diagnosing and Managing Vitreomacular TractionFurtado2015Introduction Optical coherence tomography (OCT) has allowed for improved visualization of the vitreoretinal interface. We are able to better recognize the changes that occur to the retina during a posterior vitreous detachment (PVD). In some instances, the persistent adhesion of the vitreous to the retina can cause tractional deformation leading to vitreomacular traction (VMT). Case Report A 67-year-old female was seen for an eye exam. OCT scans revealed the presence of vitreomacular traction in the right eye. She was subsequently referred for pharmacologic vitreolysis treatment. Discussion This poster examines the characteristics of the vitreoretinal interface and pathophysiology of a PVD leading to VMT. Proper diagnoses and management is discussed, including the efficacy of pharmacologic vitreolysis treatment.furtado_pvd
Objective and Subjective Assessment of the KBA contact lens for Keratoconus.GantzAbousaid Arige, Serero Gad, Gordon-Shaag Ariela,Philip Fine2015Keratoconic -bi-aspheric (KBA) lenses were fit in 3 males and 4 females with nipple cones (11 eyes). Approximately 3 trial lens modifications were necessary. After two weeks, 6 eyes were grade 0, 3 were grade 1 and 2 were grade 2 (Efron scale). Patients reported an average of 7.0 ± 2.7 hours of wear, with good scores in visual stability, satisfaction with VA and quality of vision in dim light, improvement of mood and quality of life, and low scores in feeling of foreign body or pain during wear, red eye, eye itch, difficulty with lens removal, and night glare. The total RMS wavefront error was significantly reduced with the lenses.gantz_keratoconus
An Unusual Case of Transient Visual ObscurrationGardner2015This case report outlines an unusual presentation of a 65 year old male complaining of predictable vision loss in his left eye associated with exertion. A complete work-up was ordered including carotid studies, brain MRI/MRA and CTA of the neck. Only the MRI revealed significant findings with defects consistent with ischemic or demyelinating disease. The patient refused lumbar puncture to aid in the diagnosis of MS as he previously experienced complication with this procedure. This case will outline a relatively rare presentation of transient visual obscuration presenting as Uhthoff's phenomenon is the presence of probable demyelinating disease. Appropriate work-up for this clinical presentation will be reviewed and the pathophysiology of heat or exertion induced nerve conduction deficits will be discussed.gardner_transient
A Case Study of Idiopathic Familial Retinal Arterial TortuosityGarrison2015A 36-year-old male presents for a routine eye exam with no chief complaint. The only notable finding is moderately tortuous retinal arteries bilaterally documented as stable for nine years. Review of systems shows normal blood pressure and abnormal triglyceride levels. There are many causes of vessel tortuosity in the eye. The poster examines the process by which various differential diagnosis were excluded to finally determine that the patient has idiopathic familial retinal arterial tortuosity.garrison_idiopathic
SEROUSLY?! ...a Recurring Neurosensory DetachmentGlencerKimberly Reed, OD, FAAO2015SEROUSLY?! ...a Recurring Neurosensory Detachment! Serous fluid can invade the eye in various locations and layers. It is often attributed to stress contributing to a release of the cortisol hormone. A 30 year old male in 2012 presents with a nasal field scotoma that he describes as an afterimage. The patient was followed for 4 months via OCT. The partial serous detachment of the RPE associated with a neurosensory detachment was self limiting. Two years later the patient returned with similar signs/symptoms. The patient was followed weekly and exhibited fluctuating elevation. OCT images/photos are included. Bromfenac 0.09% ophthalmic solution was prescribed off label. Signs and symptoms improved dramatically.glencer_detachment
Adult Onset Foveomacular Pigment Epithelial Dystrophy (AOFPED)GonzalezLane Fujimoto, OD2015Pattern macular dystrophies can mimic each other in appearance, and in adults can be misdiagnosed with acquired and inherited disorders. True vitelliform macular dystrophy rarely appears in the adult population and when it does it is characterized by late onset, slow progression, good prognosis and high variability in functional abnormalities. The following case demonstrates the importance of using optical coherence tomography (OCT), fundus photos, fluorescein angiography (FA), and electro-oculography (EOG) in the diagnosis of Adult Onset Foveomacular Pigment Epithelial Dystrophy (AOFPED).gonzalez_foveomacular
NAION: Post Op EditionGonzalez2015A 64-year-old white male presents for 1 week post op for cataract extraction in the right eye. Patient notes pain behind the operative eye, which is constant and aggravated by bright light. He notices periods of time when his vision seems brighter like "the iris is opening up". Patient has a history of an IOP spike in the right eye at 1-day post op. Clinical findings include: right eye 0.30 C/D with indistinct, elevated nasal margins, a flame hemorrhage on inferior rim, and dilated and tortuous vessel. His OCT findings revealed average RNFL thickness right eye of 156 microns and inferior quad RNFL of 265 microns. Patient is diagnosed with a delayed type post-operative NAION. It occurs in 1 out of 2000 cataract extractions and is less common than post-operative endophthalmitis. His signs correlate with that of incipient NAION, which is described in the literature as an asymptomatic optic nerve head edema with no visual loss.gonzalez_naion
Vascular Compression of the Optic Chiasm by a Tortuous and Enlarged Internal Carotid ArteryGonzalezTheresa Chong Fernandez, OD, FAAO, Paul Vejabul, OD2015Visual field defects related to optic chiasm compression can overlap with glaucoma and optic neuropathy findings. The following case demonstrates the importance of imaging in the diagnosis of optic chiasm compression by vascular etiologies.gonzalez_compression
Unusual Iris findingGosalia2015Arteriovenous malformation of the iris is a rare clinical finding that can be seen in one or both eyes. It is usually present in childhood, but becomes more apparent in the 5th or 6th decade of life. A 55 year old female of Scottish decent with an unremarkable systemic history presented for a comprehensive eye exam. Patient reported no visual or ocular complaints. Upon close examination of the right eye, an isolated, prominent blood vessel was visible on the iris. This finding is benign and not associated with any systemic or ocular condition; however, it must be differentiated from other causes of abnormal iris vessels. This presentation seeks to demonstrate the various differential diagnoses of unusual iris blood vessels, proper management strategies, as well as when to recognize the urgency of such a clinical finding.gosalia_iris
Contact lens Masquerader of Underlying Systemic ConditionGosalia2015Superior limbic keratoconjunctivitis is a localized inflammation of the superior bulbar conjunctiva and adjacent structures, most commonly associated with contact lens overwear or thyroid disease. A 33 year old African American male presented with recurring episodes of redness in both eyes over the past 2 years. Systemic history is unremarkable. Patient is a contact lens wearer and reported use of various topical medications and numerous contact lens brands and wearing modalities to alleviate symptoms, which continuously recur. Careful slit lamp examination revealed bilateral inflammed superior bulbar conjunctivas. Patient was referred to his PCP for a thyroid panel, which confirmed a diagnosis of hyperthyroidism. This presentation will include differential diagnoses and management of superior limbic keratoconjunctivitis.gosalia_contact
A Bump on the Head can be Serious: Visual Rehabilitation for Post Concussion SyndromeGroce2015Concussions resulting in mild traumatic brain injury are common in the pediatric population and often result in sensorimotor visual problems. The most common visual deficits include changes in refractive status, binocularity, accommodation, visual processing, vestibular-visual interaction and ocular motility. In this case, an 11 year old female hit her head, resulting in a concussion and a mTBI including visual problems: convergence insufficiency, accommodative dysfunction and ocular motor dysfunction. She started visual therapy which is helping decrease her symptoms and make it easier for her to function at school. Proper visual evaluation of children with head injuries is crucial in identifying visual problems which can be rehabilitated to alleviate symptoms and improve function.groce_bump
Managing a Case of Polypoidal Choroidal VasculopathyGupta2015Polypoidal choroidal vasculopathy (P.C.V.) has been considered a variant of neovascular age-related macular degeneration, however distinctions in appearance, target demographic, prognosis, and genetic markers question this interpretation. As both testing and intervention approaches can differ for P.C.V. versus other causes of choroidal neovascularization (C.N.V.), it is important to identify and understand this disease. We present the case of an 80-year-old white male patient complaining of decreased vision in the right eye over several months. Fundus examination and optical-coherence tomography reveal papillomacular subretinal fluid and hard exudate, without retinal-pigment-epithelium detachment. Fluorescein angiogram questions occult C.N.V.; indocyanine-green angiography confirms peripapillary choroidal leakage. Treatment is initiated with a trial of intravitreal bevacizumab.gupta_polypoidal
Low Vision Rehabilitation for Patient with Idiopathic Juxtafoveal Telangiectasia Type 2Guyette2015Idiopathic Juxtafoveal Telangiectasia (IJFT) type 2 is a disease that affects the macula and can be devastating to vision. This case presents a 58 year old male with IJFT type 2. Microperimetry was performed to determine fixation stability and preferred retinal locus for each eye. Review and classification of IJFT will be discussed as well as the unique inpatient blind rehabilitation program designed for this patient.guyette_lowvision
Double Trouble: Pontine Lesion associated with Acute Diplopia and 6th Nerve Palsy in a Patient with Longstanding Esotropia and Prior SuppressionHamidianiJarett Mazzarella, OD, FAAO & Charles Davis, OD2015The abducens, or sixth cranial nerve, originates from the dorsal pons and travels ventrally before exiting at the pontomedullary junction. Weakness of the lateral rectus due to sixth nerve palsy or paresis leads to horizontal diplopia worse to the affected side and is greatest at distance. This case presents a 64-year-old male with new onset double vision, chronic headaches and a history of longstanding right esotropia. Binocular testing demonstrated a non-comitant increase in esotropia from previous exam findings, which induced new symptoms. MRI testing revealed an expansile, diffuse lesion in the pons. Differential diagnoses for unilateral sixth nerve palsies include microvascular ischemia, mass lesions, congenital abnormalities, high or low intracranial pressure, and trauma. Typically, horizontal diplopia is managed with occlusion or prism and once the deviation is stable, surgical correction may be considered.hamidiani_diplopia
Simultaneous Bilateral NAION Resulting from a Trip to the ERHamidianiCharles Davis, OD2015Non-arteritic ischemic optic neuropathy (NAION) results from acute infarction to the optic nerve head and commonly occurs unilaterally. While later involvement of the fellow eye can occur, it is extremely rare for NAION to occur simultaneously in both eyes. This case describes a 68-year-old male who presented to the emergency room in a hypertensive crisis, which resulted in his blood pressure being abruptly lowered. Days later the patient described a loss of vision in both eyes. Optical coherence tomography imaging and visual field testing support the diagnosis of simultaneous bilateral NAION. Vasospasm from ineffective vascular autoregulation may result in increased vascular resistance and reduced perfusion pressure in the optic nerve head. Auto-regulatory mechanisms may be impaired by anti-hypertensive medications and therefore, a rapid reduction in blood pressure with medication therapy could result in a simultaneous bilateral NAION.hamidiani_naion
Eye Tide: A Case with no GainHavens2015The prognosis of eyes exposed to chemical agents depends on the duration of the exposure and the causative agent. While acidic chemical burns tend to be self-limiting, alkali substances result in liquefactive necrosis, allowing them to penetrate the anterior chamber within 5-15 minutes. A 58 year-old black female got powdered laundry detergent in her right eye 3 days before seeking treatment. At the initial visit, VAs were OD LP and OS 20/20-2. 100% of the cornea had an epithelial defect, extreme limbal thinning, and 360 degrees of a subconjunctival hemorrhaging. A hypopyon filled 40% of the AC leaving minimal to no view of the iris, lens, or any posterior structures. Treatment was initiated but the condition only worsened. Impending perforation led to a therapeutic PKP with an amniotic graft OD. At the 1-day post-op exam, the PKP looked “outstanding” and VA OD was CF, but a B scan revealed choroidal detachments with possible submacular hemorrhaging. By exploring the patient’s treatment options and follow-up care, this poster will delineate the nature of ocular burns, initial differential diagnoses, and the management therapy needed in worse case scenarios- not only preserving remaining vision, but saving the eye itself.havens_eyetide
Non-malignancy in DisguiseHernandezGrace Jeong, OD, Nancy Shenouda-Awad, OD, FAAO, Theresa Zerilli, OD, FAAO2015Actinic keratosis is a UV light induced lesion and has up to a 10% chance of progressing into a squamous cell carcinoma. AK is normally characterized as a red, scaly, and/or rough lesion. This case discusses a patient who presented with an atypical appearing actinic keratosis which showed malignant features of lid irregularity, madarosis, and mild neovascularization. A biopsy confirmed the diagnosis of AK. This case highlights the importance of recognizing possible cancerous lesions with attention to specific malignant characteristics. Differential diagnoses, clinical features, work up and management will be discussed. The role of the optometrist is essential to appropriately and timely work up and manage these patients.hernandez_disguise
“You give me FEVR!” Clinical findings, treatment, and management of the other FEVR: Familial Exudative VitreoretinopthyHoffman2015A 60 year-old white male presented to the Low Vision Clinic as a referral from his Retina Specialist. His ocular history was significant for Familial Exudative Vitreoretinopathy (FEVR) OU since birth and Primary Open Angle Glaucoma OU. His entering acuities were 20/100 OD and HM OS with vision loss attributed to recurrent vitreous hemorrhages OS>OD and bilateral retinal detachments. His medical history was remarkable insulin dependent diabetes mellitus since 1995/1996, hypertension, restless legs syndrome, rosacea, and gastroesophageal reflux disease (GERD). This presentation will discuss a unique case of FEVR which was complicated by proliferative vitreoretinopathy and review clinical characteristics, treatment options, and the indication for low vision rehabilitation in more severe cases.hoffman_fevr
Bilateral Collateral Damage: Ocular Trauma from a Suicide Bombing in an Afghan ChildHoffman2015A 6 year-old Afghan male presented to the Low Vision Clinic for a pediatric low vision evaluation. He was sent as a priority consult from his pediatric Ophthalmologist and Retina Specialist. He came to the United States nine months ago to seek refuge and treatment after a bomb went off next to his home in Afghanistan. He was living with a host family through a program called Solace for the Children which provides medical help to children in places plagued by war. His ocular history was significant for bilateral retinal detachments s/p repair, prephthisis OD, a macular scar OS, and aphakia OU. His medical history was only significant for facial scars from shattered glass. This case report will discuss the importance of early intervention in low vision rehabilitation for visually impaired children.hoffman_trauma
What Are You Looking At?Holmes2015Background: Solar maculopathy is characterized by vision loss associated with photoreceptor and retinal pigment epithelial damage resulting from periods of sun-gazing or directly observing a solar eclipse. Case Summary: A 14 year-old male presented to the clinic with symptoms of worsening vision over the past couple of months. The patient also reported a constant, unchanging, multicolored spot of about one centimeter in diameter present in his vision OD only. The spot was not present with both eyes open, and the patient denied any history of migraines, sudden vision changes, eye pain, or other visual complaints. Past medical history was unremarkable. The patient was found to have a BCVA of 20/40 OD and 20/20- OS. Pupils and extraocular muscle movements were within normal limits, and no afferent pupillary defect was evident. The anterior segment examination was unremarkable. Upon dilation, the patient was found to have a circular area of atrophy at the foveal region OD/OS. Conclusion: After further inquiry, the patient revealed a history of sun-gazing and staring at other bright lights. After a consultation with a retinal specialist involving further testing, it was concluded that the patient had solar maculopathy.holmes_looking
Evaluating a Patient with Severe Bilateral Loss of Vision: A Case of Leber’s Hereditary Optic NeuropathyJarvis2015Leber’s Hereditary Optic Neuropathy (LHON) is a mitochondrial mutation that results in sudden onset bilateral painless loss of vision and dyschromatopsia, most frequently seen in young males. The point mutation is passed maternally, and diagnosis is confirmed with laboratory blood testing. This case report details the testing and follow-up for a 20-year-old male presenting for severe loss of vision in both eyes with a final diagnosis of LHON. Testing includes visual fields, OCT, FA, MRI, and blood tests. The examination and differential diagnoses for a patient with bilateral loss of vision is discussed, with a focus on the epidemiology, diagnosis, and treatment for Leber’s Hereditary Optic Neuropathy.jarvis_lebers
Progressive Supranuclear Palsy: When All is StillJeongSuzanne Kim, O.D, Christine Burke, O.D, F.A.A.O, Theresa Zerilli,O.D, F.A.A.O , Nancy Shenouda-Awad, O.D. F.A.A.O2015Progressive supranuclear palsy (PSP) is a rare brain disorder that causes serious and progressive problems with control of gait, balance, complex eye movement and cognitive problems. Although PSP may not directly cause a decrease in visual acuity, it can cause devastating ocular motility deficits. These ocular motility deficits can include motility restriction and saccadic dysfunction which can be detrimental to functional visual tasks such as reading. This case is an overview of PSP and how to manage a patient with advance PSP by utilizing low vision method and devices.jeong_palsy
Bilateral Juvenile X-linked Retinoschisis with 20/20 acuity?JordanCory A. Grifka, OD2015We will present a case study of a 50 y/o male veteran with Bilateral Juvenile X-linked Retinoschisis. We will include fundus photography of the classic “spoke-wheel pattern” and a fascinating Cirrus HD Ocular Coherence Tomograph that reveals a tiny island of attached retina at both foveae within the schisis cavity, yielding an unprecedented 20/20 acuity OD, OS. We will then discuss the macular differentials and hone in on the condition itself, detailing its genetic origin, demographics, prevalence, prognosis, and low vision therapeutic options. Lastly, we will show the typical ERG response and how fluorescein angiographic findings including autofluorescence appear.grifka_retinoschisis
Reoccurring Periorbital Abscess Associated with Frontal SinusitisKeelTheresa Chong Fernandez, OD, FAAO and Jennifer Monarrez, OD2015Abnormal communications to the orbit can develop from frontal sinusitis. The following case demonstrates how early recognition, appropriate testing, and timely treatment of orbital complications associated with frontal sinusitis is vital in preventing vision loss.keel_abscess
Atypical Fundus FlavimaculatusKeelMichelle Matson, O.D.2015Fundus flavimaculatus is a macular dystrophy characterized by retinal flecks that accumulate at the level of the retinal pigment epithelium. The dystrophy is a variation of Stargardt’s disease that does not present itself until adulthood. While patients tend to retain central vision, acuity is largely dependent on amount of macular atrophy. The following report describes an asymptomatic 67 year old African American male with an atypical fleck retina appearance and normal maculae. This case highlights how optical coherence tomography, fluorescein angiography, and electrodiagnostics aid in the diagnosis of fundus flavimaculatus.keel_flavimaculatus
What's the Weber's Syndrome? A Case ReportKenney2015A 76 year old African American female presents with a left inferior quadranopsia, a right hemiparesis, and a complete left 3rd nerve palsy with aniscoria greater in the left eye. With further questioning, patient reports history of a stroke in 2008. Upon receiving the patient’s neurological records, MRI and CT scans illustrated that the patient experienced two ischemic events: one in the right occipital lobe causing the left inferior quadranopsia and another stroke in the left thalamus extending into the medial aspect of the left cerebral peduncle causing the right hemiparesis and the fascicular 3rd nerve palsy, also known as a Weber’s Syndrome.kenney_webers
Unilateral Presentation of A Typically Bilateral ConditionKressTyler Kitzman2015Retinitis pigmentosa (RP) is a group of inherited disorders characterized by progressive peripheral vision loss and night vision difficulties that can lead to central vision loss. This typical presentation of this disorder affects approximately 1 in 4000 individuals in the United States, with carriers of the allele estimated at approximately 1 in 100. Findings that may be consistent with RP include bilateral peripheral and mid-peripheral retinal pigmentary changes characterized as bone-spicules, arteriolar attenuation, waxy/pale optic nerve, pigmented vitreous cells, posterior subcapsular cataract, and generalized retinal atrophy extending along the retinal vascular arcades to name a few. We present a case of unilateral retinitis pigmentosa seen in a 48 year old African-American female. Although there are cases of unilateral RP reported in the literature, this presentation of the condition is considered rare and additional testing is considered necessary in order to confirm the diagnosis. The case will be reviewed, a list of differential diagnoses will be discussed along with additional testing indicated, and the prognosis and management of such condition will be reviewed.kress_unilateral
Neovascular glaucoma...a case of uncontrolled diabetesLakhani2015Neovascular glaucoma is one of the late findings that usually arise from an underlying vascular condition. The clinical findings are very prominent and often present in a dramatic fashion. In this case, a 53 year old male with longstanding and uncontrolled diabetes mellitus is found to have proliferative diabetic retinopathy and neovascular glaucoma. Prompt intervention was initiated through anti-VEGF injections, laser treatment of the retina, and topical anti-glaucoma therapy. Even so the visual prognosis is still poor. With more frequent systemic and ocular exams, this devastating condition could have been prevented.lakhani_neovascular
Double Trouble! Ophthalmoplegia and DiplopiaLaneDr. Nicole Minutolo2015Breast cancer is the most common site of origin for ocular metastasis. A 55 year old female presented as triage to the Greenville VA clinic complaining of ptosis of her left eyelid associated with occasional pressure and pain on movement. Review of patient’s medical history revealed a diagnosis of metastatic breast cancer. An MRI was ordered and revealed a lesion of the left orbit and a right anterior temporal lesion compatible with metastatic disease. Included in this report is photo-documentation of the patient and the MRI that confirmed diagnosis of the metastatic tumor. This case underscores the importance of a thorough medical history in patients with a cancer diagnosis.lane_diplopia
A Tale of Two Strokes: Homonymous Hemianopsia with Contralateral Visual NeglectLin2015Strokes can cause visual field defects as well as visual neglect, both of which can significantly impair visual function. In this unique case study, an 80 year old Caucasian patient presented with a right homonymous hemianopsia combined with left visual neglect. The patient had been diagnosed with right homonymous hemianopsia from a stroke in 2009. However, she returned for her annual exam with complaints of difficulty with the left side of her vision, which started after another stroke in May 2014. With visual field and visual neglect testing, the patient was diagnosed with a new left visual neglect in addition to the longstanding right hemianopsia. Rehabilitation was recommended.lin_neglect
Multiple Congenital Hypertrophy of the Retinal Pigment Epithelium (CHRPE): An Ominous Sign of Systemic ConditionsLoweFei Yang, Christina DalPorto2015Congenital hypertrophy of the retinal pigment epithelium (CHRPE) is a benign pigmented lesion commonly found during routine fundus evaluations; however, multiple CHRPE warrants further investigation for serious systemic pathologies. Multiple CHRPE, also known as “bear tracks,” is an ocular finding known to be associated with dangerous systemic conditions such as Gardner’s Syndrome, familial adenomatous polyposis (FAP) and Turcot Syndrome. This case describes a 69 year-old white male with multiple CHRPE “bear tracks” and a history of related systemic conditions.lowe_chrpe
An Unusual Case of A Large Pigmented Lesion: A Case Report of Spindle Cell CarcinomaLukeVinh Le OD '15, Dipti Singh OD MPH, Thanh Le OD2015Choroidal melanoma is the most common primary intraocular malignant tumor. Predominantly in European descent, metastasis of uveal melanoma most commonly occurs in the liver in 80-90% of patients. Metastasis is dependent on overall size, elevation, and rate of growth. Our case discusses a 66 yo white male with no history of malignancy and no ocular complaints. The exam revealed a large elevated choroid lesion spanning two-thirds of the right eye. FA showed little fluid accumulation within the mass. Diagnosis of choroid melanoma of undetermined histology requires CT scans in order to confirm non-metastasis to the liver. Non-metastasis of a choroid melanoma is indicative of spindle cell histology.luke_lesion
Fibrosed peripapillary exudatesLy2015Background: Fibrosed peripapillary exudates are the result of scar tissue formed from the remnants of a peripapillary chroidal neovascular membrane (PCNM). Both present in a circular pattern around the optic nerve head due to the anatomy of the underlying choroidal vessels. Continual insults can lead to further exudation, hemorrhage and can compromise vision. PCNM can be found in many conditions most common are ARMD and idiopathic. Without proper management and treatment, the condition can worsen quickly or maybe even resolve but it is extremely unpredictable. Case Report: An 84 year old Native American woman presented for a routine eye exam. Her ocular history includes pterygia, cataracts, PVDs, and mild ARMD in both eyes. Upon examination posterior segment findings included a cluster of MAs in between the optic nerve and macula OD, and peripapillary exudates OS. She was referred to a retinal specialist for a fluorescein angiogram and disease management. Conclusion: A report from the retinal specialist diagnosed her with fibrosed peripapillary exudates. Those with fibrosed peripapillary exudates should be referred to a retinal specialist to be monitored closely for early signs of recurrent PCNM so that treatment can be initiated in a timely manner.ly_exudates
Commotio Retinae and Spectral-Domain Optical Coherence Tomography Associated ChangesMaiNina Tran, O.D. and Michelle Matson, O.D.2015A patient with acute blunt ocular trauma presents with commotio retinae at the macula. Spectral-Domain Optical Coherence Tomography (SD-OCT) images document transient alterations of the retinal layers from onset to the gradual resolution of the condition.mai_commotio
Central Retinal Artery Occlusion with Cilioretinal Artery Sparing and Possible Neovascularization of the DiscMaiRussell Jew, O.D.2015Central retinal artery occlusions (CRAO) typically cause severe vision loss and can be related to an embolic, thrombotic, inflammatory, or traumatic origin. This case describes a patient who presents with sudden, painless vision loss in the left eye. The patient is able to achieve 20/30 vision in the left eye with eccentric viewing. Retinal examination displays areas of whitening without a cherry red spot, secondary to cilioretinal artery sparing. Threshold visual field testing demonstrates dense defects with paracentral sparing. Follow up examinations reveal the possible presence of neovascularization of the disc (NVD), a rare complication resulting from a CRAO.mai_crao
Radiation Retinopathy-Associated Telangiectasia showing Outer Nuclear Layer Thinning and Foveal Pit Enlargement on SD-OCTMakhloufJulie Rodman, OD, FAAO, Brandon Prete, OD2015Radiation retinopathy is an entity that results from retinal ischemia due to radiation therapy and may lead to complications including macular telangiectasia, a condition characterized by abnormalities in the foveal and juxta-foveal capillaries. A 52 yo female with a recent history of radiation therapy presented complaining of decreased vision OU. DFE showed multiple cotton wool spots in the posterior pole OU, macular telangiectasia, and macular exudates with associated thickening OD. SDOCT revealed temporal outer nuclear layer thinning and foveal pit enlargement corresponding to the area of telangiectasia. We discuss radiation retinopathy and telangiectasia, the associated OCT findings and their management strategies.makhlouf_radiation
Adult Vitelliform Macular Dystrophy Differential Diagnosis when Presenting with End Stage Disease.MarkoDorothy Hitchmoth OD FAAO2015This case demonstrates key features of end stage Adult Vitelliform Macular Dystrophy. An 80 year-old Caucasian male presented with bilateral atrophic vitreoproliferative maculopathy and subretinal deposits of unknown cause. Differential diagnoses included Best Vitelliform Macular Dystrophy, Stargardt Disease, Central Serous Retinopathy, Age-Related Macular Degeneration, and vitreo-macular traction syndrome. The diagnosis was confirmed by careful medical history and through the use of a broad set of tests to include fundus photography, ocular coherence tomography (OCT), fundus autoflourescence (FAF), near infrared fundus imaging (NIR), and visual field and electrophysiology analysis. Treatment considerations are briefly discussed.marko_vitelliform
Retinal Arterial MacroaneurysmsMatsonNina Tran, O.D.2015Retinal arterial macroaneurysms (RAM) are focal dilatations, usually occurring within the first three orders of a retinal artery. Visual acuity loss can result from macular hemorrhage or edema. Treatment ranges from observation in asymptomatic cases to surgical intervention in symptomatic cases. An 81-year-old male with a history of significant cardiovascular disease was found to have two RAM were of the left eye. Optical coherence tomography (OCT) revealed early macular edema. The patient was referred to a retinal specialist where focal laser treatment was performed. This case is unusual in its presentation of two RAM in one eye at different stages of progression. It also demonstrates resolution of macular edema on OCT after laser treatment.matson_arterial
Hemorrhagic Papillitis as Initial Manifestation of NeurosyphilisMcMahonTricia L. Newman, OD2015Syphilis is increasing in incidence in the US. Recognition of syphilis as the etiology of ophthalmic inflammation is confounded by its ability to imitate many other diseases. A 78 year old male with a complex medical history underwent placement of an Express shunt OS for uncontrolled glaucoma. During the post-operative period, new onset ONH edema and surrounding hemorrhage was observed and initially attributed to diabetic papillitis. Minimal resolution occurred over 6 weeks but vision decreased. Serology and MRI were ordered with subsequent diagnosis of neurosyphilis. After treatment with IV penicillin, ophthalmic signs resolved. Viewed post-diagnosis, systemic and ocular manifestations of neurosyphilis were all correlated in this patient to comorbidities. This case highlights the need to retain syphilis as a potential diagnosis in hemorrhagic papillitis in the elderly.mcmahon_neurosyphilis
A Review of Ocular Metastasis and Case ReportMeeks2015A 66 year old male presented for evaluation of acute blurry vision OS>OD. Best corrected visual acuities were 20/40 OD and 20/70 OS. Dilated fundus examination revealed cotton wool spots in the right eye and a slightly pale, elevated mass superior to the optic nerve in the left eye. Differential diagnoses included choroidal metastasis, choroidal melanoma, and retinal lymphoma. A chest X-ray and CT of the head were ordered. The patient was referred for further evaluation by a retinal specialist who concluded likely metastasis. The patient passed away one month later. This poster will review the epidemiology, manifestations, and treatment of ocular metastasis.meeks_metastasis
The Missing Link: Mini-Sclerals after Corneal Crosslinking for Post-Lasik Ectasia and KeratoconusMicklesRaelyn A. Ottenbreit, B.Sc. and Justin A. Obana,, B.S.2015The advent of corneal collagen crosslinking (CXL) has created a unique potential to slow or even halt the progression of keratoconus and post-lasik keratectasia. While studies have demonstrated promising outcomes from CXL, contact lenses are frequently necessary to achieve maximum vision. Mini-scleral lenses are invaluable for restoring visual function in patients with irregular corneas. Does this benefit extend to post-CXL corneas? Herein we report on two post-CXL patients who achieved maximum vision and comfort with mini-scleral lenses: (1) 38-year-old post-LASIK with keratectasia (2) 46 year-old keratoconic. Mini-scleral lenses, which minimize direct interaction with the cornea, hold promise for becoming the preferred visual rehabilitative correction following CXL.mickles_missinglink
Lacrimal Gland Tumors: A Case Report and ReviewMorris2015Lacrimal gland tumors account for 10% of space occupying orbital lesions. Generally presenting with inferior globe displacement, these masses may be benign, inflammatory, or malignant in nature. A 44 year old male presented complaining of reduced vision OS for the past year and reporting that glasses prescribed 7 months ago were no longer effective. A 2.5D hyperopic shift, mild proptosis and choroidal folds led to a diagnosis of orbital mass; CT revealed a lacrimal gland tumor. Discussion will include orbital anatomy, differential diagnosis, etiology, diagnostic procedures and treatment of lacrimal gland lesions.morris_lacrimal
Right Before Your Eyes: Acute Endophthalmitis Following Cataract SurgeryNelson2015Endophthalmitis, a severe ocular infection, is a rare postoperative complication. This potentially blinding condition often presents with blurred vision, pain, significant anterior inflammation, and vitritis. Endophthalmitis requires immediate referral, and accurate diagnosis and quick response are essential to positive outcomes. A 59 yo female presented for one-day post-op visit with decreased vision and photophobia OS following cataract surgery, though denied pain. VA was 20/70+1 OS, with 3-4+ cells and hypopyon. Vitreous was initially clear; within several hours, 2+-3+ vitritis developed in-office, obscuring fundus view. Pt was treated with intraocular antibiotic injections; uncorrected VA returned to 20/20-2 one month later. This poster will describe endophthalmitis presentation, differential diagnosis, and management strategy.nelson_endophthalmitis
The Multiple Faces of Epidemic KeratoconjunctivitisNoegelWendy M McGonigal, OD, FAAO; Shephali Patel, OD, MS, FAAO2015Epidemic keratoconjunctivitis (EKC), caused by adenovirus, is a severely contagious and vision debilitating form of viral conjunctivitis. This case report includes three similar yet unique cases of EKC that occurred in our clinic. The first patient was a 76-year-old male who presented with pseudo-membranes, infiltrates, severe chemosis, and redness. The second patient was 67-year-old male previously treated for conjunctivitis who returned for follow up, and examination revealed infiltrates. The third was patient a 53-year-old white male who presented with ocular pain, iritis, and infiltrates. All three patients were successfully treated using a combination of therapies including artificial tears, Tobradex, Pred Forte, and Betadine therapy.noegel_ekc
A Vision Threatening Choroidal Nevus and Review of Choroidal MelanomaOlberding2015The purpose of this poster is to report a unique choroidal nevus which decreased visual acuity as well as review the diagnosis and management of choroidal melanomas. Macular optical coherence tomography (OCT) of the lesion in this case demonstrated subfoveal retinal pigmented epithelial (RPE) elevation and macular thickening. Retinal photography and B-scan ultrasonography helped aid in the diagnosis. NaFl angiography was ordered due to the risk of a choroidal neovascular membrane (CNVM) and early malignant conversion. Choroidal melanomas are one of the most common primary malignant tumors of the eye. In many cases, B-scan ultrasonography is the most important additional test for diagnosis although other imaging may be used. The diagnosis and treatment of choroidal melanomas can be challenging and controversial given the life-threatening potential. A review of the Collaborative Ocular Melanoma Study (COMS) which is a large, randomized multicenter trial has provided insight about the effectiveness of radiation and enucleation. Although the primary aim is to prolong life, nearly half of patients die of metastasis. A basic preoperative systemic evaluation should be completed prior to ocular treatment because detection of systemic metastasis can affect life expectancy and thus the ocular treatment plan.olberding_nevus
Graft vs. Host Disease – Scleral Lenses to the RescueOlsenWilliam J. Denton, OD2015GVHD is a potential cause of systemic complications after an allogeneic bone marrow transplant. This disorder can manifest symptoms in the skin, gastrointestinal tract, and liver. Severe dry eye is the most common cause of long-term morbidity. We present a patient with a history of acute lymphoid leukemia and now with GVHD after receiving an allogeneic hematological stem cell transplantation from his brother. He had been treated unsuccessfully with most pharmaceutical options. His Ocular Surface Disease Index (OSDI) improved dramatically after being fit with scleral lenses. Despite literature stating that analogous serum tears are the best treatment, although unconventional, for GVHD, scleral lenses are a viable option for successful treatment.olsen_graft
Disinfection and Infection Control Update for the Optometric OfficePate2015The specific methods for infection control in the eyecare provider’s office remain somewhat controversial. The low incidence of reported cases of the direct spread of disease from ophthalmic practice has unfortunately led to a lack of concern in some cases. Reviewing the recommendations from the government agencies whose role it is to protect the public and prevent the spread of disease, as well as the most recent literature regarding microorganisms which are commonplace in the ophthalmic practice, allows us to confidently redirect our methods. This poster will focus on information practical and relevant to the eye care provider based on the most commonly performed procedures, as well as the microorganisms which are most common in our offices. Important manufacturer guidelines for the disinfection of instruments which are frequently used in ophthalmic practice will be discussed, in addition to updates on equipment care and new options available for the ophthalmic practice to minimize disease transmission. With public health and the protection of our patients in mind, eyecare providers have an important role in the prevention of the spread of disease.pate_disinfection
Central serous chorioretinopathy diagnosis complicated with neurological symptoms in a female patientPatelCharles Clark, MD2015Central serous chorioretinopathy (CSR), is a predominantly unilateral, temporary central visual impairment  ranging in size based on retinal involvement.  CSR  affects males more than females within the ages of 20-50, and is typically found  in individuals with type A personality with coinciding steroid use.  An OCT and fluorescein angiogram can add in the clinical diagnosis for these patients and a treatment plan can be formulated.  With proper diagnosis, treatment, and management these conditions typically resolve with little to no permanent vision loss.  This poster will highlight differential diagnosis, treatment, and management of CSR in a female patient with a history of steroid injections who initially also presented with neurological like symptoms.patel_central
Drug-Induced Thrombocytopenia RetinopathyPatelWendy McGonigal OD, FAAO; Ansu Abraham OD2015Many medications that are used in the treatment of cancer can result in a reduction of platelets causing ocular complications. A 64-year-old male presented for annual exam with no complaints or changes in vision. Dilated fundus examination revealed multiple large dot hemorrhages as well as Roth spots in the periphery. The patient had a history of severe anemia following treatment for lymphoma, which reduced his clotting ability leading to increased bleeding. The patient was further managed by hematology and oncology for additional treatment. As eye care providers it is important to take careful systemic history and form interprofessional relationships for optimal mangement.patel_thrombo
"Doctor, I have steamy vision is that normal?" - First presentation of Glaucomatous Cyclic CrisisPatel2015Glaucomatous cyclic crisis (GCC) also known as Posner-Schlossman (PSS), is considered a secondary inflammatory glaucoma with a unilateral presentation of high intraocular pressures and a mild idiopathic anterior chamber inflammation. Other presenting factors include; decreased vision, reports of halos, heterochromia, mild pain, and corneal edema. The gold standard treatment is steroids, mydriatics, and intraocular pressure lowering agents. The diagnosis can be complicated by other factors, but with proper diagnostics a diagnosis, treatment, and management of this condition can lead to resolution. GCC can be reoccurring and proper long term treatment should be addressed. This poster will highlight differential diagnosis, treatment, and management of GCC both short term and long term.patel_steamy
Oh MG! Multiple and Fluctuating Cranial Nerve PalsiesPatelWendy McGonigal, OD, FAAO2015Myasthenia gravis (MG) is an autoimmune disease resulting in fluctuating muscle weakness and fatigue. The hallmark ocular sign is ptosis or fatigue, but rarely presents with muscle palsies. A 77-year-old male presented with vertical diplopia. Examination revealed a constant alternating exotropia. Patient later presented with worsening diplopia and was diagnosed with a 4th nerve palsy. Patient next presented with oblique diplopia, ptosis, and abnormal gait. Examination revealed a pupil sparing incomplete 3rd and 6th nerve palsy OS and 3rd nerve palsy OD. Laboratory testing was positive for Ach receptor antibodies. MG is often missed due to fluctuating and subtle examination findings. It is important to consider MG when findings are obscure because it is a life-threatening condition.patel_myasthenia
Ocular Rehabilitation of Filamentary Keratitis with Scleral Contact LensesPatel VadapalliSumitra Khandelwal, M.D.2015Filamentary Keratitis (FK) is a corneal condition in which there are mucous filaments within the tear film anchored to the corneal epithelial layer. Common associated findings include perilimbal hyperemia, punctate epithelial erosions, reduced tear break up time, and pseudoptosis. Symptoms that are typically associated with FK include tearing, photophobia, foreign body sensation, and variable degrees of pain. The range of treatment options include manual removal of the filaments, artificial tears, punctual occlusion, acetylcysteine, corticosteoroids, NSAIDs, cyclosporine, and bandage soft contact lenses. A sixty-two year old female veteran presented with discomfort from dryness, blurred vision, and ghosting of images. Her ocular history was positive for Filamentary Keratitis, Sjogren’s Syndrome, and DSAEK in both eyes. Records review revealed poor and variable response to conventional medical treatments. Scleral contact lens fitting was performed and the patient reported an immediate improvement in symptoms. Furthermore, signs of the corneal condition were virtually eradicated with scleral contact lens use along with a marked improvement in vision for both eyes.vadapalli_filamentary
Now You See Them, Now You Don'tPeelerRichard G Gardner2015BACKGROUND: Charles Bonnet Syndrome (CBS) is a phenomenon in which the visual cortex of the brain spontaneously fires due to loss of sensory stimulation, thereby producing visual hallucinations in mentally healthy patients. CASE REPORT: E.L., an 87-year-old legally blind male with significant bilateral choroidal neovascular membranes, was referred to ophthalmology for bevacizumab injections. The patient reported a variety of visual hallucinations after treatment, one of which was very disturbing, which is atypical in CBS. CONCLUSION: Most patients do not volunteer information about visual hallucinations unless questioned. Patients with severe vision loss should be screened for symptoms of CBS so that proper intervention may be taken.peeler_charlesbonnet
Simultaneous Retinoschisis and Serous Detachment Associated with Optic Nerve Head PitPreteJulie Rodman, OD, FAAO; Rim Makhlouf, OD2015A 48 year-old female presented for comprehensive examination with a history of an optic nerve head pit OS. She was asymptomatic at presentation. Her BCVA was 20/20 OD and 20/30 OS without RAPD. Ophthalmoscopy revealed an optic nerve pit near the inferotemporal disc margin and adjacent retinal folds. A dome-like elevation surrounded the macula. SD-OCT demonstrated a prominent schisis cavity from the disc to the fovea with a localized area of serous detachment superiorly. Serous detachment and retinoschisis are well-documented maculopathies associated with optic nerve head pits; however, simultaneous presentation is quite rare. We present an OCT study of an optic nerve head pit with coexisiting maculopathies.prete_retinoschisis
"The dynamic diagnostic process and importance of interdisciplinary management in retinitis punctata albescens"QuintPatrick Lee, OD2015Retinitis punctata albescens is a rare form of night blindness characterized by the presence of irregular white flecks in the fundus. This case describes the diagnosis of retinitis punctata albescens in a 61-year-old female and the use of various vision rehabilitation tools to enhance visual demands. The presentation outlines the dynamic diagnostic process of a rare hereditary dystrophy and demonstrates the importance of an interdisciplinary management approach to maximizing a patient's quality of life. Photos, visual fields, ERG, and imaging to be included.quint_punctata
Yoked prism as a viable treatment modality for moderate visual skills dysfunction accompanied by attention deficits.Ritter2015Not all practitioners provide vision therapy services yet they still recognize the need to offer a treatment for moderate binocular and accommodative deficits. This presentation will discuss the use of vertical yoked prism as well as lateral compensatory prism as an alternative to traditional in-office vision therapy. Included in this discussion will be methods of determining the appropriate prism in terms of direction and magnitude, deciding on flat-top vs. PAL and the correct assessment for an add if needed. Included will be references to the use of such prisms in terms of studies and anecdotal evidence. A specific case will be described and will include entering complaints, appropriate pre and post treatment findings and 3 month follow-up results.ritter_yoked
Catching the Red Eye: A Case of Traumatic Intracorneal HemorrhageRoperWilliam J. Denton, OD, FAAO2015With fewer than 100 cases reported in the literature, corneal hemorrhages can be a rare but severe cause of decreased vision. We present a unique case of a subepithelial corneal hemorrhage due to trauma from scleral lens manipulation in a 76-year old Caucasian male whose cornea was compromised by neovascularization from ocular rosacea, despite having the patient leave the office well-versed in scleral lens insertion and removal. We monitored the resolution with anterior segment Cirrus OCT and photographs. We will present a comprehensive review of corneal hemorrhage etiology, differential diagnosis, and treatment, as well as scleral lens fitting steps to minimize hemorrhage occurrence.roper_intracorneal
Bilateral Disc Edema on April Fool’s Day: Not a PrankRunyon2015Optic neuritis (ON) is a very rare ophthalmic presentation in the pediatric population with varied presentation. In the pediatric population, the underlying etiology may vary and the pathophysiology is not well understood. This unique case takes a step outside of what has been largely studied, documenting the onset, treatment, and recovery of a rare case of idiopathic bilateral sequential optic neuritis in a healthy twelve year-old male treated with intravenous steroids followed by oral steroids.runyon_edema
Progressive Neovascular Glaucoma Secondary to Herpetic Anterior UveitisRyffBrianna Ryff, OD2015This case reports a chronic, recurrent, bilateral, non-granulomatous, anterior uveitis in a 21 year-old Native American female likely secondary to Herpes Simplex Type I. Patient history includes three recurrences in the past two years with non-compliance to therapy or follow-up visits. The patient presented with another bout of bilateral anterior uveitis initially treated with 1 gtt Prednisolone Acetate q2hrs and a cycloplegic agent qHS in both eyes. After non-compliance with medication, the patient developed diffuse neovascularization of the iris and pupillary block angle closure in the left eye resulting in neovascular glaucoma. Three separate laser peripheral iridotomies closed due to the significant amount of neovascularization. The posterior synechiae was surgically removed with lens extraction and implantation of a posterior chamber intra-ocular lens. A simultaneous pars plana vitrectomy and glaucoma shunt were completed. A uveitic lab panel was performed with ancillary testing. Only HLA-B27 and Herpes Simplex type I were positive. The patient had no symptoms of HLA-B27 systemic conditions often associated with a secondary uveitis. Since the viral load was more than 60 times greater than normal, Herpes Simplex is the likely culprit of the uveitis. The patient was treated with 400mg Acyclovir PO 5x/day for 7 days.ryff_uveitis
When 20/20 isn’t enough – Cases of symptomatic mild KeratoconusSchinasJulie A. Tyler, OD, FAAO2015BACKGROUND: The clinical presentation of irregular corneal astigmatism may be attributable to multiple ocular etiologies, some of which are uncommon, and create challenges in management. Fluctuating and/or decreased visual acuity may result in frustration for both the patient and the optometric physician. We present two cases in which the patient was correctable to 20/20 with spectacles, however still complained of less than perfect vision. CASE REPORT: Case I: A 28 yo BF presented with slightly decreased vision OD>OS for several years. Ocular history was non-contributory. BCVA was 20/20-3 OD and 20/20 OS. In order to address the cause of the difference in quality of VA between the eyes, a topography and diagnostic GP lens fit was performed, improving the VA to 20/20 and confirming the diagnosis of mild subclinical Keratoconus. Although the patient chose to continue with soft contact lenses, she was happy to have a diagnosis after many years of complaints. Case II: A 34 yo WF presented complaining of blurry vision which fluctuated in the right eye. Ocular history was significant for dry eye syndrome. BCDVA was 20/20- OD and 20/20 OS. Investigation regarding quality of vision revealed with corneal topography mild inferior steepening OU. A diagnostic GP fit was performed OD, improving the quality of the VA to 20/20 OD which the patient noted was sharp and better than with glasses. The patient was motivated to proceed with a GP CL fit in both eyes. CONCLUSION: Patients with all types of corneal irregularities, including those mild in severity, generally respond well to management with gas permeable lenses if they are well motivated. Differential diagnosis of the underlying etiology for corneal irregularity and mild visual quality complaints will be presented and considerations for GP lenses will be discussed.schinas_2020
A New Scleral Treatment for Presbyopia: Laser Anterior Ciliary Excision procedure.Schroeder SwartzAnnMarie Hipsley, PhD2015New evidence regarding extralenticular contributions to accommodation support scleral treatments for surgical presbyopia correction. Laser Anterior Ciliary Excision employs an Er:Yag laser to create scleral micro-excisions to restore mechanical efficiency of accommodation, and improve biomechanical mobility. These micro-incisions are created in three critical zones over the ciliary complex. Results from a prospective clinical study evaluating the procedure results over 12 months will be presented. Near and intermediate vision have been improved, as well as stereopsis, while maintaining emmetropia. Scleral procedures are advantageous because they maintain binocular vision at near and avoid teaching the cornea, reducing risk of vision loss.swartz_scleral
Diagnostic Dilemma: An atypical presentation of an EXOPHYTIC retinal capillary hemangiomaShechtmanAaron Gold OD, Timothy Murray MD, and Samantha McIntosh BS2015Introduction: Retinal capillary hemangioma (RCH) can occur in isolation or as a manifestation of von Hippel-Lindau disease (VHLD). The classic RCH is described as a globular reddish lesion with a dilated feeding artery and a tortuous draining vein; typically showing an endophytic growth pattern. Background: A 24 year-old female presented with complaints of a floater in the mid-peripheral field. Her family history, past ocular, and medical history was unremarkable. Best-corrected visual acuity was 20/20 OD, OS. Dilated fundus examination (DFE) of the left eye revealed a peripheral large inferotemporal retinal lesion with overlying vascular network. Corresponding feeding and draining vasculature was not clearly noted on DFE. OCT and ultrasonography was performed. The patient was referred for a retinology consult where an FA was utilized to confirm the diagnosis, delineating the exophytic growth pattern of the RCH. Anti-VEGF therapy was initiated and the patient was scheduled for radioactive plaque brachytherapy. Genetic testing and proper scans were performed to evaluate for VHLD. Conclusion: This case exemplifies an atypical exophytic retinal capillary hemangioma, which if often harder to detect funduscopically. The integration of a variety of diagnostic modalities were utilized to derive to the appropriate diagnosis; aiding in the proper treatment & management.shechtman_exophytic
Lipemia Retinalis: Case Reports and ReviewSpethJoanne Smith, OD; Lekha Abraham Samuel, OD; Jim Williamson, OD2015Lipemia retinalis presents with the characteristic appearance of creamy white retinal blood vessels. It is a bilateral finding in patients with hypertriglyceridemia and is generally noted when triglyceride levels exceed 2500 mg/dL. Patients are usually asymptomatic when they present to the eye care professional, however lipemia retinalis is associated with several serious systemic complications that require timely management. We report the case of a 59 year old Caucasian male (triglycerides 7105 mg/dL) and a 27 year old African American female (triglycerides 9743 mg/dL) with lipemia retinalis and diabetes mellitus. Fundus photography, laboratory testing and imaging results are included.speth_lipemia
Long-term optometric care of a patient following resection of pilocytic astrocytomaSteiner2015Case details a 14-year history of the role played by optometry in the care of a patient who underwent surgery, chemotherapy, and radiation to manage a pilocytic astrocytoma at age 7 years. As her tumor could not be completely removed at the initial surgery, she has had several recurrences and has needed the full scope eye and vision care over the years. Optometric care has been an important part of this patient’s rehabilitation. Vision therapy, maximization of visual acuity, detection of new-onset nystagmus, and finding solutions for muscle palsies and severe dry eye have all helped this patient retain the ability to stay engaged in school and avocational activities. Important of basic neurological testing and communication with other providers will be discussed.steiner_pilocytic
Use of Fresnel Prism to Manage Visual Field Loss from Pituitary MacroadenomaSukhijaAndrea Zimmerman, OD, FAAO2015Background: Pituitary macroadenomas can cause a variety of symptoms including diplopia, color vision changes, visual acuity loss, and visual field loss. These symptoms are typically not reversible and can be debilitating for patients. Widely accepted therapies such as use of prism, tints, and magnifiers can be applied. Case Report: A 40 year old Caucasian male s/p pituitary macroadenoma removal complains of difficulty with mobility as he bumps into peripheral objects. The patient has a bitemporal hemianopsia and severely reduced acuity in each eye. With the use of bitemporal base out Fresnel prism and orientation and mobility training, the patient reports increased spatial awareness and more confidence with ambulating independently. Conclusion: The use of Fresnel prism to increase spatial awareness is a common therapy to help patients with visual field loss. Coupled with orientation and mobility training, Fresnel prism can greatly improve the ability of these patients to travel independently and ultimately improve their quality of life.sukhija_fresnel
Does Trans-Synaptic Degeneration Exist?TorbitBrad Sutton, Anna Bedwell, Debra McConnaha2015Controversy exists over whether degeneration occurs across neural synapses in the visual pathway. Retinal nerve fiber loss in congenital hemianopsia is well documented. However, acquired lesions (occurring in late childhood or as an adult) rarely show funduscopic abnormalities. Therefore, it remains controversial and unproven that trans-synaptic retrograde degeneration occurs from acquired posterior visual pathway lesions. Multiple cases will be presented that demonstrate how a cerebral vascular accident can result in a reduction in macular ganglion cell complex (GCC) thickness on spectral domain optical coherence tomography (SD-OCT). The pattern of macular ganglion cell loss seen in these stroke patients does correlate to their visual field defects, suggesting trans-synaptic retrograde degeneration is occurring in the visual pathway. The ganglion cell analysis (GCA) on the SD-OCT is capable of showing trans-synaptic retrograde retinal ganglion cell loss that corresponds to visual field loss. These case reports will include visual field printouts, SD-OCT RNFL and ganglion cell analyses, and fundus photographs.torbit_degeneration
Amped up on APMPPETrafton2015Acute Posterior Multifocal Placoid Pigment Epitheliopathy (APMPPE) is a bilateral inflammatory disease affecting the retinal pigment epithelium and outer retina in predominantly young adults in their second to third decade of life. APMPPE is considered to be rare and is classically recognized as one of the few "white dot syndromes". The following case report details the evaluation and management of an institutionalized patient with APMPPE.trafton_ampedup
Bilateral Dacryoadenitis Leading to Diagnosis of SarcoidosisTuongDaniel G. Fuller, OD, William Edmondson, OD2015SH, 49 yo African-American female, presented with bilateral swelling of the lacrimal glands towards the end of her treatment for a sinusitis. Suspicious of inflammation secondary to MRSA, clindamycin was prescribed. With little improvement over a two week period, further testing was indicated with a suspicion of sarcoidosis. Computed tomography (CT) scans of the chest revealed lymphadenopathy with granulomatous nodules perilympatic which are consistent with sarcoidosis.tuong_bilateral
Ocular Ischemic Syndrome (OIS): When a little is not enoughTylerAlexandra M. Espejo, OD, FAAO2015A 57 YO white male with diabetes and hypertension presented with recent complaints of decrease in vision OU and tinnitus. BCVA was 20/60 OD and OS with peripheral retinal hemorrhages seen OU. The patient was referred immediately for carotid doppler, serology and CT scan which revealed 100% blockage of the left internal carotid and reduced flow on the right with concurrent frontal lobe damage. Further evaluations demonstrated significant restriction of visual field OD and OS, consistent with diffuse retinal ischemia. This case illustrates complications for visual acuity and visual field with Ocular Ischemic Syndrome. A correct diagnosis and proper referral are essential to save the patient’s life and preserve vision.tyler_ois
Adjunctive treatment strategies with aggressive management of chronic ocular graft-versus-host diseaseWongNina T. Tran, OD, and Jennifer L. Monarrez, OD2015A 60-year-old Hispanic male developed chronic ocular graft-versus-host disease (GVHD) after allogeneic bone marrow transplant (BMT) for acute myeloid leukemia (AML). Severe keratoconjunctivitis sicca (KCS) caused corneal filaments, recurrent erosions, and ulceration. Newer adjunctive treatment options such as an amniotic membrane ProKera lens is discussed.wong_graft
Clinical Evaluation of Macular Pigment DensityWoodyChristopher Woody, Daniel Yoon, Iuliia Barner, Sandy Weber2015Numerous studies indicate that macular pigment protects the retina from oxidative damage. There is little data, however, on macular pigment levels in the general population. Macular pigment optical density (MPOD) levels were measured in 102 consecutive patients using heterochromatic flicker photometry with a Macular Metrics II Densitometer. Patients were free of any known ocular pathology. Mean MPOD levels were found to be 0.299 (range: 0-0.920). 70% of patients fell below 0.400, the level most researchers consider acceptable for macular health. Routine MPOD measurement is appropriate, to identify those at risk and provide the opportunity to educate on macular health and interventions, and to track the natural course or treatment impact.woody_pigment
Unilateral Optic Disc Edema: Differential DiagnosesAbbottJonathan Reid, O.D.2014Background: Unilateral optic disc edema can indicate pathologies with a variance of gravity. Differentials include papilledema, compressive optic neuropathies, infiltrative optic neuropathies, vasculopathic processes, infectious processes and pathologies that cause pseudo-swelling of the optic nerve head. Case Report: A 56 year-old Caucasian female presents with Type II insulin-dependent Diabetes Mellitus, diagnosed in 1996. She complains of intermittent blurred vision with her glasses for the past several years. Examination shows normal afferent function of her visual system. Fundus examination reveals mild nasal elevation of the right optic disc with associated hyperemia and moderate non-proliferative diabetic retinopathy OU. The left optic nerve is normal. A computed tomography scan of the orbits and head showed no causative pathology. Serological evaluation was noncontributory except for the presence of antinuclear antibodies and the detection of SS-A antibody suggestive of Sjogren’s disease, raising concern for an infiltrative optic neuropathy. Conclusion: Unilateral disc edema may be the presenting sign of a multitude of ophthalmic or systemic pathologies. This presentation aims to synoptically review the differential diagnoses of unilateral optic disc edema.abbott_edema
Ischemic Optic Neuropathy: A Sequela of Spinal SurgeryAhmed2014A 63 year-old female with wet age-related macular degeneration OS>OD presented with a new superior altitudinal defect and decreased vision in her right eye after spinal surgery one week prior. Clinical examination along with OCT and fundus photos confirmed a non-arteritic anterior ischemic optic neuropathy (NAION). NAION results from interrupted blood flow to the optic nerve and often leads to long-term vision loss, scotoma, and decreased visual function. Hypotension, hypovolemia, and duration of surgery are all factors during spinal surgery that can induce NAION. Incidence of NAION as a complication is 3 in 10,000 spinal surgeries. It is crucial for all relevant healthcare providers to be aware of this visually debilitating complication from spinal surgery as this procedure is becoming more prevalent.ahmed_spinal
It’s A Crisis! – A Case Report and Review of Hypertensive Crisis and Hypertensive RetinopathyAkauLisa Fanciullo, OD, FAAO2014This is a case of a 36 year old white male without medical care for several years who presented to urgent care with complaints of a 2-3 week low-grade headache and 2 weeks of ‘floaters’ in his vision. The patient’s presenting blood pressure was 218/134 with elevated creatinine and proteinuria and he was admitted to the Cardiac Care Unit (CCU) at the West Roxbury VA, Boston VA HCS. At the request of the CCU team, Optometry examined the patient bedside the next day. The patient described translucent ‘light spots’ in his vision which did not move with eye movement as well as occasional gray spots in the vision of the left eye ‘like pixels are missing on a screen.’ Dilated examination without phenylephrine revealed florid bilateral Grade 4 Hypertensive Retinopathy with arteriolar narrowing, retinal hemorrhages, cotton wool spots, exudation, macular edema, and optic nerve head swelling. There was also evidence of hypertensive choroidopathy which is observed more often in younger patients and is linked to renal dysfunction. Three days later the patient was able to undergo examination in the optometry clinic and visual field, OCT and IR images, and fundus photos were obtained. The patient has since moved across the country and has successfully established eye care at his new local VA.akau_crisis
Why Does This Kid Keep Winking at Me?AsheGlen Steele, FCOVD, FAAO2014A ten week old infant presented to Southern College of Optometry due to the right superior lid moving simultaneously with mouth movement. The child had been seen at five weeks old for the same presentation at Le Bonheur Children’s Hospital, where neurological testing was found to be normal. We diagnosed her with Marcus Gunn Jaw Winking Syndrome. Possible sequelae of this condition include, but are not limited to: binocular vision and accommodative dysfunctions and potential amblyopia of the affected eye. This case presentation will serve to help other eye care professionals to recognize and understand Marcus Gunn Jaw Winking Syndrome in the pediatric patient.ashe_marcus
Benign Or Malign: A Syndrome Of Acquired Hyperopia With Choroidal FoldsAu2014Although uncommon, acquired hyperopia with choroidal folds is frequently a benign syndrome characterized by flattening of the posterior pole in the affected eye, enlargement of the optic nerve complex and the presence of a perineural space. These traits are best observed in radiographic studies however their mechanisms remain unclear. Choroidal folds have a number of etiologies ranging from benign causes to intraorbital masses. Bilateral folds are associated with more benign ocular and orbital pathology whereas unilateral folds demonstrate more significant ocular and orbital disease. The proper workup is therefore critical in determining and managing the underlying causes. This case report outlines the diagnosis of a patient with unilateral acquired hyperopia and choroidal folds and its differentials. The subsequent workup and management will also be discussed.au_choroidal
Optometric Management of a Patient with Down syndromeBansalYin Tea, OD, FAAO2014One in every 691 babies is diagnosed with Down syndrome (Trisomy 21) at birth in the United States. Increased understanding of visual findings in patients with Down syndrome will guide the clinician toward proper treatment and long-term management. This poster will present general physical features and the current status of ocular findings in patients with Down syndrome for the following: visual acuity, refractive error, ocular health (anterior and posterior), eye movements (fixation, pursuits, and saccades), and the binocular and accommodative status. A brief description of alternate examination techniques and possible management options will be discussed. A clinical case of a 21 year female with Down syndrome will also be presented.bansal_down
Optic Nerve Head Drusen and Refractive Error: is there a Connection?BansalAnna James, OD, Deborah Amster, OD, FCOVD, FAAO2014Although limited, current literature suggests that optic nerve head drusen (ONHD) have a greater tendency to form in eyes with a small scleral canal. ONHD are often associated with shorter, hyperopic eyes, and typically result in decreased visual acuity and loss of peripheral visual field. This poster will present two clinical cases of adolescent females presenting with high hyperopia, reduced visual acuity, and visible optic nerve head drusen. Examination findings, including optical coherence tomography (OCT), B-scan ultrasound, and visual field testing will be presented. Optometric management of such cases, a literature review, as well as differential diagnoses of optic nerve head edema will also be explored.bansal_drusen
Amniotic Membrane Therapy in Severe Dry Eye SyndromeBassionKimberly Reed, OD2014A 28 year old white male presented with complaints of blur with spectacles for the past year. Notably, he reported that visual acuity was acceptable upon arising, but when wearing spectacles, deteriorated throughout the day. Visual acuity was better, and more consistent, wearing soft hydrogel contact lenses. Medical history positive for psoriasis. Medications included topical steroid creams. Family medical and ocular history non-contributory. At several visits, visual acuity varied from 20/25 to 20/100, depending upon time of day and degree of corneal staining. TBUT was immediate; tear meniscus height was non-measurable; and corneal staining presented superiorly in a whorl-like pattern, OD>OS. Neovascularization of approximately 2 mm was noted superiorly OU. Findings were consistent with severe dry eye syndrome, with possible contributory limbal stem cell deficiency. Treatment with topical steroid, cyclosporine-A, and copious artificial tears offered limited relief. A monocular trial with an amniotic membrane (Prokera Slim®, BioTisue) was initiated OD with limited initial success. The patient was next recommended for scleral contact lenses. Photographs of the insertion procedure with the Prokera Slim lens are included with a discussion of limbal stem cell deficiency and potential benefits of AMT.bassion_amniotic
Presumed Chloroquine Maculopathy From Malaria TreatmentBedwell2014A 45 year old Burmese, male patient presented for his first ever eye examination. His health history was significant for HIV diagnosed one year ago. He also reported a history of malaria about 10 years prior. The patient was born and raised in Burma (now Myanmar) in Southeast Asia. Best corrected visual acuities were 20/20 in each eye. Color vision was mildly reduced identifying 8/10 HRR plates OD, OS. Humphrey 10-2 visual fields showed nasal defects in each eye OS>OD. Dilated fundus exam showed a large, symmetrical area of pigment dropout and mottling across the maculae and into the posterior pole in each eye. Spectral domain OCT images revealed photoreceptor integrity line thinning OU consistent with the flying saucer sign. The patient’s malaria history as well as the characteristic spectral domain OCT findings supported a diagnosis of chloroquine maculopathy. This case demonstrates an example of toxicity with minimal functional vision loss in the presence of advanced fundus changes. As no treatment is warranted, yearly observation was recommended.bedwell_chloroquine
Pathological Myopia with Peter’s Anomaly; the List of Indications for the Scleral Lens ContinuesBrown2014This case profiles a 26 year-old female with a history of pathological myopia, keratoconjunctivitis sicca and unilateral Peter’s anomaly; a rare congenital anterior segment dysgenesis characterized by iridocorneal contact glaucoma and corneal opacities. Considered a “low vision” patient secondary to her profound vision loss in her affected eye, this patient’s useful vision was greatly enhanced with a mini-scleral lens following the failure of other lens options to provide a healthy or helpful alternative. In our case, a mini scleral lens outperformed a hybrid gas permeable lens and multiple soft lens options by providing superior visual quality, therapeutic benefits as well as superior comfort.brown_anomaly
Bacterial endocarditis resulting in macular-involving posterior uveitis with good visual outcomeBuchananDr. Ryan Beyer, OD, FAAO2014Bacterial endocarditis is a rare systemic infection which can lead to ocular complication including Roth spots, retinal hemorrhaging, retinal necrosis, choroidal neovascular membrane, endogenous endophthalmitis, and arterial occlusion. This case exhibits a 47 year old white male presenting with an acute central floater and reduced vision of the right eye. Patient reported sporadic visual obscuration for the past three months with increasing frequency and severity. Patient also described concomitant, intermittent symptoms of fever and body ache. Ocular examination revealed an endophytic macular lesion with surrounding hemorrhaging and acute retinal necrosis. Further work up confirmed bacterial endocarditis. Patient completed intravenous vancomycin therapy with resolution of ocular complications and resulting 20/20-2 vision.buchanan_endocarditis
Peripapillary Subretinal Neovascularization in Presumed Ocular Histoplasmosis SyndromeBurns2014Peripapillary subretinal neovascular membrane (PSRNVM) accounts for less than 10% of subretinal choroidal neovascularization in the posterior pole.1 It can be present in many ocular pathologies. The condition most commonly presents unilaterally, however, older patients have a higher prevalence of bilateral involvement. The lesions initially may be asymptomatic, nevertheless the unpredictable and the often insidious nature of the membrane has the potential of leading to severe vision loss if it reaches the subfoveal area. Almost a quarter of undiagnosed or untreated eyes with peripapillary membranes secondary to presumed ocular histoplasmosis syndrome results in visual acuities equal to or worse than 20/500.2burns_peripapillary
The Risk of Retinal Detachment in an Adult with Choroidal Coloboma involving the Optic DiscChesterDebora Lee Chen, OD, FAAO, Pia Hoenig, OD2014Ocular coloboma is a developmental anomaly caused by incomplete closure of the fetal fissure. There are several classifications of choroidal coloboma, some of which involve the optic nerve. In these cases, patients must be monitored closely as the reported incidence of retinal detachment is as high as 40%. A 70 year old male presented for an urgent eye examination complaining of a large black spot adjacent to the central vision in his left eye upon awakening. His ocular history was remarkable for a choroidal coloboma in the left eye. Dilated examination of the retinal fundus revealed a posterior vitreous detachment located at the inferior margin of the choroidal coloboma in the left eye. The fundus of the right eye was pathology free. Both eyes had uniform maculae with visible foveal reflexes. This case considers posterior vitreous detachment as protective in patients with choroidal coloboma. The occurrence of a posterior vitreous detachment at the site of the coloboma decreases the risk of retinal detachment. Classification of colobomata, updates in evaluation using optical coherence tomography, and prudent management of patients with choroidal coloboma involving the optic nerve are reviewed.chester_coloboma
An Outside-the-Box RKCheungWilliam J. Denton2014Radial Keratotomy (RK) was introduced to the U.S. in the late 1970s as the initial surgical refractive procedure to correct myopia. This technique utilizes a blade to manually apply cuts in a spoke-like pattern on the cornea, thereby flattening it and effectively reducing myopia. An unseasoned surgeon managed this patient, to whom he applied cuts in an unfortunate square fashion within the visual axis. This ‘box RK’ resulted in a visual acuity of 1/200 along with other debilitating symptoms. Many different types of contact lenses were attempted with the best visual outcome of 20/40 following a scleral lens fit. Slit lamp photography, anterior segment OCT, as well as corneal topography were used to assess and document this case.cheung_box
Prismatic Correction of Vertical Heterophoria in Traumatic Brain Injury Patients Resulting in Improved StereopsisChongPaul Vejabul O.D., Nina Tran O.D.2014Binocular vision dysfunction and more specifically acquired vertical heterophoria (VH) is a common complication of traumatic brain injury (TBI). VH is a binocular condition where the line of sight from one eye is higher than the line of sight of the other eye. Symptoms of VH can often overlap with TBI symptoms. These symptoms include headache, eye strain, dizziness, nausea, neck pain, and shoulder pain. The following poster demonstrates eight patients diagnosed with TBI with a concurrent finding of VH. Improvement was determined by subjective comfort during prism trial and objective improvement in Randot stereopsis testing. The results indicated treatment with individualized prismatic spectacle lenses to correct for VH may result in improved stereopsis and reduction in visual asthenopia. With the increasing number of veterans returning from Iraq and Afghanistan with TBI, the importance of eliciting and treating even small amounts of VH may allow for improved visual function.chong_vertical
The Complexities of Managing the Rare Multisystem Disease: Pseudoxanthoma ElasticumChronister2014Pseudoxanthoma elasticum (PXE) is a rare inherited disorder that affects the integumentary, ocular, and cardiovascular systems. It is also known as Gronblad-Strandberg syndrome. This disorder is a consequence of mutations in the ABCC6 gene. PXE is characterized by progressive calcification and fragmentation of elastic fibers in connective tissues of the skin, eye and blood vessels. Calcium deposition, specifically in Bruch’s membrane elastic tissue, can lead to angoid streaks, choroidal neovascularization and subsequent vision loss. This case report describes the management of a 67 year old male with visual impairment from macular choroidal neovascularization secondary to PXE. This patient had the characteristic skin lesions of PXE which consisted of small, yellowish bumps in a lacy cobblestone pattern. He also exhibited a prominent mental (chin) crease which is a newer sign of PXE. The presentation will include photographs of the skin and ocular findings of this patient. Also included will be a discussion of PXE as well as the complexities of managing patients with multisystem diseases.chronister_pseudoxan
30 years of acute recurrent anterior uveitis in a noncompliant patientCiampaKM Smith, OD, MS, FAAO; PA Lenihan, OD2014Anterior uveitis is an inflammation of the iris and ciliary body. Symptoms include severe pain, hyperemia and photophobia. Resolution of this urgent anterior segment disease is imperative to reduce the risk of exacerbated inflammation that may lead to irreversible vision loss. A 64 year old white male presented to the clinic with an extensive history of an acute recurrent painful red eye which he self-treated with a topical steroid historically provided by multiple emergency departments. The patient reported he had never been seen by an eye care provider for this recurrent problem. This patient was successfully treated for acute anterior uveitis and, given his self-reported history of recurrence, a systemic workup was conducted to identify a potential underlying etiology. The patient was found to be HLA-B27 positive. This case demonstrates the importance of timely and appropriate management including extensive case history and systemic work-up when indicated in order to maximize visual potential and systemic health.ciampa_uveitis
Treatment of Corneal Erosion with Serum Tears in a Patient with Ocular Cicatricial PemphigoidCoitThomas Riley, OD, FAAO2014I. A 65-year old Caucasian male presented for a 1-week post-op phaco + PCIOL OD appointment. His complaint was that it felt like eyelashes were poking the right eye. The pain was so bad that he went to the ER over the weekend. Pertinent ocular history includes ocular cicatricial pemphigoid. II.Pertinent clinical exam findings revealed a large corneal epithelial defect involving the inferior cornea (~6mm horizontal x ~3mm vertical). III.Based on clinical findings, we diagnosed this patient with a corneal erosion. Differential diagnosis includes corneal abrasion, corneal laceration and chemical burn. IV.Initial treatment was preservative free artificial tears q1hr, prednisolone 4x/day, ofloxacin qid, doxycycline 50mg bid po and a bandage contact lens. After 3 weeks with minimal improvement a new treatment plan was initiated. He was to continue the doxycycline, ofloxacin was decreased to 2x/day, prednisolone was discontinued and serum tears started q2hrs. After 2 week the erosion was completely resolved. V. The literature reports few cases in which a corneal erosion is treated with a bandage contact lens and serum tears. This treatment modality is something to consider when other treatments methods are not successful.coit_pemphigoid
THE EFFECTS OF GLIOBLASTOMA MULTIFORME AND THE ADDITION OF ELI PELI PRISM POST TUMOR RESECTIONCoxBethany Martinez, O.D.2014Glioblastoma multiforme is a highly complex disease that requires an even more complex form of management. While research for prolonged remission is ongoing, the median survival rate has remained unchanged at about one year. Treatment can consist of palliative care, chemotherapy, radiation, tumor resection, or various other clinical trials, however, it is individually catered. This article will discuss the ocular effects of glioblastoma multiforme and the visual field deficits that can result, including the placement of Eli Peli prism to eyeglasses in order to aid in patient mobility and provide awareness of obstacles that may otherwise go unnoticed.cox_glioblastoma
Accidental Cyanoacrylate Instillation in the Eye: A Case ReportDahlDr. Nathan Tuttle2014The makers of cyanoacrylate products, or super glue, have made the unfortunate decision to house their products in containers that look similar to ophthalmic medications. This can become particular problematic for patients with poor vision and can lead to very painful corneal injuries that require significant recovery time. Large abrasions related to super glue in the eyes, or other large abrasion as well, can induce significant amounts of astigmatism which may resolve with time. This case details a patient with a 10-11 mm corneal abrasion and significant induced astigmatism after epithelial recovery secondary to cyanoacrylate instillation in the eye.dahl_cyanoacrylate
Improvement in Vitreomacular Traction with Jetrea Ocriplasmin InjectionDangJennifer Monarrez, O.D.2014Vitreomacular adhesion can lead to symptomatic traction and possibly a macular hole. Jetrea is the first drug approved to treat vitreomacular adhesion and is composed of ocriplasmin, a proteolytic enzyme that breaks down fibronectin and laminin at the vitreoretinal interface. This new intravitreal injection is a non-surgical alternative for vitrectomy. Studies show that Jetrea resolved vitreomacular traction and closed macular holes better than placebo intravitreal injections. There is also a higher rate of vision improvement in those treated with Jetrea. A 73 year old Caucasian male presented with a significant decrease in visual acuity secondary to vitreomacular traction and a macular hole in his left eye. This patient received an injection of Jetrea and returned for a six week follow-up appointment with improved visual acuity, decreased vitreal traction, and an overall decrease in macular thickening. Macular OCT scans were used to visualize the improvements in the patient’s condition. Full resolution of the macular hole was not achieved however. We are unable to determine if the traction would have decreased regardless of treatment, but clinical study results and the improvement in this patient’s condition after Jetrea suggest that ocriplasmin injection is a safe alternative to treat symptomatic vitreomacular adhesion.dang_jetrea
“Hard Blink” as Presenting Sign in Tic Disorder: 3 Case ReviewsDasinger2014Three boys between the ages of 6 and 10 presented with the chief complaint of “hard blinking.” Their parents all described similar incidents involving a recent onset of involuntary forceful blinking. All patients denied any intentional change in behavior. It is estimated that up to 20% of children may experience a tic disorder during early school years. Tic disorders can range from transient tics to the most severe form being Tourette’s syndrome. Transient tic disorders usually resolve within a year. Appropriate referral for psychological and possibly neurological evaluations should be considered. If optometrists are aware of the presenting symptoms, they can be on the forefront of diagnosis and an integral team member in the management of tic disorders.dasinger_tic
The Essential Role of Neuroimaging in diagnosing Optic NeuropathyDemerittRuchi Jadeja, BS2014demeritt_neuroimaging
Serous retinal detachment as the initial sign of metastatic bladder cancerDi MattinaAndrew Di Mattina, Raymond Chew2014A 77 year old patient presented with the complaint of pain and decreased inferior vision in his left eye for one week. His medical hoistory was significant for bladder cancer, which he believed to be well controlled. His examination was significant for a macular off serous retinal detachment. He was referred to a retinal specialist who found focal choroiditis suspicious for metastasis and recommended investigation to look for a primary tumor. A chest CT was run and he was found to have a left pleural effusion. Thorocentesis revealed metastatic bladder cancer. The patient expired two months after his initial examination.dimattina_serous
Non-secreting Pituitary Adenoma: A case reportDitmetaroj2014Pituitary adenomas are common, benign tumors of the sellar region that constitute approximately 10% of all intracranial neoplasms. These tumors are most prevalent in early adulthood and typically present with systemic effects that can include hormone imbalances, headaches, or psychiatric manifestations. Diagnosis is made with radiological imaging and surgical intervention with postoperative radiotherapy are commonplace in management. This case presents a 46 year old African American male with a large, non-secreting pituitary adenoma with no systemic side effects. The patient was referred for a glaucoma evaluation secondary to gross visual field deficits and reported no related systemic complications. Examination revealed good ophthalmic health and visual field testing yielded bilateral inferior and temporal visual field loss respecting the horizontal and vertical midlines. Subsequent MRI scans revealed a large sellar mass causing upward displacement of the optic chiasm and causing an early effect on the posterior frontal lobe and the adjacent structures of the cavernous sinus. This poster details an atypical pituitary adenoma lacking systemic side effects and typical findings in an ophthalmic setting. Visual field differentiation, subsequent diagnostic testing and treatment modalities in management of pituitary tumors are also discussed.ditmetaroj_pituitary
Rare Calcific Deposition Along Meibomian Gland Orifices in Chronic Renal DiseaseElderJames Williamson, O.D.2014Chronic kidney disease has numerous well documented corneal and conjunctival manifestations including band keratopathy, conjunctival injection, and dry eyes. However, this case will describe a rare condition in which asymptomatic calcific deposits have formed along the meibomian gland orifices in a patient with chronic renal disease and hyperparathyroidism. This patient’s case and accompanying external eyelid photos will be discussed. An overview of chronic kidney disease will also be presented with emphasis on ophthalmic complications.elder_calcium
Oh My! Myositis of the Eye: A Case ReportEngstromNicole Minutolo, OD2014Idiopathic orbital inflammation (IOI) is a rare inflammatory disorder that affects soft tissues within the orbit. A 29-year-old African American male presented to WJB Dorn VA Medical Center with acute onset of retrobulbar pain in the right eye and horizontal binocular diplopia. Objective testing revealed restrictions in extraocular movements of the right eye in all gazes with positive forced duction testing. Before initiating oral prednisone treatment, Computed Tomography (CT) was used to confirm inflammation of the muscle belly and tendon insertion of the lateral, medial and superior recti. Magnetic Resonance Imaging (MRI) was later performed. Serologic testing was ordered to rule out differentials: most commonly thyroid orbitopathy and lymphoproliferative disorders. The patient experienced prompt resolution of symptoms after initiation of treatment with oral prednisone. Ocular myositis, a subgroup of IOI, is clinically defined as non-granulomatous inflammation of the extraocular muscles causing mechanical restriction of ocular motility without an underlying systemic etiology. MRI is primarily utilized to visualize inflammation of the muscle belly and tendon insertion as a characteristic of ocular myositis. Serologic testing, MRI and CT scans were used to rule out differentials, as IOI is a relatively benign condition but a diagnosis of exclusion.engstrom_myositis
Juvenile North Carolina Macular Dystrophy: The Role of Vision Rehabilitation in the Pediatric PopulationEsposito2014North Carolina Macular Dystrophy (NCMD) is a genetic condition that can cause decreased vision in the pediatric population. A 10 year old White male was referred for a low vision evaluation diagnosed with NCMD. He presented with visual complaints of difficulty seeing the chalkboard and viewing his textbooks. The mother was concerned about him succeeding in school with his visual impairment. This case report will discuss NCMD, as well as, visual rehabilitation strategies to help the pediatric population manage their vision loss, improve their functional vision and quality of lifeesposito_north
Severe complications of chronic retinal ischemia: a case reportFisherKritika Salooja2014Secondary angle closure glaucoma can cause profound visual loss in patients with various predisposing conditions. Our case involves a 66-year-old male with a history of cardiovascular disease, insulin dependent diabetes, and unilateral progressive vision loss. Initial examination revealed an afferent pupillary defect and an intraocular pressure of 41mmHg of the right eye. Gonioscopy confirmed a completely occluded angle secondary to neovascularization of the angle and iris. There was no neovascularization of the disc or peripheral retina. Prompt glaucoma treatment was initiated. The diagnosis of this clinical case is neovascular glaucoma secondary to severe and longstanding non proliferative diabetic disease with presumed ocular ischemic syndrome. We will review the course of chronic retinal ischemia and resultant sequelae.fisher_retina
Optometrists' Role in Co-management of Guillain-Barre SyndromeFurr2014Guillain-Barré syndrome (GBS) is characterized by acute neuromuscular paralysis that usually resolves by six months or can be fatal in 3-10% of patients. Usually preceded by a recent infection, an immune response induces peripheral polyneuropathy comprised of neuromotor weakness, sensory involvement, or other neurophysiological characteristics. There are multiple subtypes that vary by prognosis and extent of neurological involvement, including internal and external ophthalmoplegia. Typical presentation includes pain and symmetric limb weakness further complicated by respiratory or cranial nerve involvement. Studies have shown that facial nerve palsy can be found in 70% of cases. Ophthalmoplegia and ptosis are more rare findings in about 5%. A 61 year Caucasian male presented with complaint of constant diplopia for three days and was diagnosed with a right 6th cranial nerve palsy initially identified as ischemic due to vasculopathic risk factors. All other cranial nerves were intact, and no other neurological symptoms were noted except garbled speech worse than baseline. MRI imaging and labs including ESR, CRP, CBC, Ach receptor antibodies, and TSH were all unremarkable. Four days later he presented with worsened garbled speech, new onset left facial nerve palsy with lower lid ectropion, dysphagia, and tongue deviation to the right. He was hospitalized and diagnosed with acute inflammatory demyelinating polyneuropathy (AIDP), common subtype of Guillain-Barré Syndrome. This poster illustrates the crucial role of optometrists in recognizing and being a part of the multi-disciplinary care necessary in the management of Guillain-Barré Syndrome.furr_guillainbarre
Sphenoidal Meningioma: A Case Report and ReviewGaffneyAlanna O'Keefe O.D.2014Meningiomas represent the most frequently encountered benign intracranial neoplasia. These tumors occur most often among females over the age of 50. It is estimated that only 20% of meningiomas will involve the sphenoid. Orbital meningiomas classically present with proptosis. Depending on the tumor location and the degree of optic nerve involvement, other findings can include: optociliary shunt vessels, reduced visual acuity or visual field defects. Herein, we report a case of sphenoidal meningioma involving both optic nerves in a 56 year-old male without proptosis.gaffney_meningioma
Charcot-Marie-Tooth Disease: shifting a life with prismGoundenMaria J. Mandese, O.D., F.A.A.O2014Charcot-Marie-Tooth (CMT) disease is the most common hereditary motor sensory neuropathy affecting 1 in 2,500 individuals worldwide. Patients will experience muscle weakness, bone deformities, and sensory loss. While the disease is rarely life threatening it can be extremely debilitating due to the demyelinating effect on the peripheral nerves. These patients can present with ocular complication such as optic atrophy, accommodative dysfunction, tonic pupils and diplopia. A 64 year old male with CMT presents with severe imbalanced gait and complaints of distance diagonal diplopia increasing with anxiety or agitation. Video documentation is provided of characteristics of CMT, evaluation, management, and improvement of gait after correction of vertical and horizontal diplopia.gounden_charcot
Double TroubleHaynesLisbet Abrante, Marlon Demeritt, Julie Rodman2014A fifty-seven year old white female presents with a previous diagnosis of combined central retinal vein occlusion (CRVO) and central retinal artery occlusion (CRAO). Upon examination, her fundus revealed a typical chronic CRAO- featureless retinal appearance, pale optic nerve head, and severe vision loss. Due to the distinct pattern of OCT images found in CRAO, an OCT was obtained as well. The OCT image will differ depending on the chronicity of the occlusion. Acute cases will exhibit increased reflectivity and thickness in the inner retina and a coinciding decrease in reflectivity in the outer retinal layers and RPE/Bruchs complex. Conversely, as the CRAO becomes more chronic, a decrease in reflectivity and thickness can be observed in the inner retinal layers with a coinciding increase in reflectivity in the outer retina and RPE/Bruchs complex. Generalized atrophy of the neurosensory retina is indicative of a long-standing CRAO. OCT is not only useful in the diagnosis of CRAO, by also in identifying the maturity of the disease. Based on the OCT imaging of our patient, it demonstrated the condition was chronic.haynes_double
Under the Dome –Scleral Lens Use in Neurotrophic KeratopathyHellerNatasha Krzyanowski2014Neurotrophic keratopathy occurs when there is corneal anesthesia following damage to the trigeminal nerve, complications from systemic diseases such as diabetes, or from herpetic keratitis. It presents as a non-healing epithelial defect with the underlying stroma appearing grey, opaque, and it may develop thinning or melting. A 64 year old white male was referred by the cornea department to the contact lens clinic for a scleral lens fitting for a non-healing HSV neurotrophic corneal ulcer. The ulcer had failed to resolve with prior treatments of oral and topical antivirals, PROKERA amniotic membrane, bandage contact lenses, and patching. A scleral lens was successfully fit with good comfort. In this case the therapeutic benefit of the scleral lens tear reservoir outweighs the risk of contact lens complications. Photos and OCT are included.heller_dome
Bilateral Optic Atrophy with Significant Vision Loss Secondary to Hypertrophic Pachymeningitis: A Case ReportHenry2014This report describes the presentation, treatment, and follow-up of a patient with hypertrophic pachymeningitis possibly secondary to sarcoidosis. This patient presented with acuities of 20/20 OD, OS and bilateral papilledema, which over twelve years developed into bilateral optic atrophy with acuities reduced to 5/600 OD, OS. A rare condition characterized by chronic inflammation and thickening of the dura mater, hypertrophic pachymeningitis causes optic atrophy due to increased intracranial pressure and compression. Due to the relatively low number of patients diagnosed with this condition, more research is needed to determine the etiology and management of this condition. Differential diagnosis, lab testing, prognosis, and management with low vision devices will be discussed.henry_pachymeningitis
Essentially Monocular Patient Achieves Binocularity With Scleral Contact Lens Fit After Overcoming Initial DiplopiaHenryDr. William Denton2014A 60-year-old male patient presented to the optometry clinic with essentially monocular vision, unable to fuse images with both eyes secondary to trauma to his left eye that left him aphakic and with a visually obstructing corneal scar. Fully spectacle corrected vision could not be fused secondary to aniseikonia so the patient had been using balanced lenses, allowing functional vision in his right eye only. Corneal irregularity due to the scarring created additional problems for correcting refractive error. After 37 years of only using his right eye to see, a scleral contact lens fit allowed the patient to see binocularly. Although the patient experienced some distance diplopia in the first few months of scleral lens wear while adjusting to using both eyes together, he noticed a significant increase in vision and quality of life.henry_sclerals
Geno-type Directed Nutriceutical treatment of Age-Related Macular DegenerationHitchmothAlysa Fassano2014This case study demonstrates the importance of combining several clinical elements before developing a treatment plan that relies solely on broadly summarized scientific evidence. Pharmacogenetic analysis, dietary history, medical history, macular pigment optical density (MPOD), Multi-spectral Imaging (MSI), fundus exam, and scientific evidence such as the Age-Related Macular Degeneration Studies (AREDS I and II), were used to determine the best treatment for this patient. The recently published data subset from The Age-Related Eye Disease Study (AREDS) demonstrated that supplementation (Ophthalmology 2013), with certain components of the original (high-dose anti-oxidants plus zinc) AREDS formulation may be beneficial or deleterious based on a patient’s genetic profile, and that 49% of the patients studied would have derived more benefit from a treatment regimen other than the original AREDS formulation. Data analysis revealed that genotype-directed therapy of the AREDS study population would have more than doubled the reduction in AMD progression rate compared with treatment with the AREDS formulation for patients with moderate to severe disease in at least one eye. The AREDS II study, in part, reveals that lutein and zeazanthin significantly reduced the risk for progression to severe disease compared to beta-carotene and that omega-3 fatty acid supplementation may have no affect for patients with advanced disease. This case supports a holistic, individualize approach in the care of patients with AMD.hitchmoth_imaging
North Carolina Macular Dystrophy in North Carolina - A Home Team DisadvantageHoffman2014A 22 year-old Indian female college student presented to the Low Vision Clinic as a referral from her Retina Specialist for a low vision evaluation, as she was having difficulty reading both at home and in school, seeing the computer, and the board at school. She was also wondering if she had enough vision to be legal to drive. Her ocular history was significant for NC macular dystrophy with bilateral central macular colobomas OD>OS. Her medical history was unremarkable. This case report will discuss the different types of macular dystrophies as well as the benefit of low vision rehabilitation for those patients with more advanced vision loss.hoffman_macular
Papilledema in a Patient with a Malfunctioning Ventriculoperitoneal ShuntHolmes2014Background: Papilledema is characterized by bilateral swollen, hyperemic discs. Blood vessels are often obscured and/or tortuous. Papilledema is associated with an increase in intracranial pressure. Headaches, nausea, vomiting, dizziness, and sometimes a decrease in visual acuity are symptoms often seen in these patients. Case Summary: A 46 year old male reported to the eye clinic with symptoms of constant blurry vision which had progressed over the course of the summer. The patient had an extensive medical history including spinal bifida with hydrocephalus and a ventriculperitoneal shunt placed 20+ years ago. The patient was found to have a BCVA of 20/30 OD and 20/50+ OS. Pupils and extraocular muscle movements were within normal limits, and no afferent pupillary defect was evident. Upon dilation, the patient was found to have disc edema OU along with tortuous vessels. Conclusion: The patient was immediately referred to neurosurgery where he underwent a same day exploratory procedure to evaluate the status of his ventriculoperitoneal shunt. The shunt was found to be malfunctioning, and the patient underwent a procedure the following day to remove the complete cerebrospinal fluid shunt system and to replace it with a new system. One month later, the patient’s vision returned to baseline.holmes_papilledema
Acquired Brain Injury: Management of Symptoms Post-Cerebral Vascular AccidentJanMimi Pham O.D., Emetisse Yazdanmehr2014Acquired brain injury (ABI) is defined as brain injuries all types of traumatic brain injury and also brain injuries caused after birth by cerebral vascular accidents (commonly known as stroke), and loss of oxygen to the brain (hypoxic brain injury). According to reserach, a majority of individuals with either TBI or ABI manifested an oculomotor dysfunction. Of those sustaining CVA, 86.7% manifested an oculomotor dysfunction such as disorders of accommodation, version, vergence, strabismus, and cranial nerve palsy(1). In this case study, a cerebral vascular accident (CVA) results in a left homonymous hemianopsia and poor binocular visual function. The patient’s ocular symptoms are managed with a combination of visual skills training and prescribed prism glasses. Additionally, loss of independence and reduction in activities of daily living function motivates the patient to pursue living skills and mobility training. In this case of sudden onset vision loss and acquired brain injury, sensations of fear and depression require careful consideration of additional mental care. 1. Ciuffreda, Kenneth J., Neera Kapoor, Daniella Rutner, Irwin B. Suchoff, M.e. Han, and Shoshana Craig. "Occurrence of Oculomotor Dysfunctions in Acquired Brain Injury: A Retrospective Analysis." Optometry - Journal of the American Optometric Association 78.4 (2007): 155-61.jan_brain
Traumatic Optic Neuropathy in a Monocular PatientJohns2014Traumatic optic neuropathy (TON) is a devastating complication that can occur in as many as 2% of patients with closed head trauma. The diagnosis of traumatic optic neuropathy requires a careful consideration of differential diagnoses. There is debate on the treatment of TON with the options of high dose corticosteroids, optic nerve decompression and observation. A 52 year old male presented to our clinic with sudden left eye vision loss after reportedly falling off of a step and hitting his head. He had a complicated ocular history including advanced right eye phthisis. Records documented past left eye 20/20 vision compared to light perception at this presentation. Over four months, left eye acuity improved to 20/400 with development of severe optic nerve pallor.johns_traumatic
A Tale of Two Diseases: Mixed Mechanism Macular EdemaJonesEdward Chu, OD, FAAO2014Vitreomacular traction (VMT) and diabetic macular edema (DME) are both common conditions which can cause loss of central vision. Less frequently, however, do these two conditions co-exist and present simultaneously in a patient. We will present a case of a 61 year old being followed for moderate nonproliferative diabetic retinopathy and vitreomacular traction OU. The patient had no macular edema from VMT or DME at his exam 6 months prior. Retinal examination and imaging revealed exudates associated with thickening within 500 microns of the fovea as well as persistent VMT. We will compare the management of VMT to DME and review the literature on treatment when both present together.jones_two
Low Vision Rehabilitation of Age-Related Macular DegenerationKaminoSwati Modi, OD, FAAO, Nicole Hooper, OD2014A 99-year old Caucasian female with advanced age-related macular degeneration presented for an initial low vision evaluation. She was noted to have a decline in vision, and was diagnosed with an active choroidal neovascular membrane. The patient’s primary goal for the evaluation was reading: this goal was addressed through electronic magnification. These devices not only provide enhanced contrast, but also variable magnification, which is especially important for patients with unstable ocular health. This case will provide an overview of the management of patients with macular degeneration, with emphasis on low vision rehabilitation. Topics discussed include selecting appropriate low vision aids for near goals, contrast enhancement, and eccentric viewing training.kamino_amd
Zoster Gone WildKaramchandani2014Herpes Zoster Opthalmicus occurs when the varicella-zoster virus is reactivated in the ophthalmic division of the trigeminal nerve. It presents as a painful dermatomal rash and damages the eye and surrounding structures by secondary perineural and intraneural inflammation of sensory nerves. Most patients with herpes zoster opthalmicus present with a vesicular rash distributed according to the affected dermatome. Ocular manifestations typically include upper eyelid involvement, conjunctival involvement, scleral and episcleral involvement, corneal complications, and even an anterior chamber inflammation. Treatment for Herpes Zoster Opthalmicus include Acyclovir, Valcyclovir, and Famcyclovir. But what happens when symptoms and findings worsen after initiation of antivirals? What if there is significant edema in addition to the vesicles? Or lower facial swelling where the ophthalmic division of the trigeminal nerve isn’t present. What does it mean when the opposite side of the face becomes edematous? These are the questions that were asked in this case of a patient who initially presented with a tremendous case of Herpes Zoster Ophthalmicus, whose findings only seemed to worsen after therapy.karamchandani_zoster
Unusual Case of Choroidal FoldsKaramchandani2014Choroidal folds can be associated with a number of pathological conditions, including but not limited to, hypotony, retinal detachment, central serous chorioretinopathy, neovascular membranes, choroidal nevi or tumors, retrobulbar mass, papilloedema, thyroid orbitopathy, and postoperative conditions. It is important to determine the etiology of the choroidal folds in order to properly treat the underlying condition in an adequate amount of time. A detailed history, vision, and testing of extraocular muscles will add clues to aid in finding the cause of the choroidal folds. This unusual case demonstrates the presentation of a patient with Mantle cell lymphoma, with nonspecific complaints, which eventually led to a diagnosis of infiltrative orbitopathy and optic neuropathy.karamchandani_chorioretinal
Decompensating Fourth Nerve Palsy Exacerbated by Monovision Contact LensesKarst Morris2014A 58 year-old white male presented to the clinic reporting vertical and horizontal diplopia that had become more frequent over the past three months. He presented in his habitual correction for the past 7 years: a toric contact lens OD, multifocal contact lens OS. BCVA was 20/20 OD, 20/25 OS, and 20/20 OU at distance and near. Cover test showed a right exotropia with hyper component; Parks Three Step test isolated a right fourth nerve palsy. Correction with progressive spectacles or multifocal contacts OU allow fusion with only rare moments of diplopia late in the evening. Re-fitting into modified monovision contacts induces instant diplopia.morris_fourth
Ocular manifestation of YawsKim2014While most medical practitioners in the United States are familiar with syphilis (Treponema pallidum pallidum) to the point where the genus T. pallidum is eponymous with the condition, several subspecies of T. pallidum exist around the world. I present a case where the patient presented initially with a bilateral granulomatous iritis, and blood work was performed. The testing revealed positive Fluorescent Treponemal Antibody Absorption (FTA-ABS) and Rapid Plasma Reagin (RPR) results which led to an initial diagnosis of syphilis as the underlying causative agent for the iritis. However, upon further questioning, she admitted that she had been infected in the past by T. pallidum pertenue, a subspecies which causes a chronic infection known as yaws that is endemic to children in rural population in tropical climates (e.g. the Caribbean islands, parts of Latin America, India) and is non-venereal. In this patient with no other positive findings, it is concluded that the patient’s iritis is a re-manifestation of yaws and is unusual both in its recurrence and location of manifestation.kim_yaws
Auto-immune Uveitis with Secondary Glaucoma; a Case Presentation and Systemic Health ReviewKiser2014Mixed Connective Tissue Disease (MCTD) is a rare, but serious auto-immune disorder that may exhibit symptoms of lupus, scleroderma, polymyositis, and rheumatoid arthritis. Given the inflammatory nature of these diseases, it is not surprising that ocular inflammation may be found secondarily. This poster aims to educate the eye care provider on MCTD and on the challenges of treatment of associated ocular inflammation. A clinical case of unilateral uveitic glaucoma secondary to MCTD will reinforce these concepts. Optic nerve and anterior segment photos, OCT, Humphrey visual field, and a review of usage and interpretation of serological testing will aid in presenting this case. Other discussion will include surgical options for treatment and visual outcomes of uveitic glaucoma.kiser_uveitis
Insane Use of a MembraneKrzyanowski2014A 75 year old male presented with painless, gradually decreasing vision over three weeks in his better seeing eye. Upon examination, a dendritic-like form with a small epithelial defect was found on his right cornea. A diagnosis of herpes simplex keratitis was made based on clinical presentation and case history. This ubiquitous virus continues to pose a challenge to identify and manage due to its multiple corneal manifestations and the chronic ocular sequelae it may cause. This case study presents a patient with quiescent disease for ten years, reactivation of live virus, and resultant neurotrophic keratitis. To protect his better seeing eye while healing, a relatively new device to optometry was used in-office: the Prokera amniotic membrane. This biological bandage is a useful tool available to optometrists to protect the ocular surface, while allowing for reepithelialization.krzyanowski_insane
Acute Syphilitic Posterior Placoid Chorioretinopathy (ASPPC) in a HIV-infected patientLeThanh Le OD, Patrick O’Connor MD, Dipti Singh OD MPH2014The incidence of syphilis is currently rising and appears to be a re-emergence with the HIV pandemic. We report a case of a 45-year-old Caucasian male with Human Immunodeficiency Virus (HIV), who presented with a one week history of blurry vision and right-sided fronto-temporal headache. Ocular examination revealed acute bilateral posterior chorioretinitis thought initially to be necrotizing herpetic retinitis. A serum Rapid Plasma Reagin (RPR) performed several months before presentation was negative and the patient was started on oral Acyclovir empirically. Repeated serum testing to rule out syphilis was positive. Cerebrospinal fluid VDRL were also positive confirming neurosyphilis. A diagnosis of syphilitic posterior placoid chorioretinitis was made and the patient was successfully treated with intravenous (IV) Penicillin (PCN) G. Although posterior placoid chorioretinitis is a rare ocular manifestation of syphilis, this case highlights the importance of clinical awareness in HIV and Syphilis co-infection.le_neurosyphilis
It’s not your typical headache!LePatrick O’Connor MD, Dipti Singh OD2014Acute invasive rhinocerebral zygomycosis, also known as mucormycosis, is a fungal infection commonly caused by Rhizopus species. It occurs in immunocompromised individuals who have AIDS, leukemia, uncontrolled diabetes mellitus, and patients on immunosuppressive therapy. Common symptoms are fever, headaches, nasal congestion, unilateral facial pain, epistaxis, visual disturbance, and lethargy. Typical eye presentations are proptosis, periorbital cellulitis, and loss of extraocular muscle movement. We present a 66 year-old uncontrolled diabetic with severe retrobulbar pain and sudden visual loss, who was initially misdiagnosed with Giant Cell Arteritis. Further evaluation revealed rhinocerebral zygomycosis involving the sphenoid sinus. This was confirmed by positive smear and culture of Rhizopus species from the sinus and patient’s symptoms improved with antifungal treatment. Sphenoid sinusitis is an unusual site of zygomycosis because no drainage is presented making the diagnoses hard without imaging. Although rare, acute invasive rhinocerebral zygomycosis should always be considered in any uncontrolled diabetic or immunosuppressed patient with acute headache and visual loss.le_atypical
Vitamin A Deficiency and Nyctalopia in a patient with Chronic PancreatitisLeeNina Tran, O.D., Jennifer Monarrez, O.D.2014Vitamin A deficiency and resulting progressive night blindness are common in the developing world. In developed countries, it is attributed to alimentary malabsorption associated with chronic systemic conditions of the liver or pancreas, inflammatory bowel disease, cystic fibrosis. Bariatric surgery for obesity has also been shown to cause vitamin deficiency. A patient with a history of chronic pancreatitis presents with nyctalopia due to malabsorption of vitamin A. As serum vitamin A levels were found to be low on laboratory testing, vitamin supplementation is initiated to improve retinal photoreceptor function and reduce symptoms of night blindness. Electroretinogram testing reveals decreased rod function with borderline cone response to stimuli, consistent with complaints of night blindness. Along with symptoms of nyctalopia, the patient also displays early bitot spots and xerophthalmia from destruction of conjunctival goblet cells, which require vitamin A to maintain their integrity. Characteristic yellow-white retinal pigment epithelium lesions are observed in the posterior pole, which are expected to resolve with vitamin A supplementation. With appropriate treatment , it is expected that symptoms of nyctalopia will be reduced and repeat electroretinogram testing should demonstrate improved rod function.lee_vitamin
Topical nepafenac ophthalmic suspension and the resolution of central serous chorioretinopathy: a case reportLi2014Central serous chorioretinopathy (CSCR) is an idiopathic condition typically occurring in men aged 25 to 50 years old and may be associated with increased levels of endogenous or exogenous cortisol. Contemporary treatment modalities include clinical observation and lifestyle modification, discontinuation of steroids or surgical interventions. A 46 year-old Asian male presented with complaints of central blurred vision in his left eye of 3 months duration, and in his right eye since the previous evening. This was his first eye exam. His medical history was unremarkable except for systemic hypertension for which he recently started taking lisinopril. A macular OCT scan supported the diagnosis of CSCR. The patient was counselled to reduce stress. Nevanac (nepafenac ophthalmic suspension 0.1%, Alcon) was initiated bid. At the one week follow-up, the patient’s visual acuity, visual symptoms and fundus appearance were all significantly improved. At the two week follow-up, OCT showed almost complete restoration of macular anatomy, and visual acuity of 20/20 OD, OS after 3 weeks. This case report demonstrates the use of a topical NSAID augmenting resolution of structure and function in CSCR. Additional studies are needed to explore this novel treatment modality.li_nepafenac
Managing Diplopia of a TBI Patient with Cranial Nerve IV PalsyLin2014A 25 year-old Hispanic male veteran presented with a chief complaint of diplopia. The patient history included multiple TBIs between 2007 and 2011 from IEDs, mortar rounds, and boxing concussions. Double vision was first noticed in 2010. Strabismus surgery in 2011 reduced but did not resolve the diplopia. In order to reduce or eliminate the diplopia, the patient adopted a chin down head posture or closed one eye, especially during near work. Other symptoms included daily headaches, memory problems, and difficulty sleeping. The examination in 2013 revealed a constant 2 PD Exotropia and 3 PD Hypertropia OS at distance and 14 PD Exotropia and 3 PD Hypertropia OS at near. Ocular deviation increased in downgaze. Other test results were also consistent with a CN IV palsy and history of strabismus surgery. A pair of glasses with relieving prism of 2.5 PD BD over the left eye was ordered for full-time wear. At follow-up, the patient reported no diplopia with the prism glasses at distance or near while stationary in primary gaze. Vision therapy is planned for oculomotor dysfunction and the residual diplopia noticed when moving and in secondary gazes.lin_diplopia
Blurred Lines: Weiss Ring, Swollen Disk or Vitreopapillary Traction?LooEdward Chu, OD, FAAO2014Persistent vitreopapillary traction (VPT) is a less common but significant finding associated with incomplete posterior vitreous detachment (PVD). While vitreomacular traction is diagnosed more frequently, OCT has enhanced our ability to detect persistent adhesion of the vitreopapillary interface as well. Sometimes misdiagnosed as optic nerve swelling or complete PVD, patients with VPT can present with gaze-evoked amaurosis, hemorrhages, and concomitant maculopathies. We will present a case of a 68 year old being followed for epiretinal membranes OU and complete PVD with Weiss ring OS. Detailed OCT examination revealed persistent VPT associated with an incomplete PVD OS, pseudohole OS, and lamellar hole OD. Differential diagnosis and management of VPT will be discussed.loo_vitreopapillary
Unilateral Optic Disc Edema and Neurofibromatosis Type 2LouprasongKevin Mercado OD FAAO2014A 37 year old white male presented with complaints of floaters OS for the past four months and recently noticed floaters in OD. The patient’s previous ocular history was positive for traumatic Horner’s syndrome. The examination was remarkable for anisocoria without an afferent pupillary defect and color vision was normal OD and OS. Dilated examination revealed unilateral disc edema with radial folds OD and normal OS. Visual fields revealed an enlarged blind spot corresponding with elevation on OCT-rnfl OD. A MRI was ordered and consistent with bilateral acoustic neuromas, a right frontal meningioma and a bilateral enlargement of the optic nerve sheath. The MRI supported the diagnosis of neurofibromatosis type 2. Neurofibromatosis type 2 is a rare autosomal dominant disease characterized by the development of CNS tumors. Ocular findings and complaints can result in initial diagnosis of neurofibromatosis. This case will review neurofibromatosis type 1 and 2 and the systemic and ocular associations and the differential of unilateral disc edema.louprasong_neurofibromatosis
An observational case report on the best type of Best’s Disease: ExtrafovealLyMichelle Matson, O.D.2014Best’s disease is a rare autosomal dominant macular dystrophy characterized by an accumulation of lipofuscin in the macula and central vision loss. The onset of the disease arises before or after puberty with some cases arising as late as the 5th decade. Diagnosis consists of abnormal electro-oculogram (EOG), fundus autofluorescence of lesions, fluorescein angiography showing blockage, and positive family history. We present a case of a patient with a rare form of the disease with an atypical solitary extrafoveal lesion in both eyes. This patient has a positive family history of the typical best’s disease as well as demonstrating an abnormal EOG test result.ly_best
Normal visual acuity within a ring scotoma in Foveal Sparing Geographic AtrophyLyGeoffrey Chiara, O.D.2014Age related macular degeneration represents a broad category of macular disease that causes central vision loss. This group can be divided into two categories which are the dry (atrophic) and wet (hemorrhagic) form. Geographic atrophy is the manifestation of the late stage of the dry form of the disease which presents itself in older patients. It has been known that atrophic areas of the outer retinal layers coalesce and form larger areas of atrophy that typically starts around the parafoveal retina and moves toward the center. Many patients with this condition present themselves with a ring scotoma on visual field with a corresponding decreased in central acuity. We present an interesting case of this disease with normal visual acuity inside a ring shape area of scotoma. Fundus autofluorescence, fluoresceine angiography, Heidelberg optical coherence scans and central visual field results confirm the diagnosis.ly_parafoveal
"Is that really the best that he sees? A diagnostic challengeMakatiDiana Shechtman, Eulogio Besada2014Best’s disease is a dystrophy characterized by macular “egg yolk” lesions. It appears in childhood and typically progresses through stages with associated vision loss (VL). Adult vitelliform dystrophy (AVD) is a pattern dystrophy of the RPE characterized by macular “egg yolk” lesions. Unlike Best’s, lesions are smaller with progression towards mild retinal disruption. AVD manifest signs in adulthood, with only mild to moderate VL. 52 yo male presents with an unremarkable ocular history. DFE revealed pseudohypopyon. OCT revealed hyporeflective zone with accumulation of hyperreflective material within the RPE. EOG testing confirmed the diagnosis. This case reveals a diagnostic dilemma emphasizing significance of auxiliary testing to determine the prognosis and management.makati_best
The Role of Vitreomacular Traction in Development of Macular EdemaMakhloufJulie Rodman, OD, FAAO2014Diabetic macular edema (DME) is a leading cause of vision loss in diabetes and has a variety of clinical presentations. Leaking microaneurysms can lead to focal edema, or the swelling can take on a more diffuse presentation. The etiology of diffuse DME is poorly understood, and thus treatment is more challenging. The advent of optical coherence tomography has allowed for optimal visualization of DME and has led to a better understanding of the pathophysiology. Vitreomacular traction (VMT) has been implicated in the development of diffuse DME via several mechanical and physiologic pathways, all of which result in increased vascular permeability. Thus, releasing mechanical traction on the macula either by spontaneous posterior vitreous detachment or with vitrectomy, subsequently reduces the amount of retinal thickening in patients with DME and VMT. We present the case of a 48 y/o female with decreased vision OS x one month. The patient’s medical history was positive for Type 2 Diabetes of 10-year duration. BCVA was 20/50 OD and HM OS. Fundoscopy revealed multicystoid foveal thickening with overlying VMT. The patient was referred to a retinologist for vitrectomy evaluation and management. Meticulous observation of the vitreomacular interface in patients with DME is crucial for management.makhlouf_traction
Glaucoma Considerations in the Patient with Disolcated LensMartin2014Dislocation or subluxation of the crystalline lens is a common finding with certain systemic disorders including Marfan’s Syndrome and Homocystinuria. It is also common after blunt force trauma to the eye. This presentation covers a case of bilateral lens dislocation following trauma. The patient presented one year after initial injury with elevated IOP and glaucomatous optic nerve cupping. Secondary glaucoma is common following lens dislocation. The mechanisms of glaucoma are analyzed based on location of the dislocated lens whether anterior or posterior. Management and surgical options will be discussed.martin_dislocated
Amaurosis Fugax: an unlikely culpritMcCainDr. Richard Gardner2014Amaurosis Fugax(AF) is defined as transient monocular vision loss which can have a variety of embolic or non-embolic causes. A 27 year-old male presented with several recent episodes of amaurosis fugax affecting his left eye. The patient was previously diagnosed with systemic lupus erythematosus (SLE) and associated cerebral vasculitis. Magnetic resonance angiography revealed stenosis of left anterior cerebral artery. This poster will review AF related to collagen vascular disease with attention to SLE. Other less common embolic, hemodynamic and vascular etiologies of AF will be reviewed as well.mccain_fugax
Pellucid Degeneration: Sclerals to the RescueMcCainDr. Richard Gardner2014Pellucid Marginal degeneration is a corneal condition characterized by ectasia in the inferior and peripheral cornea. Early stages may be managed by soft contact lenses or spectacles; however scleral design lenses prove beneficial in patients with late stage disease. A 77 year old male presents to our clinic with decreased vision. Spectacle BCVA was 20/40-2 OD, 20/25 OS. Corneal topography revealed classic topographical findings consistent with Pellucid. Soft lenses were fit in the past with no success. Scleral lenses were successfully fit to improve the vision. This case will demonstrate how scleral lenses provide exceptional vision and comfort in patients with eye disorders such as Pellucid Marginal degeneration. Images/topography included.mccain_pellucid
Relentless Bilateral Scleritis. Painful Scleromalacia with Scleralization of the Cornea.Meyer2014A patient with an unknown systemic inflammatory disorder has been followed for many years with chief complaints ranging from dry eyes to severe and debilitating eye pain. This patient recently presented with constant eye pain and slit lamp exam reveals severe scleromalacia OU with near total cornea scleralization OD and partial involvement OS; photo documented. B-Scan imaging revealed mild bilateral posterior scleritis evident with the classic “T-Sign.” Systemically, this patient additionally has been found to have giant vessel vasculitis and non-rheumatoid hand arthropathy. Treatment has mainly been DMARD therapy, systemic steroids, and planned is topical cyclosporine 1%. Discussion topics include systemic associations of scleritis, pathogenesis of scleritis, management from optometry’s perspective, and treatment options to include topicals.meyer_scleritis
Sclerals for Normal Corneas: A Not So Normal ApplicationMickles2014Scleral lenses are a therapeutic option for Sjogren’s syndrome (SS) sufferers. However, the large size and expertise required to fit these lenses limits their widespread use. This case describes a SS patient who achieved maximum relief of her dry eye symptoms with a smaller design, the first semi-scleral lens designed for “normal” corneas. A 26-year-old female SS patient presented with dry eyes that prevented her from wearing soft contact lenses of several brands comfortably. She could only tolerate lens wear for 2-3 hours despite using artificial tears QID OU. Entering acuities were 20/25 OD and OS with Ciba Dailies Aqua Comfort Plus 8.6/13.8/-2.25 OU. Biomicroscopy revealed moderate dry eye signs. Topographies revealed prolate corneas of regular astigmatism OU. Blanchard’s Onefit Prolate + Astigmatism semi-scleral lens was chosen as it is intended to accommodate prolate and regular astigmatic corneas. With the lenses 7.0/14.3/-5.25 OD and 6.9/14.3/-5.50 OS, she achieved 20/15 vision OD and OS. After 3 weeks of lens wear and artificial tears QID OU, she had improved dry eye signs and enjoyed comfortable lens wear for a full day. With the simplified fitting and easy handling, semi-scleral designs may prove to be a practical therapeutic option for these patients.mickles_scleral
Amiodarone Induced Bilateral Optic NeuropathyNealKeith Head2014Amiodarone associated optic neuropathy is a rare and poorly understood complication of the widely prescribed anti-arrhythmic medication. This submission will discuss in detail a case of bilateral amiodarone associated optic neuropathy in a 68 year old Caucasian male. The presentation will include color fundus photos and visual field test results from the periods before, during, and after the event. Lab testing and imaging results will also be included and discussed. A brief literature review of amiodarone associated optic neuropathy and its differentials will also be included along with a discussion of other potential side effects of the drug.neal_amiodarone
A historic case of retrobulbar optic neuritisNichols2014Retrobulbar optic neuritis accounts for 50% of all optic neuropathies. The most common condition found in association with optic neuritis is multiple sclerosis. Presenting signs include acute monocular vision loss, pain on eye movements, and afferent pupillary defect. A 32-year-old black male presented to clinic with a history of reduced vision in the right eye for 2 years. Patient’s best corrected visual acuity was 20/40 in the right eye. All entrance testing was within normal limits. At a previous eye exam, 2 years prior patient reported episode of pain in right eye during eye movements along with blurred vision, which resolved a few days later. Dilated fundus examination showed diffuse pallor with no acute swelling or hemorrhages in the right eye, while the left optic nerve was pink and distinct. The patient was sent for an MRI, which revealed severe atrophy of the optic nerves bilaterally, right greater than left. This appearance is consistent with the sequela of previous multiple clinically occult episodes of optic neuritis with white matter demyelination and is consistent with multiple sclerosis. Previous case history led to the diagnosis in this patient.nichols_historic
Visual change as the initial symptom of hemangioblastomaOtaloraJoseph Sowka, OD, FAAO, Diplomate2014Background: Hemangioblastomas are tumors of the central nervous system that usually presents with symptoms of headaches, imbalance, vomiting and nausea. Visual changes are not common presenting symptoms. Case: A 48 year old black male presented for evaluation of blurred vision in both eyes for about 2 months, the onset of which was progressive and affected both distance and near. The patient specifically denied any headaches or other physical changes. Pinhole visual acuity testing was 20/30 OD and OS. Funduscopic examination revealed bilaterally edematous optic nerves, flame-shaped hemorrhages around the discs and a macular star in the left eye. The patient was initially diagnosed with neuroretinitis. Subsequent evaluation including magnetic resonance imaging revealed the presence of an intracranial hemangioblastoma. Conclusion: While macular star formation is typically associated with neuroretinitis, bilateral disc edema should lead to the suspicion of an intracranial process. This case details the uncommon presentation of a hemangioblastoma presenting with visual rather than central nervous system symptoms.otalora_hemangioblastoma
When a red eye is more than a red eyeOttoCaroline B. Pate2014A 42 year-old African American female presented with complaints of a red right eye, blurry vision and mild headaches for 2-3 weeks. On preliminary testing she was found to have decreased visual acuity, abnormal color vision, visual field defects, and proptosis on the right side. Ocular health exam revealed mild signs of dry eye and dilated fundus exam was unremarkable in both eyes. Further imaging revealed a large meningioma that involved the right orbit. Following removal of the majority of the tumor along with medial wall orbitotomy and decompression, the patient had improvement in visual acuity, color vision and reduction of proptosis.otto_redeye
An unfortunate sequence of events: Horners Syndrome secondary to carotid artery dissection.ParanthanJarett Mazzarella OD, FAAO2014A 49 year old male presented with amaurosis fugax, general myalgia, and left neck and infraclavicular pain. Examination revealed ptosis with miosis of the left eye, classic signs of Horner’s Syndrome. Absence of anhidrosis further localized the insult to the left internal carotid artery. Computerized tomography angiography confirmed dissection and total occlusion of the proximal left internal carotid artery with postganglionic third neuron location. The patient was diagnosed with a painful left-sided, partial Horner syndrome secondary to carotid artery dissection. The presence of significant left carotid stenosis reveals an uncommon thread in the presentation of this condition. The patient was treated with antiplatelet therapy to prevent thrombus and subsequent embolization.paranthan_horners
The Implantabe Miniature Telescope: A case study highlighting the optometrist's rolePasner2014The Implantable Miniature Telescope is an FDA-approved telescope prosthesis to improve visual acuity in patients with End-Stage age-related macular degeneration (AMD). The device itself and the role of the Low Vision Optometrist on the implant team in evaluating potential candidates to see how they might benefit from the telescope prosthesis will be elucidated. A case study will be presented.pasner_telescope
Rapidly Progressing Multiple Cranial Nerve Palsy Secondary to Progressive Multifocal Leukoencephalopathy (PML)PatelWendy McGonigal OD, FAAO2014PML is a rare, potentially fatal, viral demyelinating disease characterized by inflammation of cerebral white matter. Occurring in severely immune-compromised patients, PML is caused by the JC virus, which is present and controlled within the normal immune system. The pathogenesis of PML is similar to multiple sclerosis, but progresses more rapidly, and myelin breakdown is commensurate with level of immune-compromise. There is no known cure, but treatment to improve the immune system increases survival. A 58-year-old male with history of HIV (not on HAART therapy) presented complaining of constant horizontal diplopia with noted speech and gait difficulties. The patient was diagnosed with left lateral rectus palsy, managed for diplopia with 12 prism-diopter BO Fresnel prism, and referred to ER for MRI and neurologic evaluation. One week later, he was reevaluated for worsening diplopia and refit with 25 BO. MRI revealed moderate demyelination, and the patient was immediately started on HAART. At one month follow-up, testing revealed bilateral sixth and left third nerve palsy. The patient was treated with additional prism, and scheduled for one month follow-up. Unfortunately, he continued to deteriorate, and died. Approximately 20% of PML patients die, and others are significantly disabled. Prompt diagnosis and treatment is necessary.patel_cranial
Taking the Function Out of VisionPollardTrennda Rittenbach, O.D.2014Functional vision loss (FVL) is a term encompassing any type of vision loss that is not explained by organic pathology. Perhaps the most intriguing cause of FVL is hysterical amblyopia. In this case of hysterical amblyopia, a 32-year-old Iraqi war veteran with perceived decreased visual acuity and visual fields, intentional esotropia and spasm of the near reflex presented with no prior ocular disease and no organic cause for vision loss. There are no guidelines for treating these patients as reassurance and placebo methods are equally effective. However, in this case it was evident that excellent communication between the co-managing physicians, including ophthalmology and mental health, is imperative for improvement.pollard_functional
Empty Sella Syndrome Resulting in Visual Field DefectsPsaltisKristen Gayeski, O.D.2014Background: Empty sella syndrome (ESS) is a disorder that involves the sella turcica appearing empty in radiological studies because the pituitary gland shrinks. Primary ESS is believed to occur due to an anatomical defect above the pituitary gland causing the gland to become flattened. The condition is more common in women and associated with obesity and high blood pressure. It may also be a sign of pseudotumor cerebri. Case Report: A 59 year-old female presented for a comprehensive examination without complaints. Her past medical and ocular history was unremarkable. She had an incidental finding of a lower temporal field defect OD. Further visual field testing confirmed the defect and extending to a 60-2 revealed a nasal defect OS. Her ocular health was normal and MRI of the brain was ordered revealing an empty sella. A referral was made to neurology and endocrinology. Conclusion: Several patterns of visual field loss have been reported in ESS; however, little is known of the exact cause of the defects. Ocular signs reported with ESS include decreased vision, optic disc edema, optic atrophy and visual field defect. A prompt referral to neurology and endocrinology is recommended for work-up and visual field patterns should be closely monitored.psaltis_empty
Unilateral Elevated IOP? Think HZV Trabeculitis!PsaltisKristen Gayeski, O.D.2014Background: Unilateral elevated intraocular pressure (IOP) may be the result of trabeculitis caused by herpes zoster virus (HZV) and may occur without dermatological or corneal involvement. The presentation may be unassuming with little or no cells visible in the anterior chamber. Case Report: A 66 year-old female presented complaining of blurry vision OD for 2 days. Her vision was 20/40 OD. Slit lamp examination revealed a rare cell in the anterior chamber and corneal edema. IOP was 40 mmHg OD and 16 mmHg OS. Medical history was positive for shingles on the right side of her face 1 month prior that had since cleared. A diagnosis of HZV trabeculitis was made and her IOP was topically lowered in office before she was dismissed. She was prescribed another round of Valtrex as well as an aggressive dosing of Pred Forte and Combigan and told to follow-up the next day. Conclusion: In cases of unilateral open angle elevated IOP, HZV trabeculitis must be a differential especially in the immunosuppressed and 60+ population. It must be treated with topical steroids, aqueous suppressants, as well as an oral antiviral, although the need for the use of the oral antiviral agent is controversial.psaltis_hzv
Rare Case of Severe Bilateral Lupus Retinopathy and NeuroretinitisPsaltisKristen Gayeski, OD2014Background: Systemic lupus erythematosus (SLE) in an autoimmune condition that can cause a number of ocular conditions. SLE retinopathy may range from a mild presentation with cotton wool spots and retinal hemorrhages to severe disease with arteriole occlusion, retinal infarction and proliferation. We report a case of a rare bilateral retinal panvasculitis and neuroretinitis. Neuroretinitis secondary to SLE is rare in literature. Fundus photos will be included. Case Report: A 21 year-old female was referred from her rheumatologist for complaints of slowly progressive blurry vision OU. Her visual acuity was 20/250 OD and 20/100 OS. Dilated fundus examination revealed florid retinopathy with multiple hemorrhages, cotton wool spots, vascular occlusions and ischemia OU. There was also a coexisting neuroretinitis. She was urgently admitted to the hospital and placed on IV steroid treatment. Her vision improved following treatment and is now monitored by retinal specialists. Conclusion: SLE or lupus-like juvenile conditions may result in sight threatening retinal disease. Detection of severe retinopathy and neuroretinitis required prompt referral and treatment. Non-infectious causes of neuroretinitis are rare and may be a sign of SLE and secondary antiphospholipid syndrome.psaltis_lupus
Differentiating Sclerochoroidal Calcification from Intraocular TumorsRamirezNina Tran, O.D., and Theresa Chong, O.D., FAAO2014Sclerochoroidal calcification (SCC) is a rare condition of calcium deposits in the sclera and choroid that appear as bilateral, yellow-white elevated fundus lesions. However, it can mimic and is most commonly misdiagnosed as an intraocular tumor. Ancillary testing such as ultrasonography, optical coherence tomography, computed tomography, and fluorescein angiography can confirm or differentiate SCC from intraocular neoplasms. SCC is typically found in older white males and most likely idiopathic, but certain underlying systemic disorders can be associated and must be ruled out before diagnosed as idiopathic. A 67-year-old white male presents with bilateral, yellow-white elevated lesions located in the superotemporal arcades. Laboratory results are suggestive of underlying Gitelman’s syndrome.ramirez_calcification
Bone Growth in the Eye? An Atypical Case Presentation of a Choroidal Osteoma.RamirezPaul Vejabul, O.D.2014Choroidal osteoma, or osseous choristoma, is a rare, benign, slow-growing ossifying tumor involving replacement of choroidal layers with bone. It usually presents unilaterally in young healthy females. It is typically a solitary, slightly elevated, orange-yellow lesion at the posterior pole. The pathophysiology is unknown, however, calcium and phosphorus metabolism do not have a role in their development. Ultrasonography, the best method to differentiate a choroidal osteoma from a malignant tumor, confirms dense bone with a highly reflective anterior surface and orbital shadowing. Optical coherence tomography demonstrates normal retinal layers with a hyper-reflective choroid. An asymptomatic 67-year-old white male presents with a large, unilateral, yellow-white elevated lesion in the posterior pole.ramirez_osteoma
Retinal capillary hemangioma: A review of key retinal features and treatment optionsRandhawa2014Forty-eight year old female presented for a contact lens re-evaluation, when a reduction in visual acuity in the left eye was noted. Facial amsler revealed an inferior temporal paracentral scotoma in the left eye, pupil testing revealed no relative afferent pupillary defect. Dilated fundus examination revealed a vascular lesion within the retina and optic nerve superiorly surrounded by intraretinal hemorrhages and paramacular exudates, suggestive of a retinal capillary hemangioma. Fluorescein angiography confirmed the presence of a feeder vessel from the superior retinal arteries and late leakage. Magnetic resonance imaging of the brain and orbits revealed no additional lesions. A review of key retinal features of retinal capillary hemangioma, benign retinal capillary hemangioma versus von Hippel Lindau-related retinal capillary hemangiomas, as well as a summary of differentials including vasoproliferative tumors of the retina, Coat’s disease and retinal cavernous hemangiomas. Various treatment options, including verteporfin photodynamic therapy and intravitreal anti-vascular endothelial growth factor, are discussed.randhawa_hemangioma
Plaquenil induced loss of parafoveal photoreceptor inner and outer segment junction line using the SD-OCTRandhawa2014Twenty-eight year old female developed chronic graft versus host disease secondary to a bone marrow transplant after the diagnosis of acute myeloid leukemia. Chronic graft versus host disease can affect multiple organs. It’s characterized by immune dysfunction with an increased risk of infections. She was treated with hydroxychloroquine 200mg QID for a total of 800mg daily. Based on her body mass, she was consuming 10.66mg/kg/day. There was no reported hepatic or renal disease. Retinal evaluations prior to the initiation of treatment revealed no retinal disease. A cumulative dose of 1080 grams caused paracentral visual field loss along with the loss of the inner and outer segment junction line, using the spectral domain optical coherence tomography. Retinal toxicity caused by the binding of hydroxychloroquine to melanin in the retinal pigment epithelium, disrupting the metabolism of retinal cells. Visual field defects continued to progress bilaterally after discontinuing the use of hydroxychloroquine. A summary of the revised recommendations on screening for chloroquine and hydroxychloroquine are discussed. A review of screening tools in identifying early signs of paracentral field loss or paracentral retinal tissue damage, before the development of bull’s eye maculopathy.randhawa_hydroxychloroquine
Implantable Telescope for End-Stage Age-Related Macular DegenerationRedmondAndreea Chih, O.D.2014A patient with profound visual impairment from bilateral, untreatable advanced AMD presented to cornea specialty for evaluation of an implantable telescope. The patient had undergone assessment with low vision specialists and was efficient in the use of an external telescope. Implanted intraocular telescopes have demonstrated improvement in vision and quality of life for suitable individuals affected by end-stage AMD. Challenges include the unique procedure and complications arising from the size of the implant. Success is based on a multi-specialty team approach, realistic patient expectations and rehabilitation after surgery. Implantable telescopes are a potential treatment for end stage AMD patients with no other viable options for improvement in quality of life.redmond_telescope
Clinical Presentation of Posterior Internuclear Ophthalmoplegia (INO) of LutzReidCatherine R. Abbott, O.D.; William S. Slagle, O.D.2014Background: Posterior INO of Lutz is a rare condition in which abduction is impaired, unlike the more common anterior INO in which adduction is impaired. It can be differentiated from an abducens nerve palsy because vestibular stimulation remains intact. The pathogenesis of this clinical manifestation is not well understood. It has been hypothesized to be caused by a lesion in the rostral brain stem, however an infranuclear cause has also been suggested. Case Report: A 63 year-old African American male with diabetes and hypertension presents with sudden onset binocular, horizontal diplopia. Extraocular motilities reveal a complete restriction of abduction in the left eye (OS) on pursuits with intermittent spasm of the right medial rectus that is most evident in primary and left gazes. There is no cyclodeviation or vertical deviation. Dolls-head maneuver was employed to stimulate the vestibulo-ocular reflex which facilitated complete abduction of the OS, despite its gross limitation on pursuits. The intact vestibulo-ocular reflex and impaired abduction on pursuits, coupled with convergence dysfunction, yielded a diagnosis of a posterior INO of Lutz. Conclusion: Although considered to be a rare condition, it is important for the optometrist to differentiate a posterior INO of Lutz from an abducens nerve palsy. Presented is a case displaying the typical features of this brainstem pathology.reid_lutz
Aberrant Regeneration of CN III/V with the “Jaw-Winking Phenomenon” In Veteran With A History Of Head TraumaRoperChristian W. Jordan, O.D., FAAO2014We will present a case report of aberrant regeneration of cranial nerves III and V after our patient sustained head trauma while on active duty. In our presentation, we will detail the pathological process of the involved cranial nerves as they apply to the ocular health exam, as well as discuss key differentials of etiology (i.e. Marcus Gunn, Bell’s Palsy, etc). We will include a video clip of our patient’s “jaw-winking” phenomenon and discuss both palliative and surgical treatment options. Lastly, we will provide a brief, yet concise caveat-rich “quick guide” for in-office cranial nerve testing for the primary care optometrist.roper_winking
To Be, or Not to Be Malignant: That is the QuestionRoperKimberly Dillivan, OD, FAAO2014Malignancies of the conjunctiva and cornea comprise a large continuum of presentations often making recognition and diagnosis of the tumor difficult. We will present a case series of three patients who presented with malignant-appearing lesions on routine examination, including an unusual pigmented papillomatous caruncle lesion, a benign pterygium masquerading as carcinoma in situ of the cornea, and a basal cell carcinoma with an atypical presenting chief compliant. We will include biopsy results, anterior segment OCT, and anterior segment photographs of the lesions. We will also review key differential diagnoses, emphasize appropriate diagnostic testing and treatments, and discuss an approach to clinicopathologic comanagement with oculoplastics and surgical pathology.roper_malignant
New technologies in diagnosing and managing Punctate Inner ChoroidopathySchmidtJames Williamson, OD2014Patient presents with punctate inner choroidopathy (PIC) and choroidal neovacular membrane (CNV). This inflammatory disease is often confused with histoplasmosis yet has a higher incidence of CNV, therefore timely diagnosis is crucial. Previously, PIC was limited to investigation by fundoscopy and fluorescein angiography . Optical Coherence Tomography (OCT) now allows for an enhanced understanding of the pathological process at the histological level through utilization of fundus autofluorescence (FAF). This technology can aid in the diagnosis and monitoring of subclinical diseases. This poster will examine PIC and other similar diseases in an attempt to show how use of newer diagnostic modalities can aid in the appropriate diagnosis in a timelier manner.schmidt_punctate
Cytomegalovirus Retinitis: It still exists?!SchuetteDr. Greg Black2014Cytomegalovirus retinitis is a member of the Herpes virus, which most individuals are exposed to in their lifetime. However, only those individuals with immunocompromised conditions are susceptible to the infection. CMV retinitis accounts for approximately 30% of the vision threatening retinopathies seen in AIDS patients. Before the introduction of highly active antiretroviral therapy, many AIDS patients suffered severe vision loss due to this devastating infection. Our patient presented with decreased vision for 10 days in the left eye and stated a CD4 count of 50 cells/mm3 after the initiation of HAART. Upon fundus examination, CMV retinitis was evident in the left eye and scattered hemorrhages and a single cotton wool spot were present in the right eye. CMV retinitis and the case management will be discussed.schuette_retinitis
You’ll Shoot your Eye Out!Smith2014Injuries resulting from BB pellet guns continue to be one of the most common causes of severe ocular injury among adolescent males. Ocular sequelae can be visually devastating and include vitreous hemorrhage, commotio retinae, traumatic uveitis, endophthalmitis, traumatic hyphema, ocular siderosis, retinal tears, retinal detachment, and sympathetic ophthalmia. This case illustrates a 19 year old male presenting with a BB pellet injury with a retained posterior intraocular foreign body and a large horseshoe tear. Potential complications of penetrating ocular injuries and management strategies will be discussed.smith_shoot
Refractive Management of a Pediatric Patient with Marfan SyndromeSolis2014Background: Marfan syndrome is an autosomal dominant condition which affects numerous tissues. The main ocular features consist of ectopia lentis and high myopia. Case Report: 11 year old white male complains of decreased visual acuity. The patient was first diagnosed with ectopia lentis at the age of four. The lenses have increased in subluxation over the past seven years, which resulted in varying myopic refractive errors. With best corrected visual acuity of 20/40 OD and 20/125 OS the decision for bilateral lensectomies were made. Refractive error was corrected with contact lenses until intraocular lenses could be implanted. After insertion of the intraocular lenses best corrected visual acuity was 20/20 OD and 20/20 OS. Conclusion: When ectopia lentis occurs early in life the patient risks the development of amblyopia if proper treatment is not given. Frequent refractions are necessary to ensure that accurate optical correction is maintained throughout the amblyogenic period. Lensectomies may occur early or later in life. Post surgical optical corrections consist of contact lenses, spectacle and intraocular lenses.solis_marfan
New Approaches To Treating Ocular Histoplasmosis SyndromeSoltanian2014Histoplasmosis is a disease cause by the fungus Histoplasma capsulatum. Ocular histoplasmosis syndrome (OHS) is a leading cause of vision loss in Americans ages 20 to 40. OHS can present as small areas of granulomatous fundus lesions. Choroidal neovascularization and resultant disciform scarring can also develop. Clinical diagnosis is made with a classic triad of punched-out peripheral choroidal scars, peripapillary pigmented degeneration, and macular CNV leading to disciform scarring. The presence of subretinal hemorrhage, RPE detachment, subretinal fluid, or disciform scarring confirms a more debilitating form of OHS. A 65 y/o male presented with complaint of metamorphopsia OD. VA was 20/20 OD, and 2/200 OS. Patient had been previously diagnosed with OHS and had his left macula treated with PDT 20 years prior. As a result of the PDT he developed macular scarring and decreased vision OS. Retinal evaluation showed multiple punched out lesions OU, dense macular scarring OS, and a juxtafoveal CNV OS visualized on OCT and FA testing. Pt was started on anti-VEFG injections. This poster will include a review of the differential diagnoses, indications and options for treatment and management of OHS.soltanian_histoplasmosis
Identifying and treating Vogt-Koyanagi-Harada SyndromeSpears2014Vogt-Koyanagi-Harada (VKH) syndrome is a very rare multisystem inflammatory disorder with a prevalence of approximately 1.5 to 6 per 1 million people in the United States. VKH is characterized by severely decreased vision, bilateral panuveitis and serous retinal detachments. It is often associated with neurologic and dermatologic manifestations such as headache, poliosis, hearing loss and vitiligo. VKH has a male to female ratio of approximately 1: 3 and is most commonly seen in patients of Asian and Middle Eastern descent. With early and aggressive treatment the visual outcome of VKH is typically good. Visual acuity is >20/40 in 50 to 90 percent of treated cases. Permanent vision loss in patients with VKH results secondarily to glaucoma, choroidal neovascularization, cataract, optic atrophy and phthisis bulbi. Oral corticosteroids are the usual first line of treatment. Rarely are intravenous steroids and hospitalization required.spears_vkh
Cavernous Sinus Syndrome due to invasive RhabdomyosarcomaSullins201466 year old female presented with complaints of vision loss and diplopia. She has found to have a restricted extra ocular motilities and compressive optic neuropathy. Magnetic resonance imaging showed a neoplasm orbital neoplasm invading the cavernous sinus. Trans-sinus biopsy demonstrated a rhabdomyosarcoma which is extremely rare in the seventh decade.sullins_orbit
From Eye Exam Lane to Emergent Blood TransfusionThayilJeffrey Joy, OD2014Hematological disorders manifest in millions of Americans nationwide. These disorders can cause significant ocular complications. In up to 90% of patients with a blood disorder, the ocular manifestations can be the initial presenting signs 1. 75yowm presented for routine follow-up for suspected exudative macular degeneration OU. Patient had positive history of diabetes type II, hypertension, and suspicious colon polyps. Slit lamp examination of the anterior segment was generally unremarkable. Dilated fundus examination revealed cotton-wool spots along the arcades OU; blot hemorrhages along inferior temporal arcades, and a hollenhorst plaque along the superior temporal arcade, all findings OD. Left eye examination revealed a flame hemorrhage and blot hemorrhage inferior to the nerve. There were also scattered peripheral hemorrhages OU. A complete blood count was ordered and performed the day of examination. Complete blood count returned with an abnormal hemoglobin level of 6, marked critically low. Patient was sent to emergency department for further management. After evaluation in the emergency department, the patient was diagnosed with severe anemia; he soon received an emergency blood transfusion and was admitted to inpatient care. Occult stool sample returned positive, patient then underwent a colonoscopy, which revealed suspicious polyps, which were subsequently removed. Several esophageal varices were also noted which were suspicious for possible liver cirrhosis, hepatoma or vascular obstruction to the liver. Follow-up evaluation confirmed portal hypertension and liver cirrhosis. Chronic liver disease is frequently associated with various hematological disorders. Anemia of varied etiologies occurs in nearly 75% of patients with chronic liver disease. Hemorrhage along the gastrointestinal tract is a common finding in chronic liver disease. Such hemorrhaging can lead to an anemic state that can manifest with a number of signs and symptoms and can affect various organ systems. Anemic retinopathy is one such sign that affects the ocular system.thayil_transfusion
Iatrogenic Aniseikonia from Surgical Emmetropization of a Pre-Operative AnisometropeTheisPia Hoenig, OD, MA, DBO(T), FAAO and Debora Lee Chen, OD, FAAO2014Aniseikonia is the cortical perception of image size difference between the two eyes. Differences in image size greater than 3% are clinically significant and create a barrier to binocular fusion, as well as disrupt spatial orientation. Symptomatic patients often complain of asthenopia, difficulties reading, and diplopia. Aniseikonia is most common in refractive anisometropes. However, it has also been noted in patients with differences in the spatial distribution of retinal elements, as seen in some patients with epiretinal membranes. Increases in refractive and cataract surgeries, have led to a higher prevalence of iatrogenic refractive aniseikonia. This case discusses a 66 year old female with asthenopia and complaints of "unequal planes of focus" after bilateral cataract extraction. Pre-operatively, the patient had four diopters of anisometropic compound myopia. Post-operatively, the patient had compound hyperopia in the right eye, simple myopia in the left eye, and resulting clinically significant aniseikonia. This poster emphasizes the complications of surgical emmetropization in anisometropic patients, and also discusses current diagnostic and treatment techniques for aniseikonia.theis_aniseikonia
Visual Sequelae Following Anoxic Brain InjuryToChrystyna M. Rakoczy, O.D., Imelda V. Llanos, OTR/L2014A 22-year-old male presents for consultation following a recent history of anoxic brain injury secondary to sudden cardiac death after performing a parachute jump out of an airplane. Visual acuity was normal, but visual fields were severely constricted. Assessment of the binocular visual system revealed dysfunctions in fixation, extra ocular motility, ocular alignment, and accommodation. This case describes the visual sequelae in a patient following anoxic brain injury and the recommended vision rehabilitative interventions.to_anoxic
Evaluation of a Post-Operative Wound Leak Enhanced by OCTTorbitDr. Brad Sutton2014A 47 y.o. Caucasian male presents 10 days after cataract surgery OD complaining of decreased vision and diplopia. VA was reduced (20/150 OD) and the right anterior chamber was narrow with grade 2 cells/flare. Low IOP (5mmHg) and a positive Seidel's sign were noted. OCT confirmed a narrow anterior chamber, mild wound leak, and peripheral anterior synechiae. Mild choroidal folds were discovered (and photographed) in the posterior pole but no choroidal detachments were detected on Bscan. Treatment included a bandage contact lens and topical antibiotics. A suture was placed in the leaking wound and shortly thereafter, OCT confirmed a sealed wound, deepening of the anterior chamber, and resolution of the corneal iris adhesion. Two weeks later, VA returned to 20/20 and there was complete resolution of the hypotony maculopathy.torbit_wound
Conjunctival Intraepithelial Neoplasia in an HIV Positive PatientTorbitDr. Brad Sutton2014A 44 year old African American HIV positive male presents with a nasal conjunctival lesion in the left eye that he has noticed for the past eight months. The mass is located at the nasal limbus and has feeder vessels. It appears pink in color, gelatinous and vascularized. An excisional biopsy of the lesion revealed a conjunctival intraepithelial neoplasia which was classified pathologically as severe squamous dysplasia (CIN III). Cryotherapy was performed and the patient continues to be monitored for reoccurrence. The poster will include the case report with photographs as well as discussion about CIN etiology, clinical features, differential diagnosis, prognosis, and treatment.torbit_cin
Ulcerative Colitis and the Eye: A "Serous" complicationTylerGregory S. Black, OD2014A 59 year old Hispanic male presented with visual complaints x 3 weeks following a flare up ulcerative colitis. The pt had been treated with oral prednisone for approximately 5 weeks prior to our exam. The patient reported blur OD>OS and was taking Vytorin, Prednisone and Tribenzor on the date of his examination. Visual acuity was 20/20 OD, OS with normal preliminary testing. Slit lamp was without cells and flare, cataract or synechiae. IOP measured 13mmHg OD, OS. Dilated fundus examination revealed a serous elevation in the retina approximately 1DD in size near the macula OD. Central Serous Retinopathy was diagnosed secondary to oral prednisone therapy for ulcerative colitis. The poster will review common ocular complications associated with ulcerative colitis, along with various associated etiologies for central serous retinopathy.tyler_serous
Don't Blow It: Proper Diagnosis and Management of Blow-out FracturesTylerKimberly K. Reed, OD, Alexandra M. Espejo, OD2014We present two cases of orbital blow-out fractures associated with variable trauma etiologies. The first case is a 73 YO male who presented with double vision and soreness x 2 days OS associated with a trip and fall. The patient's VA was normal with orthophoria at distance and 7-9XP at near with intermittent double vision inferior. The second case is that of a 22 YO male who suffered an injury during an automobile accident. He complained of double vision in up gaze. Visual acuity was normal with left hypotropia noted in superior gaze only. Both cases presented without obvious ecchymosis or restriction of normal eye movements. The poster will review common presenting signs and symptoms with orbital trauma, along with proper ocular management and referral.tyler_blowout
A Case of Blurred Vision and Temporal Field loss in a Pregnant Patient: Presentation of a Pituitary Tumor, Prolactinoma.Watkins2014Prolactinomas are benign tumors of the pituitary gland that are associated with production of the hormone, prolactin. This hormone is upregulated during pregnancy. Abnormal growth of the pituatry gland due to prolactin producation may lead to a macroadenoma. This tumor can press on the optic chiasm and cause temporary or permanent vision and visual field loss. A 21 year old female presented with blurred vision and head aches. She was five months pregnant. Upon examination, her best corrected vision was 20/60 OD, OS and peripheral vision loss was noted. She was sent for an MRI and a prolactinoma was diagnosed. The patient underwent surgical removal of the tumor.watkins_pituitary
Thyroid Eye Disease Secondary to Over Treatment of HypothyroidismWilliamsAngela Zurowski O.D.2014Thyroid Eye Disease is not a condition that afflicts only those with hyperactive thyroid glands. This condition is prevalent in those with over treatment of hypothyroidism secondary to a thyroidectomy. Other times it is present in a normal functioning thyroid, which is termed euthyroid thyroid eye disease. Although the systemic assessment and treatment of these condition might differ than Graves Disease, however the ophthalmic findings are addressed the same. Ten years after a thyroidectomy secondary to hyperthoyroidism, a 65 year old male presents with symptoms of diplopia. After further testing and workup, inferior rectus muscle involvement is suspected. Imaging is ordered to rule out ONH involvement, which confirms the inferior rectus belly enlargement. Fresnel prism is prescribed to alleviate diplopia. Patient is being followed closely for monitoring of ONH compression.williams_thyroid
Pink eye? "Eye" think not...Wong2014Bacterial conjunctivitis is a common childhood ocular condition. We have all treated these emergency patients, arriving with red goopy eyes, in our office. For this common run of the mill condition we typically prescribe a broad spectrum antibiotic eye drop. But what do we do if the infection returns every time the patient is taken off the medication and worsens? This is a case presentation of a 2- year-old healthy boy with a history of chronic eye infections that persisted for months worsening to a pre-septal cellulitis. The patient was given multiple antibiotic eye drops, oral antibiotics, IV antibiotics, and even a normal CT scan, yet the condition returns and worsens every time he is taken off the medication. This poster will present a very interesting twist to what appears to be an atypical case of conjunctivitis.wong_pinkeye
Eye Pain as a Presenting Symptom of an Intraorbital MassAbrashoff2013BACKGROUND: Eye pain can be a presenting symptom of numerous conditions including orbital neoplasm. Diagnosis of orbital tumors is done through radiologic testing, and treatment varies based upon type, location and symptoms. CASE REPORT: A patient presented to the Chalmers P. Wylie VAACC with complaints of constant, sharp eye pain OS for two weeks. Examination revealed increased pain with eye movement, but was otherwise normal. CT scan was ordered and found a left orbital mass. MRI was ordered for further differentiation. Final diagnosis was cavernous hemangioma, treated and improved with oral steroids. CONCLUSIONS: Poster will discuss the characteristics of several orbital neoplasms, indications and options for treatment, CT, and MRI.abrashoff_pain
Cuando solicitar Tomografia Axial Computerizada y/o Resonancia Magnetica en las patologia orbitarias y lesiones de la via optica? - Una RevisionAcunaSara V. Angulo, OD2013Objective: To determine the clinical applications of imaging (CT and MRI) for diagnosis and management of certain diseases and injuries of the orbital path length, from a bibliographical revision. Materials and methods: We performed a bibliométric search strategies using the databases PubMed, Medline, among others. We initially conducted the search of articles published about the generalities of neuroimaging techniques, its physical principles, clinical indications and contraindications, and later the review was aimed at the exploration of literature on the use of Computed Tomography and Magnetic Resonance in the diagnosis of specific pathologies. Discussion: This review identified bibliometric examination of preference for certain authors from 2009 to 2012 for some orbital diseases and injuries of the optic pathway. However, in the search process is evidenced by some pathologies which present similar frequency during the period of time, while others demonstrated significant changes in the examination of choice through the years, it would be an indicator to ensure that both techniques are complementary for the diagnosis, treatment and monitoring of pathology. However, it is essential to recognize the clinical manifestations since they will have predictive value when choosing the diagnostic test, on the other hand it is important to emphasize the benefit of early detection of deadly diseases which has led to research in the field of preventive medicine, since the image not only plays a role in diagnosis, but is crucial in assessing the extent of eye disease, and intracranial metastasis retrobulbar extension.acuna_cuando
MVA Related Concussion Confounds Diagnosis of Lyme EncephalomeningitisAkauLisa Fanciullo, O.D.2013This is a case where an optometry examination performed on the brink of a 57yo male’s discharge altered the course of treatment. The patient was hospitalized for one day with acute onset right facial nerve palsy and five-week duration of variable headaches, generalized weakness, body aches, and tingling in the lower extremities. Patient reported that one-week prior to hospitalization he was involved in a motor vehicle accident and was diagnosed with a concussion at an outside hospital. Discharge orders had already been written at the time of the eye exam with diagnosis of coincident Bell’s palsy and post-concussion related headaches. Neurology consulted our service to provide protective measures for corneal desiccation. Upon undilated examination there was suspicion for bilateral optic nerve swelling and a full examination including visual fields, fundus photos, and OCT was performed. Optometry advocated for deferral of discharge and a lumbar puncture to investigate suspicion of Lyme meningitis. Over the next two days, the patient developed severe headaches, nausea, and vomiting with periods of confusion. He was treated presumptively for Lyme encephalomeningitis. His mental status then GREATLY improved and his vision was unaffected. One week after discharge, the cerebral spinal fluid returned positive for Neuroborreliosis and co-infection with Anaplasma Phagocytophilum. The patient complete his treatment course as an outpatient during which the facial palsy largely resolved and vision remained stable.akau_mva
Two is Not Better than One: Dealing with Intractable DiplopiaAuYin C. Tea OD, FAAO; Melody Tong OD2013Intractable diplopia describes double vision that persists even after treatments such as lenses, prism, surgery or vision therapy. The condition can occur post trauma or after strabismus surgery or vision therapy in visually mature patients. The recalcitrant nature of the condition often leads to grave distress in patients who exhaust multiple avenues without significant improvement. Diagnosis and treatment options will be discussed along with case reports of patients experiencing intractable diplopia from various etiologies, including post strabismus surgery and head trauma.au_two
Ocular Manifestations of Juvenile XanthogranulomaBartolacci2013A 14 month old female with multiple Juvenile Xanthogranulomas (JXG) presented to pediatric optometry clinic in a large Medical Hospital in Brooklyn, New York for a comprehensive eye exam. Manifestations of her disease included multiple xanthogranulomas of the eye lids, periorbital areas, face, neck and torso. Multiple Juvenile Xanthogranuloma is a relatively uncommon dermatological disease with potentially severe ocular manifestations. Most children with JXG often show signs by 6 months to one year of age. JXG is usually diagnosed based on the presence of only one nodule/tumor, however, multiple lesions can be present (such as in this case) and are quite rare. Treatment and management of JXG includes monitoring for iris tumors. If any are present, optometrists must inform parents of risk of spontaneous hyphema and the increased risk of glaucoma. The ocular manifestations can be detrimental to the ocular health of a pediatric patient. Fortunately such manifestations are rare. Thorough examination of the anterior and posterior segments of the eye are important part of managing these patients along with routine follow up and prompt treatment should any manifestations occur.bartolacci_juvenile
Legal Blindness Due To Optic Nerve Head DrusenBennett2013Optic nerve drusen are extracellular calcific deposits within the nerve head that are often diagnosed as incidental findings on routine exam. They are usually bilateral with 1% - 2% prevalence in the general population. Optic nerve drusen are typically asymptomatic and visual acuity loss is rare, although visual field defects are common. Visual field loss can worsen as the drusen progress throughout adulthood, most often presenting as arcuate or nerve fiber bundle defects, but progression to severe visual field loss is rare. This case illustrates a 69 year old patient with severe bilateral visual field constriction due to optic nerve drusen. The extensive visual field damage classified the patient as legally blind, and low vision services were provided. Potential complications of optic nerve drusen will be presented, and management strategies will be discussed.bennett_drusen
Orbital Cavernous Hemangioma Causing Compressive Optic Neuropathy, Posterior Globe Compression, and OphthalmoplegiaBernardo2013Cavernous hemangiomas of the orbit are the most common benign primary orbital tumor in adults. They are typically unilateral and most often occur in females during the fourth decade of life. Initial presentation is a gradual painless proptosis, but other signs and symptoms can develop over time including lid swelling, ocular pain, globe compression, diplopia, and decreased vision. Diagnosis can be made with either CT or MRI imaging of the orbits. Surgical intervention is usually indicated when the aforementioned symptoms develop or progress, and can include either excision of the lesion or radiotherapy. This poster presents a case report of a patient who was referred for periorbital pain, proptosis, and decreased vision of the right eye along with diplopia that has been ongoing for the past few months. MRI imaging revealed a right orbital mass that had features characteristic of a cavernous hemangioma, and which was causing compressive optic neuropathy, posterior compression of the globe, and ophthalmoplegia. She subsequently underwent lateral anterior orbitotomy with excision of the lesion. This poster also discusses the current diagnostic techniques and treatments associated with cavernous hemangiomas.bernardo_cavernous
Ocular trauma in pediatric patients: A case series highlighting difficulties and considerations for emergent careBolles2013Cases of emergent care are critical and can be made difficult when the practitioner is unfamiliar with difficult patient populations. This poster will present a case series of pediatric patients that presented urgently with ocular trauma. Cases of blunt trauma, corneal abrasion, foreign body, and chemical exposure will highlight the critical treatment that is needed, as well as discuss challenges that present specifically for pediatric patients. Discussion will include techniques to aid in examination and diagnosis, approved medication for pediatrics and administration, and special considerations for treatment and coordination of care. Familiarity with the differences in the examination and care of pediatric patients will aid in emergent clinical decision making.bolles_trauma
Corneal Cross-Linking for Keratoconus and Post-Refractive EctasiaBrown2013Corneal cross-linking began in Europe and the FDA has recently started a clinical trial to determine its efficacy and safety for patients with Keratoconus and post-refractive ectasia in the United States. Cross-linking is thought to strengthen the weakened cornea in ectasia and stop its progression. The surgical procedure involves debriding the corneal epithelium (although cross-linking can be done without debridement) and soaking the exposed corneal stroma in Riboflavin. The eye is then exposed to a UVA light source which activates Riboflavin's interaction with the corneal stroma. Corneal cross-linking is thought to be an effective way of stopping progression of corneal ectasia while remaining a relatively safe procedure. An ideal candidate for corneal cross-linking would be someone of a young age with mild to moderate, advancing corneal ectasia, relatively good best corrected visual acuity, and no visually significant corneal scarring. Patients who do not fit any of these criteria may be better suited for Intacs sgement implantation or corneal transplantation. Intacs and corneal cross-linking can be done sequentially or in some cases concurrently.brown_ectasia
Pediatric Optic Neuritis: A Case Presentation and Review of Diagnosis and TreatmentChen2013Pediatric optic neuritis involves subacute loss of vision in children often in severe degree. This presentation of a eleven year-old female diagnosed with optic neuritis will go through the signs, symptoms, clinical testings, and differential diagnosis, and treatment associated with the disorder. Unlike optic neuritis in adults, the differential diagnosis of this disease in children is more extensive. Therefore, the discussion of neuroimaging and serologic evaluation will be covered to exclude any infectious or neoplastic processes. A review of possible causes of pedatric optic neuritis such as ADEM, pediatric multiple sclerosis, and neuromyelitis optica will also be discussed.chen_optic
Basal Cell Carcinoma of the Eyelid and Subsequent Reconstructive Surgery OptionsChocky2013A 68 year old white male presents to the New Jersey VA Medical Center complaining of irritation to the eyelid along with a slowly growing eyelid lesion. After biopsy, he is diagnosed with basal cell carcinoma of the eyelid. This case will be presented, followed by a discussion relating to diagnosis, risk factors, excision of the tumor, and eyelid reconstructive surgery after removal of the tumor. Ultimately, the patient was recommended to have a Hughes tarsoconjunctival flap for his eyelid reconstruction, however due to the procedure requiring the eyes to be closed for two to four weeks, he elected simple direct closure.chocky_basalcell
Old Virus, New TreatmentChu2013Epidemic keratoconjunctivitis (EKC) is a communicable adenoviral infection capable of producing weeks of ocular irritation, folliculosis, preauricular lymphadenopathy, corneal infiltration, photophobia, variable visual disability and pseudomembrane formation. In addition to the disease’s protracted course, affected individuals often lengthen the event by infecting the fellow eye and must remain out work because of the contagious potential. We present a case in which a 34 year old black female with EKC was treated, in a matter consistent with the literature with a topical Betadyne wash and a cocktail of Tobradex and Zirgan. Timely uncomplicated resolution supports the addition of this case to anecdotal and literature-based citations which advocate the approach.chu_ekc
Treatment of Chemical Burns with an Amniotic Membrane Contact Lens: A Case StudyConnollyMing Wang MD, PhD; Amy Waymire OD2013Purpose: To evaluate the efficacy of treating alkaline chemical burns with amniotic membrane contact lens History: A 19 year old female presented 1 week s/p decreased vision secondary to an alkaline burn OU. Exam: Entering VA was 20/80 OD and 20/100 OS uncorrected and pinhole 20/70 and 20/100. Slit lamp findings revealed 4+ conjunctival hemorrhaging and corneal edema OU. Pachymetry was 752 microns OD, 825 OS. Treatment: A dehydrated, sterilized disc of human amniotic membrane was placed into a scleral lens and applied to eyes for two weeks time. After two weeks, the membrane was fully absorbed. Since epithelial defects were still present, the process was repeated OU until the cornea had healed. Results: After multiple AMCL’s al defects were fully healed. Present VA was 20/400 OD (PH: 20/150) and 20/20 OS. Conclusion: The AMCL has advanced the healing properties of the amniotic membrane from what was once an extensive surgery to a simple office procedure. Treatment with AMCL’s have shown to decrease healing time, thus reducing the keratocyte apoptosis and thus reduce overall scarring. This decreases the likelihood of extreme corneal procedures, like a penetrating keratoplasty. This treatment provides optometrists the opportunity to help their patients with alkaline burns.connolly_amniotic
A Rare Case of Phacolytic GlaucomaCorteStephanie Klemencic O.D., F.A.A.O.2013Background: Phacolytic glaucoma is a rare condition in the United States, caused by leaking of lens proteins from a mature cataract. Case Report: An 86 y.o. African American female reported a red, painful eye. Examination revealed refractile elements in the anterior chamber associated with a mature cataract and elevated IOP. Guarded prognosis for phacoemulsification cataract extraction was determined due to phacodonesis and zonular dialysis. Pars plana vitrectomy and pars plana lensectomy was performed to improve comfort and vision. IOP normalized after surgery. Conclusion: Inflammation and IOP must be aggressively controlled prior to cataract extraction. Urgent referral for removal of the exciting lens material is crucial to maximize visual prognosis.corte_glaucoma
Bleb leak and blebitis following Ex-PRESS miniature shunt implantationDalton2013The Ex-PRESS miniature implant is a recently developed drainage device used as an alternative to trabeculectomy in the surgical management of glaucoma. Recent studies demonstrate a significantly low rate of postoperative complications limited almost exclusively to post-operative hypotony. Although there is little evidence demonstrating bleb-related complications, bleb leaks, blebitis, or endophthalmitis may occur following Ex-PRESS insertion. The current literature regarding surgical technique and rate of postoperative complications associated with Ex-PRESS implantation will be reviewed, and a case of blebitis and bleb leak following Ex-PRESS insertion will be presented in detail. Early diagnosis and appropriate management of rare bleb-related complications after Ex-PRESS implantation is essential to prevent significant loss of vision.dalton_bleb
Asymptomatic Congenital Retinal MacrovesselDella BellaAnia M. Hamp, OD, FAAO; Jarett A. Mazzarella, OD, FAAO2013A 76 yom presented for examination with 20/20 vision OD, OS and was found to have a Congenital Retinal Macrovessel OD. This finding involves an abnormal vessel which emanates from the nerve and crosses the horizontal raphe into the foveal region. In our patient, the vessel split into 2 branches encircling the macula with no macular edema. The patient’s complaints can range from asymptomatic to decreased vision secondary to leakage and subsequent serous macular detachments or capillary nonperfusion. Some consider this to be a variant of racemose angiomatosis, this and other differentials will be explored. In addition, recommendations for patient precautions and prognosis will be discussed.dellabella_macrovessel
Atypical Lesion of the Lacrimal CaruncleDePoeKatherine Sanford O.D.2013Lesions of the lacrimal caruncle are uncommon and rarely reported in the literature. This case describes a 52 year old African-American male who presented with a recent-onset and painful ‘bump’ on his left eye. The ‘bump’ turned out to be a palpable, tender nodule on his left caruncle that was causing ocular irritation on right gaze through mechanical rubbing of the cornea. Based on its acute onset and tenderness, the lesion was presumed to be of infectious etiology and the patient was prescribed a course of oral antibiotics and a combination antibiotic/anti-inflammatory ophthalmic ointment. This case report will describe the clinical course of an atypical caruncular lesion and will include digital anterior segment photography. Also included in this presentation will be a review of anterior segment anatomy, the differential diagnoses of caruncular lesions and their appropriate treatment and management.depoe_caruncle
Routine Diabetic Retinal Evaluation Reveals Advanced Lung AdenocarcinomaDePoeJames Williamson O.D.2013A 79 year old African American male without ocular complaints presented for his yearly retinal evaluation due to diabetes. Dilated fundus examination revealed extensive cotton-wool spots OU and a solitary intraretinal hemorrhage OD. His diabetes, however, was well-controlled. Given that the retinopathy seemed out of proportion to systemic disease, blood tests were ordered and revealed severe anemia. The patient stated recent weight and appetite loss, along with a long-term history of smoking. Due to this, a chest x-ray was ordered which found an advanced adenocarcinoma of the right lung. This presentation will discuss the clinical presentation of anemic retinopathy and will include fundus photography and radiological imaging from this case. Also discussed will be differential diagnoses of anemic retinopathy, as well as the appropriate treatment and management of these conditions.depoe_diabetic
Juvenile Herpes Zoster Ophthalmicus: An Active Ocular & Dermatological Case StudyDerewyanko2013Herpes Zoster (HZ) Ophthalmicus is an ocular entity associated with patients over the age of 60-years-old. Attributed to a reactivation of the dormant Varicella-zoster virus within the ophthalmic division of the trigeminal nerve it can create both ocular and dermatological issues. Presented is an unusual case of Juvenile Herpes Zoster Ophthalmicus in an otherwise healthy, black 13-year-old female. Clinical presentation includes unilateral painful skin lesions localized along the forehead and upper eyelid, both respecting the vertical mid-line, as well as, unilateral conjunctival chemosis and follicles, sodium-fluoroscein staining corneal pseudo-dendrites, and anterior chamber cells and flare. Due to the high incidence rate of active Herpes Zoster cases throughout the United States each year, it is important that ophthalmic physicians understand the etiology, clinical presentation, and proper treatment and management of HZ Ophthalmicus in order to provide exceptional care to both the geriatric as well as younger patient populations.derewyanko_herpes
Disc-at-Risk or Patient-at-Risk? A Second Look at Progressive Nonarteritic Anterior Ischemic Optic NeuropathyDornbosJessica Hartwig2013Nonarteritic anterior ischemic optic neuropathy (NAION) is a common cause of significantly impaired vision. NAION is characterized by vascular insufficiency to the optic nerve head, axoplasmic stasis, and disc edema. Disc edema is exacerbated in patients with a small optic nerve head cup-to-disc ratio. In the absence of vasculopathic risk factors, alternative etiologies to NAION must be explored. A 58-year-old Caucasian male presented with a chief complaint of blurred vision in his right eye. Examination revealed sectoral disc edema and altitudinal field loss that progressed over several weeks. This case explores additional differential diagnoses for optic disc edema and highlights common misconceptions about NAION.dornbos_ischemic
Migrating Epiretinal Membrane with Restoration of Foveal ContourDruckmanAlina Balasa, OD2013An epiretinal membrane, (ERM), is a progressive condition, which can impair vision. Visually significant ERMs undergo pars plana vitrectomy with ERM-peels however, there are sporadic case reports of natural resolution. We present a rare case of a symptomatic ERM and it’s spontaneous resolution, supported by serial OCT images. We discuss theories related to mechanism of action and highlight this rarely documented phenomenon. A 66-year-old male complains of blur in the left eye. Entering vision is 20/20 OD and 20/40 OS. Slit lamp exam is remarkable for PCIOL OU. DFE shows a central ERM and loss of foveal contour OS. OCT shows central thickening of 467μm OS. At 6 month follow-up there is a 133μm reduction centrally. The tractional component has shifted superiorly and foveal contour is restored. Long-term observation shows a continued decrease in thickening and further migration of the ERM. OCT allows visualization of varying patterns of the ERM and sub-clinical changes. We theorize the histologic composition of the ERM allows for this tractional change. Current research shows the potential of intravitreal microplasmin to improve vision while reducing traditional surgical risks. Our patient is now asymptomatic and the ERM no longer poses a visual threat without any surgical intervention.druckman_epiretinal
Mini-scleral contact lens management of exposure keratitis due to lagopthalmos from Bell’s PalsyDuchnowskiJulie A. Rodman, Zoeanne Schinas, Kandace Haines2013We report a case of therapeutic mini-scleral lens management of severe exposure keratitis due to lagopthalmos caused by Bell’s Palsy. A 72-year old white male presented to contact lens department complaining of blurry vision, severe dryness, and inability to close the left eye (OS) since the onset of Bell’s Palsy two months prior. He was being treated with intensive ocular lubrication and lid taping without any relief. Vision on presentation was 20/70 OS with no improvement on pinhole. External observation revealed decreased blink rate, incomplete lid closure, and drooping of the face on the left side. Slit lamp biomicroscopy showed severe, diffuse, grade 4 punctate keratitis and reduced tear break up time OS. Therapeutic, saline filled, mini-scleral lens was fitted for daily wear to vault the cornea OS enabling the corneal surface recovery whilst retaining visual and social function. The visual acuity 3 months post mini-scleral fitting improved to 20/25 uncorrected. Although Bell’s Palsy improved, the patient had persistent lagopthalmos and mini-scleral lens wear was continued to hydrate and protect the exposed cornea.duchnowski_exposure
Unexpected Retinal Finding in Hepatitis CDuncan2013Acute Posterior Multifocal Placoid Pigment Epitheliopathy (APMPPE) is a rare white dot syndrome affecting the retinal pigment epithelium. This disorder has been characterized as an acquired inflammatory condition causing a vasculitis within the choroid/choriocapillaris leading to focal ischemia and subsequent RPE disruption. This poster will include a case study of a 28 year-old female who presented with APMPEE while being monitored regularly for the use of high-risk medications in the treatment of Hepatitis C. Posterior examination revealed multiple, bilateral, creamy-white, subretinal plaques throughout the posterior pole sparing the macula. All previous ocular examinations were negative for retinopathy. The patient also presented with red, pruritus lesions surrounding the wrists resembling erythema multiforme, which has been linked to APMPPE in literature. APMPEE has been shown to occur in individuals with a depressed immune system. The use of Interferon alpha in combination with Ribavirin in the treatment of Hepatitis C can cause marked anemia through bone marrow suppression spiraling individuals into an immunocompromised state. This poster will further explore the nature of this condition, systemic associations, proper examination and treatment.duncan_retinal
Retinal Cavernous Hemangioma - Incidental Finding in an Otherwise Healthy PatientElder2013A cavernous hemangioma is a benign vascular tumour, often occurring within the cerebral vasculature. Orbital cavernous hemangiomas are the most common benign tumour of the orbit. Retinal cavernous hemangiomas are more rare than those of the orbit and are often diagnosed incidentally with no presenting symptoms. This case describes the finding of a retinal cavernous hemangioma in a young, healthy patient. Cavernous hemangiomas of the retina can be associated with cerebral cavernous malformations that may produce intracranial hemorrhage or focal neurological deficits. Treatment of retinal cavernous hemangiomas is rarely required but anti-VEGF drugs may hold potential for future treatment protocols given the higher rates of VEGF expression in endothelial cells of cavernous hemangiomas.elder_cavernous
Hemi-Retinal Vein Occlusion in a Young Hypertensive Patient with associated Fen-Phen use.ElkinsDevin Duval2013Fen-Phen is a weight loss drug removed from the market by the FDA in the late 1990’s due to its association with primary pulmonary hypertension and cardiac valve disease; however it has no specified association with retinal vascular disease. Ninety percent of vein occlusions occur in people over the age of 50; yet this case involves a hemi-retinal vein occlusion in 48 year old hypertensive patient that reported using “fen-phen” for the past 45 days to aid in weight lifting. This case discusses the etiology, diagnosis and treatment of vein occlusions utilizing fluorescein angiography and highlights the dangers of over the counter supplements not regulated by the FDA.elkins_vein
The Ultimate Diplopia MasqueraderEngsOlena Moiseiykina, OD, Lori Vollmer, OD, FAAO2013A 64 year-old Hispanic female presented with a one week history of intermittent vertical diplopia that varied throughout the day. Systemic history is positive for diabetes, hypertension, hypercholesterolemia, and rheumatoid arthritis. Ocular history is remarkable for hemicentral retinal vein occlusion OS. Vertical deviation was initially measured to be 2^BD OD, but over the course of several weeks had worsened to 10^BD OD. Parks 3-step test showed possible right inferior rectus involvement which was not consistent with the signs or symptoms of a third nerve palsy. Fresnel prism was initially placed over the right eye to help alleviate her symptoms. Our differential diagnoses included giant cell arteritis (GCA), ischemic partial cranial nerve III palsy due to hypertension or diabetes, thyroid eye disease, Sjӧgren’s, systemic lupus erythymatosis (SLE), and myasthenia gravis (MG). Appropriate workup was performed for each differential and was remarkable for elevated antinuclear antibodies (ANA) and equivocal acetylcholine receptor binding antibodies. The clinical diagnosis of myasthenia gravis was made and a chest x-ray was performed to rule out concomitant thymoma. Patient was started on Mestinon (pyridostigmine) by a neurologist and showed a significant improvement in diplopia symptoms. This case demonstrated an atypical case of MG where diplopia was the only presenting symptom.engs_diplopia
Ocular Complications of High Dosage ChlorpromazineEngstromKimberly M. Dillivan OD2013Thorazines are a class of anti-psychotic drugs used to treat schizophrenia and other psychiatric disorders. A 39-year-old Caucasian male was referred for evaluation of ocular toxicity secondary to long-term Chlorpromazine use. Patient was prescribed an unusually high dosage of Chlorpromazine to manage his overwhelming feelings of demonic presence during which he performs rituals associated with obsessive compulsive disorder and psychosis. A thorough ocular examination was conducted to reveal severe corneal and lenticular side effects with integument involvement. In addition, information will be provided from visual fields, fundus and anterior segment photos, optical coherence tomography, and dermatologic photos. Presented is a rare case detailing ocular toxicity and systemic correlations due to an atypical high dosage of Chlorpromazine with emphasis on patient management and consultation with his psychiatrist.engstrom_ocular
Cat Scratch NeuroretinitisFrauensEulogio Besada, O.D.2013Background: Cat Scratch Disease is a systemic infection by the gram-negative bacillus, Bartonella henselae. A detailed medical history including recent travel, animal exposure, skin rashes and general health is necessary to facilitate the diagnosis. Case Report: A 52 year-old Hispanic male complained of a blind spot in his left eye for 3 weeks. History revealed exposure to a newborn litter of cats in his home. His general health was unremarkable with no recent illness or fever. BCVA was 20/20 OD, 20/20- OS. A + RAPD was present OS. Dilated exam revealed optic disc edema with associated hemorrhages. Patton’s folds were present temporally and macular edema striations were present without lipid deposition. HVF showed an enlarged blind spot OS. Lab tests revealed elevated serum antibodies (IgG) to Bartonella henselae at 1:256 dilutions. The patient was treated with oral doxycycline 100 mg BID resulting in complete resolution of the neuroretinitis. Discussion: Cat Scratch Disease is oftentimes self-limiting, however oral antibiotic therapy has been shown to decrease the resolution time. Recognizing the clinical signs of this condition and ordering the proper lab tests are critical in the Optometric management.frauens_cat
Chronic Papilledema in Patient with Chiari 1 MalformationGady2013Chiari 1 malformation is a herniation of the cerebellar tonsils through the foramen magnum, obstructing CSF flow between the intracranial space and the cervical spinal canal. It is a congenital or acquired malformation, and can lead to intracranial hypertension. A 24-year-old female presents with recent onset blurred vision and a longstanding history of headaches. DFE reveals bilateral nasal optic disc edema with temporal optic atrophy. OCT testing confirms sectoral RNFL edema as well as sectoral RNFL thinning. MRI of the brain and orbits reveals Chiari 1 malformation. This presentation will focus on the differential diagnosis of optic nerve head edema using OCT, fundus photos, visual fields, and detailed history as well as an overview of Chiari 1 malformation.gady_malformation
Intelliwave Silicone Hydrogel lens for Aphakic AdolescentsGarcia2013Introduction: Soft contact lens management of pediatric aphakia is often complicated by limited parameter availability. Silsoftby Bausch and Lomb satisfies the management of infantile aphakia, but fails to provide adequate parameter availability for aphakic adolescents. Young children and adolescents often exceed the Silsoftparameters (both pediatric and adult versions of the lens) by two years of age. If silicone hydrogel lenses are preferred over Gas Permeable (GP) lenses for comfort and compliance concerns, lens availability can pose a significant challenge for this patient population. This case provides grounds for management of adolescent aphakics with the use of Intelliwave lenses by Art Optical. Case Report: A 12-year-old African American male was referred to The Eye Institute at Salus University by Wills Eye Institute for a medically necessary contact lens fitting for aphakia OD. The patient was diagnosed with uveitits in 2010, etiology unknown, and the desired management resulted in visually significant posterior subcapsular cataracts OU. Consequently, in July of 2012, cataract extraction was performed in the right eye. During his contact lens examination, entering visual acuity revealed 20/1600, with pinhole improvement to 20/100-1 OD. A subjective refraction of +12.00-0.50X010 provided 20/25-1 visual acuity. The patient’s topographical keratometry readings were 42.96 @ 094 and 41.49 @ 006 with a horizontal iris diameter of 12mm in the right eye. An Intelliwave contact lens was order empirically with the following parameters: 8.6/+13.75/14.0. When the patient returned for the dispensing appointment, the lens exhibited optimal centration, coverage and movement with 20/20-1 visual acuity. Although the patient has since been lost to follow-up, the exceptional 20/20-1 visual acuity obtained during dispensing is likely repeatable and can be attributed to the magnification effects of the contact lens. Discussion: This case demonstrates the successful use of a custom silicone hydrogel lens for a young adolescent who lies outside the parameters of the Silisoft lens. The Intelliwave lenses by Art Optical remains the only custom silicone hydrogel lens on the market that provides the comfort of a soft lens with the needed parameter availability. This case provides anecdotal evidence for the successful use of Intelliwave lenses in the treatment of adolescent aphakics.garcia_silicone
OPTIC NEUROPATHY SECONDARY TO THYROID EYE DISEASE: OCULAR FINDINGS, PATHOGENESIS AND TREATMENT OPTIONSGentryRichard J. Zimbalist, OD, FAAO and Amber Mayberry BS2013Thyroid Eye Disease (TED) is an immune-mediated disease associated with Graves’ disease and other dysthyroid states. The most common signs and symptoms of TED include eyelid retraction, lagophthalmos, foreign body sensation and photophobia. More severe cases present with diplopia and optic neuropathy secondary to the glycosaminoglycan deposition, fibrosis of the extraocular muscles and adipogenesis in the orbit. Graves’ orbitopathy is a relatively common disorder, but approximately 5% of Graves’ patients will have sight-threatening optic neuropathy. This case describes two patients with optic neuropathy secondary to thyroid associated orbitopathy and the differences in their presentation and treatment plans. A review of ocular pathology and literature outlines the etiology of optic neuropathy secondary to TED. Corroborative testing includes Computed Tomography (CT) of the orbits, Humphrey visual field testing, Hertel exophthalmometry, fundus photography, optical coherence tomography (OCT), and color vision.gentry_thyroid
Benign Intracranial Hypertension - A Case SeriesHartRussell W. Hart, OD and Angie P. Baker, OD2013Three cases will be presented demonstrating the clinical presentation, diagnostic workup, and necessary follow-up for papilledema. OCT characteristics and visual field implications will be demonstrated. Radiologic studies and lumbar puncture will be reviewed. A discussion of differential diagnoses and the emergent/urgent care required will be discussed. Evidence-based treatment guidelines and follow-up will be provided.hart_benign
Eight Ball Hyphema following Selective Laser TrabeculoplastyHeady2013Selective laser trabeculoplasty is a relatively safe and repeatable non-invasive surgical procedure for the reduction of intraocular pressure in open angle glaucoma. It is thought of to be a safe and uncomplicated procedure. This is the first case of an eight ball hyphema reported in literature following SLT. A seventy-three year old female with advanced open angle glaucoma was treated with SLT in the right eye with an uncomplicated application of laser to the lower 180’ of the anterior chamber. The patient presented with a complete eight ball hyphema about 2 hours following application of SLT. Full recovery to pre-treatment vision and pressure followed further surgical treatment.heady_hyphema
Early Detection of Age-Related Macular Degeneration and Retinal Pigmented Epitheliopathy by Multi-spectral ImagingHitchmothDr. Kent Nguyen and Dr. Priscilla Lenihan2013AnnidisTM multispectral imaging (MSI) is an effective, efficient, novel examination method that provides a broad, deep view of the retina. Highly detailed, en face images, of the retinal pigmented epithelium (RPE), retinal vasculature, choroid, and the optic nerve are revealed with this technology. A variety of wavelengths, representing a broad portion of the electromagnetic spectrum, are applied in sequence to create 15 spectral slices that allow the examiner to differentiate a wide variety of pathologies to include the early detection of RPE dysfunction associated with age- related macular degeneration (AMD). This poster will demonstrate the advantages of utilizing MSI to detect early AMD and retinal pigment epitheliopathy to include a brief discussion of emerging pharmaceutical and nutraceutical therapies.hitchmoth_early
Clinical Findings, Treatment, and Management of Ocular Albinism: A Case ReportHoffman2013Albinism is a group of inherited genetic disorders affecting the regulation of melanin biosynthesis. The classification of albinism is quite complex, and there has been much research in recent years to further identify and categorize this disease. Because of the genetic variation present in albinism, there are often different phenotypes expressed. In terms of ocular manifestations, the two types that have been identified are oculocutaneous albinism and ocular albinism. Both of these types share clinical commonalities, most notably hypopigmentation, which help aid in the diagnosis, treatment and management for patients affected by the disease. This case report discusses a pediatric case of ocular albinism in particular, which is a type of albinism where the hypopigmentation is isolated to ocular structures.hoffman_albinism
Ocular complications of Sticker's syndrome with ManagementHuynh2013A 15-year old African-American male with a history of Stickler’s syndrome presented to our clinic for a low vision evaluation. The patient reported a decline in his vision, right more so than left eye, since his last low vision evaluation one year prior. He also reported low vision goals of seeing the whiteboard at distance and with near work, as he had difficulty with both. This case involves a discussion of Stickler’s syndrome with ocular complications and management, pathophysiology and differential diagnosis. In addition, a review will be included on the following: low vision rehabilitation treatment with a detailed discussion concerning the selection of appropriate devices for distance and near; an evaluation of patient effectiveness with and without accommodative demand, effective viewing distance, enlargement ratio and angular magnification.huynh_stickers
Malignant Hypertension With Bilateral Serous Macular DetachmentjoPetra Jo, OD2013Malignant hypertension is a medical emergency affecting 1% of the hypertensive population. It is more common in younger adults, with African-American males being more commonly affected. Associated complications can include brain and cardiac damage, renal failure, pulmonary edema and retinopathy. A 44 year old African-American male was referred to the Dorn VA Medical Center emergency room following an eye exam and diagnosis of acutely elevated blood pressure (220/112 mmHg). Following blood pressure management the patient was referred to our clinic for re-examination. Entering acuities were 20/70- OD and 20/30+ OS. Dilated examination revealed heavy macular and paramacular exudation. Cirrus OCT revealed bilateral serous macular detachments OD>OS. Upon 2 month follow-up, the exudate remains, the macular detachments are near fully resolved with normalization of acuity in both eyes. This case represents an uncommon ophthalmic complication of malignant hypertension. We will review the characteristics of malignant hypertension, as well as its management and associated ophthalmic findings.jo_hypertension
Optic Nerve Drusen and Angioid Streaks: A Case ReportJohnsNathan Whitaker, OD, FAAO2013Angioid streaks and ONH drusen can be found in conjunction with one another. One study found ONH drusen in 21% of pseudoxanthoma elasticum patients with angioid streaks, and 25% of patients with angioid streaks of different origin. A 32 year-old male presented for his initial eye exam in our clinic and reported he had been diagnosed with tuberous sclerosis based on ocular findings. His BCVA was 20/20 in each eye and pupil testing revealed a 2+ APD OD. DFE revealed prominent ONH drusen with angioid streaks OU. A CT scan showed calcifications consistent with ONH drusen in both eyes and no additional findings to support the previous diagnosis of tuberous sclerosis. ONH drusen and angioid streaks are both associated with abnormal calcium accumulation. These entities appear to have similar histopathological origins which may explain why patients with angioid streaks present with ONH drusen at a higher rate than patients without angioid streaks. Patients with ONH drusen and angioid streaks deserve an evaluation for any underlying systemic associations. Eyes with ONH drusen are at an increased risk for visual field defects and vessel occlusions, whereas the presence of angioid streaks increases the risk of vision loss secondary to CNVM.johns_drusen
Choroidal Melanoma Metastasis in 70 y/o Male Veteran with H/o Prostate CancerJordanMelanie Peeler, OD2013We will present a case report of a 70 year old male veteran with a newly diagnosed large choroidal melanoma metastasis in his right eye. The presentation will include analysis of various ancillary testing i.e. fundus photography, B-scan ultrasonography, Cirrus high definition OCT, commuted tomography of thorax, etc. We will detail key features of these reports to aid the primary care optometrist in differential diagnoses including retinal detachment, retinoschisis, retinal cyst, and various other degenerative entities. We will also thoroughly describe both the implantation process and implications of plaque brachytherapy, which our patient is currently undergoing as an alternative treatment to radiotherapy.jordan_melanoma
Chronic anticoagulant use contributing to choroidal hematoma formationKangJulie Rodman, O.D, FAAO2013A 68 y/o female presented with complaints of decreased vision in both eyes for the past 2 years. The patient had a history of chronic warfarin use. Her medical history was positive for bilateral macular scars, secondary to neovascular macular degeneration. Dilated examination OD revealed a large, creamy yellowish paramacular subretinal mass lesion extending into the inferior and superior arcades. The appearance resembled that of a choroidal melanoma or retinal detachment. Retinal oncology confirmed no malignancy, but the presence of an extensive choroidal hematoma due to macular degeneration. The final diagnosis was choroidal hematoma/hemorrhagic eccentric disciform scar possibly secondary to CNVM. Chronic anticoagulant use is associated with an increased risk of the intraocular hemorrhage development in patients with neovascular ARMD. Proper diagnosis and co-management with internal medicine is critical in reducing the formation of these visually devastating lesions.kang_chronic
Corneal Superinfection: A Unique Case of Polymicrobial KeratitisKarst Morris2013Background: Microbial keratitis affects 30,000 Americans annually. When cultured, typically a single microorganism is identified as the etiology. On rare occasion a polymicrobial ulcer occurs, presenting a clinical challenge. Case Report: A 50 year-old soft contact lens wearer presented with a red, painful eye. Examination revealed a 3mm x 3mm infiltrate with epithelial defect, corneal edema, and anterior chamber reaction. After initial diagnosis of bacterial keratitis and treatment with fortified antibiotics, she was referred for evaluation due to poor response to treatment and severe pain. Confocal microscopy was suspicious for Acanthamoeba and cultures showed Pseudomonas and Fusarium growth. A multiple drug regimen was initiated, the infection resolved two months later.morris_keratitis
Crack Cocaine Corneal UlcerLeeRichard Wu O.D., Kelly Thomann O.D. F.A.A.O.2013Crack cocaine, after its first introduction on the illegal drug market in 1985, quickly gained popularity due to its low cost and the potential of giving a fast “high.” “Crack eye syndrome” was first described in 1989 to describe corneal injury in association with crack cocaine use. A 67 year old male presented with a painful swollen right eye, extensive corneal ulceration with purulent discharge was present. The patient was immediately admitted to another facility for corneal consultation and around the clock treatment. After further inquiry, the patient admitted to a history of crack cocaine use, with a recent pipe explosion injuring his right eye, followed by topical NSAID drops use for the next three days, before seeking care for his now painful, red eye. This case reviews the toxic effects of crack cocaine the eye and the proper treatment and management.lee_cocaine
Phacomorphic glaucoma: A surprising turn of eventsLeeRichard Wu, OD. Anuradha Veerappan, OD. Kelly Thomann, O.D. FAAO2013A hyper-mature cataract which causes phacomorphic glaucoma generally will respond favorably once cataract surgery is performed. However, management becomes challenging if the patient defers surgical intervention. A 69-year-old male with schizophrenia presented with no light perception and a hyper-mature cataract in the left eye. The patient reported vision had been poor for many years in the left eye. The patient remained stable for four years but subsequently developed extremely elevated intraocular pressure. Iridodenesis and an anteriorly bowed iris with irido-lenticular touch was present. Anti-glaucoma treatment was initiated with good response. However, a series of pressure spikes developed despite maximum medical therapy. Lenticular debris and inflammatory cells were found in the anterior chamber. The patient was educated regarding the risks and benefits of cataract extraction but adamantly opposed and preferred to remain on maximum medical therapy. In a surprising turn of events the hyper mature cataract liquefied within a few months. Secondary angle closure resolved, and the intraocular pressure was once again manageable with medical therapy. This report discusses the progression of cataracts and its relationship to intraocular pressure and the irido-corneal angle. Proper treatment and management interventions for phacomorphic glaucoma are also reviewed.lee_glaucoma
Choroidal FoldsLeeDr. Lee Vien2013Choroidal folds are an uncommon ophthalmoscopic finding but may be found in various choroidal or retinal disorders. They may indicate compression of the sclera or a disruption of the anatomical relationship between the sclera and the retina. This compression may be due to an orbital mass, hypotony, inflammation, thyroid ophthalmopathy or any other condition that affects the scleral-retinal relationship. Additional testing should include OCT, VF, B-scan, CT scan or axial MRI, and Fluorescein or Indocyanine green angiography. Recognition of choroidal folds and determination of etiology are critical for appropriate management. This case highlights the clinical presentation of choroidal folds and reviews their differential diagnoses, as well as demonstrates the use of SD-OCT in differentiating the anatomical layers involved.lee_folds
Custom Contact Lenses in Pediatric PatientsLeisnerHeidi Wagner, OD, MPH, Andrea M. Janoff, OD2013PURPOSE: To increase awareness of silicone hydrogel custom contact lenses in the treatment of pediatric patients. METHODS: Retrospective data was collected from ten consecutive pediatric patients who were recently fit with contact lenses at an academic health care center. Clinical attendings were subsequently queried regarding their practice preferences for this patient population. RESULTS: Six of the ten patients were fit with soft contact lenses, two of ten patients were fit with a silicone elastomer lens and the other two patients were fit with gas permeable piggyback systems. Candidates deemed uniquely suited for custom silicone hydrogel lenses included patients with a small or large horizontal visible iris diameter (HVID), atypical corneal curvature and lens powers greater than 20 diopters. CONCLUSIONS: Custom silicone hydrogel lenses are available in a wide variety of parameters, making them an ideal option for pediatric patients. These made to order lenses appear to be an underutilized modality.leisner_custom
Managing Keratoconus with Scleral Contact Lenses in a Patient with Multiple Ocular DisordersLiAdam Gordon, OD, MPH2013Keratoconus is a visually debilitating, progressive corneal disorder affecting 1 in 2000 people. A 61-year-old African American male presented for possible contact lens fitting. His ocular history included longstanding keratoconus OU, advanced open angle glaucoma treated with multiple medications and dry eye disease treated with Restasis. His best corrected spectacle acuity was OD 20/70+, OS 20/50+. He complained of previous unsuccessful corneal gas permeable lens wear due to dryness symptoms as well as problems with lenses spontaneously dislodging from his eyes. This patient was successfully refit in 15.8 diameter scleral contact lenses to achieve vision of OD 20/50+, OS 20/25+ with good quality and excellent comfort for his desired wear time. The patient remarked that his improved vision allowed him to better enjoy time with his new daughter. He was also able to resume refereeing basketball games, which he had given up due to poor vision. Scleral contact lenses are a viable option for patients with keratoconus and other corneal irregularities and can have a tremendous impact on the quality of life for these patients. An overview of scleral lens fitting and evaluation will be presented. This case will be illustrated with corneal topographies and anterior and posterior segment photographs.li_keratoconus
Piggybacking a Hybrid Lens in a Complicated Keratoconic Fitting: A Case ReportLiSteven Ali, O.D., Ann Kim, N.C.L.E.2013Piggyback lens systems have been utilized to allow for greater contact lens wearing time and greater comfort by reducing corneal bearing from a gas permeable lens. A 32-year-old white male with a history of keratoconus and wearing Synergeyes ClearKone OU presented complaining of blurry vision, redness, irritation and discomfort with contact lens wear. With the current lenses, the patient suffered from discomfort from recurrent corneal abrasions due to corneal bearing and neovascularization and corneal edema from hypoxia due to lack of movement from the lens. All of these issues resulted in decreased visual acuity. This case report details the use of the unconventional method of piggybacking a Synergeyes A hybrid lens with a daily silicone hydrogel, and how this combination was ultimately attained. By utilizing tools such as the Visante Optical Coherance Tomography (OCT) and slit lamp photography, the optimal fit to get movement to improve corneal hypoxia, eliminate corneal bearing to augment comfort, and boost visual acuity was achieved.li_hybrid
Examination following motor vehicle accidentLohithaswa2013Commotio retinae is a transient retinal whitening due to photoreceptor disruption, often occurring after ocular trauma. When the macula is involved, it is called Berlin’s edema. A 61-year-old Caucasian male presented complaining of decreased vision following a motor vehicle accident. Vision was decreased to 20/30 OS. Fundus examination revealed commotio retinae with mild Berlin’s edema. Patients presenting after blunt ocular or head trauma must be evaluated for development of commotio retinae, as well as more serious ocular pathology such as traumatic glaucoma, Purtscher’s retinopathy, orbital fracture, and retinal breaks. This case explores the importance of a thorough ocular examination, the pathogenesis of commotio retinae, and the optometrist’s role in management.lohithaswa_accident
INTRALENTICULAR NEOVASCULARIZATION AS A RESULT OF CATARACT PHACOLYSISMakhloufJulie Rodman, O.D., F.A.A.O; Eva Duchnowsky, O.D.2013Background: Intralenticular neovascularization is a rare clinical entity, as the crystalline lens is anatomically avascular. New blood vessel growth within the lens occurs secondary to an imbalance between the angiogenic and antiangiogenic mechanisms within the eye. Trauma, surgery, pseudophakia, or a hypermature cataract can alter the integrity of the lens capsule and upset the natural balance within the eye, resulting in inflammation and/or hypoxia which in turn provides an environment conductive to new blood vessel formation. Case Report: A 49-year-old Haitian female presented with a positive history for trauma with a subsequent retinal detachment in her left eye 4 years prior. Her BCVA was 20/20 OD and NLP OS. Slit-lamp examination revealed a 1+ cellular reaction in the anterior chamber, and a hypermature cataract with 360 posterior synechiae and blood vessel growth through the lens matrix. Conclusion: The lens is embryologically avascular. However, structural weakness in the presence of hypoxia and inflammation may lead to the formation of intralenticular neovascularization. In our patient, phacolysis of the hypermature cataract lead to dissemination of lens particles resulting in ocular inflammation, synechiae formation, and overall release of angiogenic factors, all of which contributing to the formation of intralenticular neovascularization.makhlouf_phacolysis
Central serous retinopathy exacerbated by testosterone patchesMintonDr. Ania Hamp, OD, FAAO2013It has been estimated that approximately 39% of men over the age of 45 have low testosterone. Transdermal testosterone patches are becoming an increasingly popular form of therapy for these patients. A clear association has been established between steroids, both endogenous and exogenous, and central serous retinopathy (CSR). The link between testosterone patches and CSR, however, has not been well documented. We present a case of CSR believed to be exacerbated by the use of transdermal testosterone patches in a 63 year old African American male. Supportive photographs, serial OCT’s and fluorescein will be included, as well as differential diagnosis, treatment and literature references for this likely association.minton_serous
Not Turning a Blind Eye on a Blind EyeMoiseiykinaJoseph Sowka OD, FAAO2013As primary eye-care physicians, it is routine to encounter patients with painful blind eyes in day-to-day practice. Causes for blind painful eyes include glaucoma, neovascular disease, retinal detachments, intraocular tumors, endophthalmitis, phthisis bulbi, and trauma. Regardless of the etiology, the management options can range from topical pharmacological management to surgical procedures. This poster focuses on three cases of blind painful eyes and the appropriate management strategies that were tailored to each individual presentation. Specifically, topical pharmaceuticals, cyclodestructive procedures, retrobulbar neurolytic block (alcohol vs. chlorpromazine), enucleation and evisceration are explored in this poster.moiseiykina_blind
Torpedo Maculopathy: A Pediatric Retina CaseMontgomeryJason Duncan OD, Dan Smith OD2013Torpedo maculopathy manifests as a benign, non-progressive, congenital chorioretinal lesion temporal to the macula and usually presents as a singular, unilateral finding. The lesion is oval in shape with a tapering end pointing toward the macula. The clinician is able to view choroidal vasculature through the lesion. Torpedo maculopathy is asymptomatic and therefore found by means of routine fundus evaluation of the pediatric patient. Though an exact etiology has not been determined, theories suggest torpedo maculopathy may represent RPE nevi, may be secondary to choroidal vascular events, or may be the result of a developmental defect in the RPE. We present a case of torpedo maculopathy utilizing fundus photography and OCT. The color fundus and OCT images respectively demonstrate the form and structural aspects characteristic of the torpedo maculopathy lesion.montgomery_torpedo
Acute Vision and Hearing Loss: Can Susac Syndrome Explain these Symptoms?Moore2013Susac Syndrome is a rare condition characterized by a triad of encephalopathy, Branch Retinal Artery Occlusion and hearing loss. Predominately seen in woman, Susac syndrome has been reported in men and can occur with an atypical presentation. This case report highlights a 65 yo white male who was diagnosed with Susac Syndrome after reporting to the ER with a complaint of acute hearing and vision loss. Since vision loss can be a presenting symptom and the condition can be misdiagnosed or underdiagnosed, optometrists should be aware of this condition in order to coordinate proper screening, diagnosis, care and follow up.moore_susac
Myopic Shift with Angle Closure Glaucoma; Culprit::Sulfamethoxazole/trimethoprim::Ngoddy2013Adverse reactions to medications can be visually impairing. Sulfamethoxazole/trimethoprim has had such reactions. Sulfa based drugs have been specifically implicated in myopic shift, pupillary block and angle closure glaucoma. A 25 year old male presented with complaints of blur and nausea. Medical history was incomplete, the patient reported he was being treated for abdominal pains and had a history of mononucleosis. On initial visit his medication list was incomplete although he reported ten different medications. Vision was correctable to 20/25 OD and 20/30 OS with a 3 Diopter myopic shift OU. SLE was remarkable for pupillary block/shallow A/C. DFE was remarkable for cotton wool spots. Treatment, Atropine 1% BID, restored vision and angle. This case emphasizes the importance of complete case history and proper treatment for medication induced angle closure.ngoddy_myopic
Isolated Third Nerve Palsy Due To Cerebellopontine Angle MeningiomaNguyenLoren Bennett OD, MPH, James H. Quillen VAMC2013A third cranial nerve palsy (CN III) is not uncommon with 29% prevalence in adults. CN III palsy can be complete or partial and can be isolated with or without pupil involvement. An acute presentation in the adult population is most commonly due to ischemia or microvascular problems. It can also be associated with aneurysm, trauma, tumors, and ophthalmoplegic migraine. This case describes a 73 year old male with insulin dependent diabetes mellitus who presented with acute diplopia, a slight restriction in superior temporal gaze OD, no ptosis, and pupil sparing. After 4 months the partial third nerve palsy OD was not resolved and MRI revealed a left cerebellopontine angle meningioma. The patient underwent successful craniotomy, but suffered residual diplopia and trigeminal neuralgia. This presentation highlights the clinical evaluation and management for acute CN III palsy in the adult population.nguyen_palsy
Bilateral Corneal Edema and AmantadineNguyenLee Vien, OD; David Yang, OD; Alex Park, OD2013Purpose: To discuss a case of bilateral corneal edema in aims of better understanding the spectrum of corneal damage associated with Amantadine toxicity for proper timely diagnosis and management to prevent irreversible corneal toxicity. Case Report: A 63-year old male with notable tremor and a history of tardive dyskinesia and Parkinson’s disease was being treated with Amantadine for 1.5 years. He presented with severe bilateral stromal edema and prominent Descemet’s folds without signs of inflammation, guttatae or Fuch’s endothelial dystrophy. Although difficult to discern without successful gonioscopy, angles were narrow in both eyes via Van Herrick and OCT evaluation. Anterior chambers were quiet and formed with intraocular pressures measuring 15 mmHg in both eyes. Pachymetry and anterior segment OCT confirmed significant corneal thickening of 870um OD and 889um OS. Discussion: Amantadine is a commonly used medication in the treatment of Parkinson’s disease and for drug-induced dyskinesia associated with anti-Parkinsonian medications. Few reports have been published regarding the reversibility of the corneal edema after discontinuation of the therapy though recent literature suggest that Amantadine-induced corneal edema may irreversibly damage corneal endothelium in a dose-dependent manner and may even lead to corneal graft rejection without timely diagnosis and management.nguyen_bilateral
Using Advanced Technologies to Diagnose Idiopathic Uveal Effusion SyndromeParker2013Uveal Effusion Syndrome is a rare idiopathic condition that usually occurs in middle-aged hyperopic males. The condition is characterized by diffuse choroidal detachment with associated retinal folds and exudative retinal detachment. A 67-year-old WM presented with a complaint of long-standing decreased vision OS with a central clear area of vision surrounded by a grayish circle. The patient had been previously diagnosed with age related macular degeneration (ARMD) in 2003. Upon examination, the patient was found to have mildly decreased vision OD (20/20-) and moderately decreased vision OS (20/40-) with a hyperopic refraction OU. Retinal findings included retinal pigment epithelium (RPE) atrophy and pigmentary changes nasal and temporal to macula OD and centrally within the macula OS. Along with these retinal findings, diffuse choroidal folds were found OU. All retinal findings were evalulated and documented using fundus photography, optical coherence tomography (OCT) and fundus autofluorescence (FAF). This poster will demonstrate the use of today’s technology in the documentation, analysis, and management of ocular disease, specifically retinal photography, OCT, and the emerging imaging technique of FAF to more rapidly identify and manage a patient’s disease process.parker_advanced
The history never ends - a case of Talc RetinopathyPateBrandon Runyon, BS, Jace Dale Martin, BS2013Talc retinopathy is an uncommon ophthalmologic finding of intra-retinal deposition of talc particles in patients with a history of intravenous drug abuse. Patients are rarely symptomatic and usually very hesitant to admit to drug use when questioned during their medical history; therefore, this diagnosis could easily be overlooked or misdiagnosed. A 50-year-old African American male presented for his first eye exam with symptoms of blurred distance and near vision for one year, having only used reading glasses for near vision in the past. Only after the patient was re-questioned at the end of his exam about his past social history did he admit to over a 20 year history of IV drug abuse. This case presentation highlights the many differential diagnoses for refractile deposits in the retina and signifies the importance of a careful case history to making an accurate diagnosis. Clinical course, associated systemic complications and management of the condition are also discussed.pate_talc
Fishing for a Diagnosis: Two Case Reports and a Clinical Review of Mucous Fishing SyndromePateMolly Clark, BS; Karla Thomason, BS2013Mucus fishing syndrome is a rare condition characterized by a history of recurrent mechanical removal of mucus from the eye, which then ignites a cycle of surface damage followed by nonspecific surface irritation, leading to further mucus production and foreign body sensation. Patients do not often present with a chief complaint of excess mucus production due to feelings of embarrassment; instead patients may complain of dryness and/or irritation, and the clinician must search further for the correct diagnosis. A 52-year-old male presents complaining of a “gummy white” discharge along with dryness, itching and burning. A 30-year-old female presents for a comprehensive eye exam with no complaints, but later reveals that she removes “goops” of mucus from her eyes daily. These two case presentations emphasize the significance of a thorough patient history along with sensitivity to patient’s emotions. In addition to topical therapies, treatment for patients with mucus fishing syndrome involves behavioral modifications to eradicate the cycle of mucus production and ocular surface irritation.pate_fishing
An Unusual Case of Early Onset Acute Corneal HydropsPatelWilliam Miller, O.D., Ph.D., FAAO2013Acute corneal hydrops (CH) is an infrequently seen complication in patients with advanced keratoconus. In these patients, severe keratoectasia results in spontaneous rupture of the posterior limiting lamina (PLL) resulting in bullous stromal edema. Although the current literature suggests that the mean onset of keratoconus is during the second decade of life, onset of CH only occurs in cases of advanced disease. This report describes an unusual case of early onset CH during the first decade of life. An 8-year-old Hispanic male presented to the University Eye Institute with complaints of bilateral decreased vision and intermittent unilateral pain and photophobia. The patient’s guardian reported a history of keratoconus OU with CH occurring in the right eye four months previously. The patient was treated during the acute phase but the symptoms had failed to resolve completely. His symptoms and clinical presentation at our initial examination confirmed the diagnosis of keratoconus OU with severe corneal scarring secondary to CH OD. Subsequent irregular astigmatism required this patient to be managed with gas-permeable contact lenses to obtain best possible visual acuity.patel_hydrops
Iris Implant and the Harmful Effects Post ImplantationPatel2013Iris implants or iris prosthesis, have been considered and used for individuals with congenital and acquired iris defects. These defects can cause debilitating symptoms for patients. Thus, iris implants have been used to decrease or eliminate symptoms. However, several studies and case reports have shown that risks may outweigh benefits due to severe complications. A 36-year-old white female complained of nighttime glare, dryness, and dissatisfaction with iris implant cosmesis. Ocular assessment included dry eyes, anterior chamber reaction, iris pigment liberation, and subsequent increased IOP. Clinical findings, photos, and management of iris implantation are discussed. This case report depicts some of the complications post implantation, the potential devastating course of disease, and its management and treatment.patel_iris
Alternative Pharmacological Testing in Horner's SyndromePerkins2013Horner’s Syndrome is characterized by the classic neurological triad of ptosis, miosis and facial anhidrosis. The etiology of this condition is an interruption of the oculosympathetic nerve pathway to the eye. A lesion anywhere in the eye, head, or neck along the three-neuron sympathetic pathway from the hypothalamus to the eye can produce this syndrome. Determining the location of the lesion is essential as causes can range from benign to life threatening. The patient outlined in this case presented to our clinic with ptosis of the left eyelid and miosis of the left pupil. He had no other neurological symptoms but did report a history of Cluster headaches. Pharmacological testing was preformed with apraclonidine to confirm Horner’s syndrome, then on a subsequent visit Phenylephrine 1% was used to localize the lesion to a Third-order neuron. The patient was sent for neurological testing including head and neck MRI, carotid ultrasound, and a chest x-ray. All testing was normal and Cluster headaches were determined to be the cause of this patient’s acquired Horner’s syndrome.perkins_horners
How diplopia can creep up on you: differentiating between age-related distance esotropia and sixth nerve palsyPolonenkoPia Hoenig, OD, MA, DBO(T), FAAO2013Sixth nerve palsy is regarded as the most plausible and foremost differential when adults present with an onset of distance horizontal diplopia and restrictions in abduction. However, other mechanical causes may present similarly. MRI studies have shown that age-related atrophy of involutional fat in the orbit may cause a weakening of the lateral recti and a resultant eso-deviation greatest with distance viewing. Using a case example, this poster will highlight essential clinical tests to aid in differentiating between serious etiologies requiring immediate action from those of anatomical or mechanical causes. Viable treatment options will also be discussed as they relate to the case presented.polonenko_diplopia
Sizing up the options: a step-wise approach to managing refractive and pathology-related aniseikoniaPolonenkoPia Hoenig, OD, MA, DBO(T), FAAO2013Aniseikonia is a binocular condition induced by refractive anisometropia and/or macular pathology. It is characterized by the unequal image size and/or shape seen by the two eyes and processed by the visual cortex. While contact lenses are successful in minimizing refractive aniseikonia, they are less effective with aniseikonia induced by macular pathology. Often, spectacle correction is also used in management, either as primary or secondary treatment options. Designing a spectacle lens, which minimizes the aniseikonia via manipulation of the shape and power factors, can be perplexing. Using case examples, this poster addresses the types of aniseikonia and the stepwise approach to measurement and treatment of the various types of aniseikonia.polonenko_aniseikonia
Induced Plateau Iris Syndrome and Diagnostic Function of AS-OCTPotterMarco Gonzalez2013The primary cause of plateau iris syndrome is steep insertion. Secondary causes of plateau iris syndrome include iris cysts and tumors. Ultrasound biomicroscopy (UBM) is useful for differentiating between iris cysts and tumors. A 40 year-old male presented to our clinic for the first time with a complaint of decreased vision. Anterior segment was remarkable for patent laser peripheral iridotomy (LPI) OU, otherwise unremarkable. Anterior segment post dilation revealed a bullous, pigmented lesion eminating from the posterior iris into the pupil space at 5 o'clock. Ocular history revealed that the patient underwent LPIs for a diagnosis of anatomic narrow angles with elevated IOP. After treatment, the angles remained narrow and elevated IOP persisted, even with addition of topical pilocarpine. Based on poor treatment results, plateau iris was suspected. UBM revealed pseudoplateau iris syndrome secondary to bilateral iridocilliary cysts. ECP along with clear lens extraction was performed to try and open the angles. The majority of the cysts diminished in size. Anterior segment optical coherence topography (AS-OCT) in our office confirmed the prior diagnosis of an iridociliary cyst. AS-OCT could be helpful for the primary care optometrist in diagnosing primary and secondary plateau iris in office and referring as indicated.potter_iris
Primary Oculomotor Nerve Palsy Induced by High HIV Viral LoadPsaltis2013Background: Human Immunodeficiency Virus (HIV) causes a variety of adnexal, anterior segment, posterior segment, orbital and neuro-ophthalmologial findings. In this case, a patient presented with a pupil-sparing oculomotor nerve palsy coinciding with a dangerously high viral load without secondary infection or neoplasm. Case History: A 50-yr-old AAM presented to University of South Carolina Ophthalmology for a CMV screening complaining of blurred vision OU. Upon presentation he had a RUL ptosis and abnormal adduction, supraduction and infraduction OD. The pupils were equal and reactive without APD. The remaining cranial nerves were unaffected. MRI and MRA of the brain with contrast were negative. Fasting glucose, HA1C, EAG, CBC with differential, IgM, IgG, RPR and CSF cytology were unremarkable. Discussion: The nervous system is involved in up to 50% of HIV infected patients with a wide range of clinical presentations. Primary HIV induced oculomotor nerve palsy has been rarely documented. This patient presented with a pupil-sparing oculomotor nerve palsy without evidence of secondary infection or neoplasm. HIV testing should be included in the work-up of a patient presenting with a third-nerve palsy and primary HIV-induced palsy should be a diagnosis of exclusion.psaltis_palsy
Scleral Contact Lenses in the Treatment of Pediatric Aphakia Following Traumatic Cataract ExtractionPsaltisLauren Hacker, OD2013Background: In this case, multiple specialties collaborated recovering the vision of a 6-year-old girl with a traumatic cataract and retinal dialysis following globe rupture. A scleral RGP was the vision corrective option for this post-trauma aphakic patient. Scleral lenses should be considered for pediatric patients due to comfort and stability. Case Report: A 6-year-old female presented to the pediatric emergency department after a BB injury OD which resulted in a violated lens capsule with cortical matter extending into the anterior chamber. Evaluation following cataract extraction and vitrectomy revealed peripheral retinal dialysis with commotion retinae with no intraocular foreign body. The patient was fit in an Essilor Jupiter lens and a nasal corneal suture was removed to avoid limbal lens bearing. The patient was successfully fit in a +17.00 D, 15.7 mm diameter, 7.54 mm base curve in Boston XO2 material with a BCVA of 20/25. Polycarbonate bifocals were prescribed with two hours of patching OS daily. Conclusions Pediatric ocular trauma generally requires the teamwork of ocular specialties. Scleral RGPs should be considered in pediatric aphakic contact lens fittings. The vision correction achieved with these lenses may delay the need for an IOL implant at an early age prior to myopic shift.psaltis_scleral
Tumors of the Choroid: A Case SeriesPuglisJonathan P. Reid, O.D.; W. Scott Slagle, O.D., FAAO2013Background: The rich vascular supply of the choroid renders it susceptible to various neoplastic processes. The variety of choroidal tumors demonstrates a spectrum of diverse prognoses, underscoring the importance of clinical acumen in discriminating benign from morbid or potentially life-threatening disease. Case Report: A case series of patients with primary choroidal melanoma, metastatic choroidal carcinoma, choroidal osteoma, and an atypical choroidal nevus are contrasted. Distinguishing sonographic features are presented along with discerning clinical characteristics to differentiate these four types of choroidal masses. Appropriate ophthalmic management is also reviewed. Systemic evaluation is necessary to determine remote involvement of malignant choroidal tumors, and a summary of pertinent systemic cancer evaluation is outlined. Conclusion: Utilization of ophthalmic ultrasonography and clinical appearance to differentiate choroidal neoplastic processes is paramount. After accurate diagnosis, further systemic evaluation and surveilance is mandatory for metastatic processes. Very often, choroidal masses present asymptomatically, but may be important indicators of detrimental systemic disease.puglis_tumors
Chronic Recurrent Central and Non-Central Serous Chorioretinopathy in a Combat VeteranRademacher2013Central Serous Chorioretinopathy (CSCR) is a disease of the retinal pigment epithelium (RPE) characterized by a neuro-sensory retinal detachment. CSCR has a predilection for young to middle aged males with psychosocial stress or increased cortisol levels. Patient symptoms include central blur and distortion along with a dark spot in the central vision. A 33 year old male presented to clinic with symptoms of blur and a dark ring in his central vision. Funduscopic evaluation revealed a macular neuro-sensory retinal detachment confirmed with optical coherence tomography (OCT). The patient continued to be monitored monthly. At the four-month recall the patient reported improved central vision. Funduscopic evaluation revealed resolution of the central neuro-sensory retinal detachment with a fluid-blister along the superior vessel arcade. OCT imaging revealed a non-central RPE detachment with an overlying neuro-sensory retinal detachment. The patient continues to be monitored monthly for resolution of the neuro-sensory retinal detachments.rademacher_recurrent
What do diabetes, deafness and macular pattern dystrophy have in common?RambeauRebecca Diller, OD2013A 64 year old veteran presented for a vision exam with decreased vision OD>OS. Previous exams had reported extensive macular pattern dystrophy, progressive choroidal atrophy and worsening vision. The veteran had a medical history significant for diabetes and hearing loss. After thorough examination and a careful review of his health records, the veteran was diagnosed with Maternally-inherited Diabetes and Deafness (MIDD). MIDD is a subset of diabetes attributed to a mutation of mitochondrial DNA that uniquely presents with a macular pattern dystrophy. These patients can have significant visual impairment secondary to the macular changes contrary to the characteristic retinopathy and macular edema typically associated with diabetic vision impairment.rambeau_diabetes
Bilateral optic neuritisRambeauRebecca Diller, OD, FAAO2013Unilateral optic neuritis in adults is typically associated with multiple sclerosis, but what about an acute attack of bilateral optic neuritis? A 30 year old male veteran presented with ocular pain, decreased vision, no afferent papillary defect, pain with eye movements, and non-specific color vision defects two months after sudden onset vision loss secondary to a seizure. This case will highlight the etiology, systemic associations, and clinical features. We will review the Optic Neuritis Treatment Trial (ONTT) and the Longitudinal Optic Neuritis Study (LONS) as well as the treatment and management of our patient with bilateral optic neuritis.rambeau_neuritis
Ocular Manifestations of Mantle Cell LymphomaReidChristie L. Puglis, O.D., W. Scott Slagle, O.D., FAAO2013Background: Non-Hodgkin’s lymphoma (NHL) is a neoplastic process of the lymphatic system in which tumors develop from lymphocytes. The absence of Reed-Sternberg cells differentiates non-Hodgkin’s from Hodgkin’s lymphoma. Mantle cell lymphoma is a mature B-cell non-Hodgkin’s lymphoma, typically with a moderately aggressive course. Case Report: A 71 year-old caucasian man presents with recent onset blurred vision OS resulting from corneal edema and a fulminant, recalcitrant anterior uveitis. With treatment and associated resolution of corneal edema, iris examination reveals topographic and morphologic atypia. Anterior chamber paracentesis with aqueous cytological and flow cytometry was inconclusive. Subsequently, the patient developed posterior cervical lymph node involvement and was restarted on chemotherapy and radiation for recurrence of mantle cell lymphoma. The iris involvement, deemed to be neoplastic, and the associated uveitis are assumed to be a manifestation of the cancer recurrence. It is expected that the iris condition will respond to chemotherapy for lymphoma. Conclusion: Lymphoma may present with ocular manifestations such as uveitis and morphologic changes to the uvea.reid_lymphoma
Bilateral Cranial Nerve IV Palsies Secondary to Traumatic Brain InjuryRobbins2013This is the case of a 46 year old male with bilateral cranial nerve IV palsies secondary to a hemorrhagic contusion in the occipital horn of the right ventricle after an 18 wheeler truck roll-over accident. Throughout the long course of neurological healing, management included occlusion foils, prism, modification of spectacle modalities and the future possibility of strabismus surgery. Based on symptoms and results of specific ancillary testing, the appropriate treatment for this patient will vary throughout his neurological healing. A collaborative treatment approach supporting his rehabilitative therapies will allow him to regain all functional aspects of his life.robbins_cranial
Should Durezol (difluprednate 0.05%, Alcon) be considered the new standard of care for anterior uveitis? A Case Study.Roberts2013Introduction: Pred Forte (prednisolone acetate 1%, Allergan) has long been considered the drug of choice in a patient who presents with signs and symptoms of anterior uveitis. However, in 2008 the Food & Drug Administration (FDA) approved a new topical corticosteroid for the treatment of post-operative ocular pain and inflammation. Although its use is considered off label, the properties of Durezol have made it a successful option in the treatment of anterior uveitis. Case Presentation: A 46 year old African American female with a history of bilateral recurrent anterior uveitis presents with complaint of redness, photophobia, and cloudy vision. At initial presentation the patient was currently being treated with 1 gtt Pred Forte q3h. Upon examination patient was found to have 2+ cell and flare with a cyclitic membrane and small hypopon in the OS with a deep and quiet OD. In addition, the OS displayed a small area of posterior synechiae and OD showed pigment on the anterior lens capsule indicative of remnants of posterior synechiae. At this visit IOP was 20 mmHg OU. She was diagnosed with chronic uveitis OS and treatment was changed to 1 gtt Durezol q2h and Cyclogyl tid OS. Patient was also advised to consult a rheumatologist and return follow up in 3 days. Management and Outcome: Upon her return patient showed marked improvement in signs with the disappearance of the cyclitic membrane and reduction in flare presentation; as well as resolution in symptoms of redness and photophobia. The patient was subsequently tapered off all medications successfully. The consult with the Rheumatologist revealed no abnormalities. Discussion: Difluprednate ophthalmic emulsion 0.05% (Durezol, Alcon) is a modification of prednisolone FDA approved in 2008. The change in its structure helps to increase corneal penetrance and glucocorticoid receptor activity allowing for less frequent dosing than prednisolone. Durezol’s emulsion vehicle provides a uniform concentration of medication in each drop and eliminates the need for shaking. Despite prednisolone’s long history as the gold standard, the effectiveness of Durezol has placed it in the realm if first line treatment options for anterior uveitis.roberts_durezol
Systemic Disorders Associated with Prominent Corneal Nerves: A Case ReportRobinson2013In this poster I will discuss systemic disorders associated with prominent corneal nerves. The case report involves a patient with Multiple Endocrine Neoplasia (MEN), a rare, but potentially fatal disease. The main focus will be on MENs three subtypes and will discuss its genetics, systemic findings, and treatments. Other systemic diseases to be discussed include Refsums's disease, Hereditary Ichthyosis, Neurofibromatosis Type 1, and Primary Amyloidosis.robinson_systemic
Like Mother, Like Daughter: Using Anterior Segment OCT To Visualize and Monitor Corneal Granular DystrophyRodmanEva Duchnowski OD, Rim Makhlouf OD2013BACKGROUND: Granular Corneal Dystrophy is a hereditary bilateral disorder characterized by the deposition of small, gray-white, irregular hyaline deposits in the stroma separated by clear intervening spaces. AS-OCT of the cornea localizes the anatomical abnormality and provides an additional way of examining and monitoring patients with granular dystrophy. CASE REPORT(s): A 67-y/o African–American mother and her 40-y/o daughter, both previously diagnosed with Granular Dystrophy, were examined with chief complaints of blurry D and N vision OU that had occurred gradually within the last few years. Their BCVAs were 20/40 OU. SLE was positive for scattered stromal granular opacities OU. AS-OCT showed multiple highly reflective lesions, corresponding to the same location where "breadcrumb" deposits were clinically seen in the stroma. CONCLUSION: AS-OCT is helpful in visualizing the granular deposits and their surroundings and can be used to document the presence of a lucid area surrounding the discrete opacities seen on SLE. It also aids in documenting the depth of the deposits allowing us to more closely monitor those patients at risk for corneal erosion. Furthermore, the biomicroscopy and AS-OCT findings were nearly identical between the mother and daughter, thus supporting the genetic predisposition associated with this rare dystrophy.rodman_granular
Synchysis Scintillans: A Case ReportRodmanTaewon R Kim2013Background Synchysis scintillans is a rare vitreous disorder, defined as angular crystals in a degenerated vitreous or aqueous. The crystallization occurs from severe or recurring vitreous hemorrhage. Histopathological evaluation of these crystals has revealed the presence of cholesterol, and thus this entity has also been called cholesterolosis bulbi. Case Report A 35-y/o female presented with a painful, red OS for four weeks. She had no vision OS as a result of RD from blunt trauma. She was taking Atropine, Prednisolone Acetate, and Dorzolamide OS. The sharp pain was alleviated temporarily, but returned. PMH was positive for HIV and pre-diabetes. POH was pertinent for cataract extraction OU. BCVA was 20/30-2 OD and NLP OS. EOMs showed pain OS without diplopia or restriction OU. Fields were full and unrestricted OD. Her right pupil was round and reactive to light without reverse APD. Biomicroscopy OS demonstrated ptosis, 3+ conjunctival injection and corneal edema. There were crystalline bodies within the aqueous and an inferior hyphema in the A/C. Conclusion Synchisis scintillans is a rare vitreal abnormality resulting from severe or recurring vitreous hemorrhage. Due to the association with chronic vitreous hemorrhage secondary to trauma or neovascularization, the visual prognosis is poor.rodman_synchysis
Carotid Crisis: First Recognized by Optometrists with a Multidisciplinary ManagementRoperKimberly Dillivan, O.D., F.A.A.O.2013With a five year mortality rate of 40% from cardiac disease, ocular ischemic syndrome (OIS) is a rare but commonly underdiagnosed ocular disease with a highly insidious underlying etiology. After misdiagnosis of his symptoms as a possible stroke by emergent care, a 64-year-old Caucasian male presented one week later for an annual eye exam with complaints of light sensitivity and blurred vision. Pertinent ocular findings included unilateral midperipheral hemorrhages and venous dilation. What will be discussed is an interdisciplinary approach to managing OIS, supplemented by diagnostic testing including carotid duplex studies, carotid arterial CT angiography, and myocardial perfusion imaging. After bilateral endarterectomies, our patient’s ocular signs completely resolved. This case demonstrates the significant role that optometrists play in the systemic health of their patients by recognizing OIS and the life threatening conditions associated with it. By proper multidisciplinary management, our patient is stable and his systemic symptoms have resolved to where he is now routinely monitored by optometry, cardiology, and vascular.roper_carotid
Deciphering Multiple Diagnoses: Systemic Vascular Disease complicating the Ocular Clinical PresentationRosatiJonathan R. Hamilton, O.D., Kara Gagnon O.D., F.A.A.O.2013Vertebrobasilar insufficiency (VBI) results from decreased blood flow to the posterior portion of the brain. The basilar artery supplies circulation to the occipital lobe, cerebellum and brainstem. Therefore the symptoms can vary, ranging from vertigo to dysphagia depending on the location of the ischemia. Symptoms may appear isolated or in conjunction with other pathology making the initial diagnosis difficult. Transient bilateral vision loss is the most common ocular manifestation of VBI. This report reviews a unique case of VBI in a legally blind patient presenting with intermittent amaurosis. This previously unexplored finding was discovered during his comprehensive low vision examination. Differential diagnoses, work-up and patient management will be discussed.rosati_vascular
Congenital Optociliary Shunt VesselsSanbornNadia Zalatimo2013Documented cases of congenital optociliary shunt vessels are quite rare and bilateral presentations are exceedingly more rare. Optociliary shunts represent an atypical communication between the choroidal circulation and the retinal venous system. There are distinct differences between congenital and acquired optociliary shunts and due to the more typical associations with a variety of ocular pathology, it is important for the primary eye care provider to be aware of these associations and to rule these out with a thorough examination with the requisite secondary testing. Here we discuss a case of a 30 year old asymptomatic white female with no notable medical or ocular history who presents with bilateral optociliary shunts on clinical exam.sanborn_shunt
Polypoidal choroidal vasculopathySantapaolaAnuradha Veerappan, O.D., M.S., Nancy N. Wong, O.D., PhD, F.A.A.O., Becky Forman, O.D.2013Background: Polypoidal choroidal vasculopathy (PCV) is a vascular disease characterized by formation of polypoidal lesions at the choroid. Lesions may result in serous and serosanguineous retinal neurosensory and pigment epithelial detachments. Although the pathogenesis remains elusive, recent investigations suggest PCV represents a variant of type 1 neovascularization. PCV neovascularization is optimally visualized with indocyanine green angiography and spectral domain optical coherence tomography (SD-OCT). PCV lesions demonstrate characteristic findings on SD-OCT which facilitate diagnosis. Differentiating PCV from other retinal neovascular diseases may optimize treatment. Case Report: A 77 year-old male presented for examination. Best-corrected visual acuities were 20/20 in both eyes. Fundus examination revealed para-papillary subretinal hemorrhaging in the right eye. SD-OCT demonstrated polypoidal lesions underneath the retinal pigment epithelium (RPE). SD-OCT revealed the “double bubble” sign characterized by the polypoidal lesion separating the RPE from Bruch’s membrane. Conclusion: Clinical examination and fluorescein angiography to assess neovascularization may not differentiate PCV from other retinal diseases. However, ancillary testing, in particular, SD-OCT, demonstrates unique findings which are suggestive of PCV. Recognition of the characteristics facilitates diagnosis and guides treatment optimized for PCV. This poster examines the demographics, genetics, clinical characteristics and proposed pathogenesis of PCV. Moreover, PCV treatment and management are discussed.santapaola_polypoidal
Etiology of Endotheliitis: Case review of Herpes Simplex Type II EndotheliitisSantaroRachel Beneski, O.D.2013A 68 year old white male presented with history of ulcerated lesion on right upper lid followed by photophobia, foreign body sensation and blurred vision of the left eye for a month prior. A non granulomatous anterior uveitis with associated endotheliitis was found on exam. Corneal endotheliitis commonly presents with corneal edema primarily in the endothelium, keratic precipitates and an anterior chamber reaction; all of which had manifested in our patient. Disease etiology is thought to be associated with various viral infections including herpes simplex virus, varicella zoster virus and cytomegalovirus. Antiviral treatments in conjunction with corticosteroids are typically successful in treating the inflammation and underlying etiology. However, it is important to keep in mind that permanent endothelial dysfunction may develop from prolonged inflammation and damage to the cornea. Also, due to viral etiology patients and practitioners should be aware that recurrent episodes of endotheliitis are possible if underlying virus is not treated.santaro_herpes
Losing more than you bargained forSayaniJen Idoni, O.D.2013Losing more than you bargained for As gastric bypass surgery increases in popularity, it is crucial optometric physicians are aware of potential ocular and systemic manifestations, some of which can be life threatening. A 57-year-old African American female was diagnosed with Wernicke Encephalopathy following gastric bypass surgery. The classic triad of this condition is ophthalmoplegia, ataxia and short term memory loss. The patient complained of hazy/cloudy vision and a perception of the world shifted upward, presumably as a result of new onset vertical nystagmus. As decreased thiamine levels were restored, the nystagmus essentially resolved and symptoms improved. Understanding potential sequelae of gastric bypass surgery and appropriate management is essential in optometry. Amar Sayani, O.D. Pediatrics and Vision Therapy Resident Southern College of Optometry Jen Idoni, O.D. Pediatrics and Vision Therapy Resident Southern College of Optometrysayani_losing
It’s all relative – An Afferent Pupillary Defect Associated with Optic Nerve Head DrusenSchinasJulie A. Tyler, OD, FAAO; Alan Kabat, OD, FAAO2013Background: Optic nerve head drusen (ONHD) is a relatively uncommon finding with a prevalence of 0.3% to 2%. ONHD are hyaline-like bodies which may be seen within, on the surface, or in the peripapillary region of the optic nerve. Case Summary: A 54 year old female presented for comprehensive examination and CL fitting. Ocular history was significant for S/P LASIK and RK OU and systemic history significant for Diabetes. Best corrected visual acuity with RGP over-refraction was 20/40 OD and 20/30 OS. Of note, pupillary testing revealed a relative afferent pupillary defect OS. Biomicroscopy revealed RK incisions into the line of site and topography confirmed very flat central corneas with areas of irregularity. Dilated fundus examination revealed crowded optic nerve OD without swelling or NVD; the optic nerve OS had a drusenoid appearance sup-nasal. The patient returned to the clinic for VF testing and B-scan. A distinct, large drusen was visualized on B-scan and VF defect was noted OS>>OD. Conclusion:Patients with ONHD may be asymptomatic; however, a patient may also present with visual field defects and decreased vision. Reports of relative afferent pupillary defects (RAPDs) associated with ONHD are uncommon. The various diagnostic tests relevant to this case, the differential diagnosis, and the features of ONHD will be discussed.schinas_afferent
"Rings" around the Conus: Wessley ring in a patient with concurrent keratoconusSchinasJulie A. Tyler, OD, FAAO2013Wessley rings represent immune complex depositions around the central cornea due to nearly equal concentrations of antigens and antibodies that become a visable “circle” in the stroma. They have been associated with various infectious etiologies, including herpes simplex, Acanthamoeba, and other bacterial, fungal and viral agents. A 25 year old female presented with blurry vision and photophobia OS. The patient had a seven year history of keratoconus OU and one year prior, she had an episode of iritis OS. During examination findings of interest included apical corneal scarring OS>>OD, Vogt’s striae and corneal thinning -consistent with keratoconus – and concurrent microcystic edema, disciform keratitis and evidence of an Wessley ring.schinas_wessley
The conundrum of optic disc pit related maculopathyScottDr. Julie Rodman2013Optic disc pits are a very rare clinical entity, most often found on routine eye examination. Visual acuity may be affected when a coinciding maculopathy is present. Macular involvement varies and includes macular edema, schisis-macular detachment, or variations in macular pigment. The pathophysiology of opticdisc pit related maculopathy remains unclear. There is uncertainty regarding the origin of the fluid and how the fluid leads to detachment of the macula with subsequent complications. The mechanism appears to involve liquefied vitreous over an abnormally developed optic nerve, resulting in the migration of fluid under and/or into the retina resulting in maculopathy. We present the case of an optic pit associated with an irregular, diffuse retinal atrophy.scott_opticpit
Off-label Use of a CRT Lens to Solve Glare and Fitting Challenges With Post RK CorneaShulerDr. John Mark Jackson, Dr. William Edmondson2013A 58 YOM truck driver presented with two post RK (2001) issues that affected his occupation: significant night glare and large hyperopic shift. While a standard GP lens provided acceptable centration and vision for the OD; neither standard GP nor reverse geometry lenses were satisfactory for OS. A piggy-back system provided acceptable vision for the OS, but glare issues continued. In an attempt to reduce glare by controlling pupil size, he tried both Alphagan P and driving with the overhead light, but without relief. In an off-label use, a Paragon CRT lens (-1.00/9.2/550/32) successfully provided the comfort, fit, and vision with reduction in glare. Video and photos are available.shuler_crt
Ocular conditions associated with Obstructive Sleep ApneaSingh2013Obstructive sleep apnea (OSA) is a condition where individuals experience episodes of upper airway blockage while sleeping. The number of cases has risen as the prevalence of obesity increases in the population. There are several ocular conditions associated with this sleep disorder including floppy eyelid syndrome (FES), glaucoma, nonarteritic anterior ischemic optic neuropathy (NAION), and papilledema. Each of these may be the presenting condition that prompts further evaluation of the patients sleep behavior. A 63 year old Caucasian male presented with complaints of foreign body sensation and mucus discharge OD>OS for 6 weeks. His case will be discussed along with the treatment and management of the previously mentioned ocular manifestations.singh_apnea
Ocular Manifestations of ChlorpromazineSinghB. Roya Attarhosseini2013Chlorpromazine is a dopamine antagonist commonly prescribed worldwide for the treatment of schizophrenia since 1952. It was the first drug developed with specific antipsychotic action. Chlorpromazine is classified as a low-potency typical antipsychotic. It has been used in the past for the treatment of both acute and chronic psychoses, including schizophrenia and the manic phase of bipolar disorder as well as amphetamine-induced psychoses. Chlorpromazine works on a variety of receptors in the central nervous system, producing antidopaminergic, anticholinergic, antihistaminic, and weak antiadrenergic effects, although the main side effects of chlorpromazine are a result of its anticholinergic properties. Ocular manifestations of Chlorpromazine are rare, however when taken in high doses over a long period of time, ocular side effects usually include deposition in ocular tissues. Our case report discusses a patient who is well controlled on long term use of chlorpromazine with new rare case of abnormal retinal pigmentation.singh_chlorpromazine
An Asymptomatic Case of Ocular FlutterSkidmoreSusan Zacatelco, OD2013This poster overviews the case of a 72 year old white male that presented to clinic with a complaint of blurred vision. External observation revealed a bilateral and intermittent pendular nystagmus in primary and right gaze that dampened at near and with corrective lenses. The external and internal findings were unremarkable. The patient was diagnosed with acute onset nystagmus and sent to the neuroophthalmologist. Upon consultation, the patient was re-diagnosed with ocular flutter and sent for neoplastic antibody testing, CT/PET and MRI scans. Results of the initial testing were negative and the patient was placed on a 4-month recurrent recall for observation and retesting. Ocular flutter is a neuroophthalmic condition that causes bilateral, intermittent, horizontal saccades. The flutter is often triggered by eye movements and in general is accompanied by oscillopsia. The etiology is a bit unclear and the most frequent causes are paraneoplastic carcinomas and viral encephalitis. Treatment always starts with the underlying cause, while treating acute symptoms is somewhat experimental. This poster will review the signs, symptoms and pathophysiology of ocular flutter as well as discuss treatment options and follow up care. Key words: Ocular flutter, oscillopsia, saccades, omnipause neurons, burst neurons, nystagmus, opsoclonus.skidmore_flutter
What Lies BeneathSmith2013A 65 year old white male presented to the eye clinic for new glasses. Dilated fundus examination revealed bilateral optic nerve head drusen, which was confirmed with a B-scan. Fundus autofluorescence highlighted the exact location of the drusen, superiorly in the right eye and inferiorly in the left eye. OCT of the optic nerves showed thinning superiorly in the right eye and inferorly in the left eye. Humphrey Visual Field tesitng showed dense, steep defects inferiorly in the right eye and superiorly in the left eye. The location of visible optic nerve head drusen highly colocalizes with OCT thinning and fundus autofluorescence, and highly correlates with HVF defects, if present. In addition, autofluorescence is an easy, relatively accessible, non-invasive procedure that can be used to further correlate clinical findings.smith_beneath
A Twist of Fate: A case on Racemose Hemangioma of the RetinaSt. MartinJulie Rodman, O.D.2013A 14 year old patient presented with unilateral extremely dilated, tortuous arteriovenous communications extending from the optic disc to the mid-periphery consistent with Racemose Hemangioma of the retina in his right eye. Currently, the patient’s vision remains unaffected; however, A/V malformations such as Racemose Hemangioma, may cause both ocular and systemic complications, and at times, may even lead to death secondary to rupture or hemorrhage. A/V malformations either lack or have abnormal capillaries and produce a direct connection between the arteries and veins, known as a shunt vessel. Without intervening capillaries, the blood does not go to its adjacent tissues and instead gets pumped straight back to the heart. Severe retinal A/V malformations have a greater than 40 percent association with additional systemic A/V malformations. Ocular complications and risks include but are not limited to, vascular occlusions, retinal or macula ischemia, neovascular glaucoma, and vitreous hemorrhage. Even though, Racemose Hemangioma has a classic appearance clinically, it is important to know how to confidently manage these patients due to their increased risk of additional systemic A/V malformations and the danger of morbidity.stmartin_racemose
"I'm Back!": Herpes zoster ophthalmicus after surgeryStanberry2013Herpes zoster ophthalmicus is a well known and potentially devastating ocular condition. The varicella virus reactivation occurs most commonly in the immunocompromised or elderly populations. This case chronicles a less common inciting factor of varicella reactivation due to facial surgery. A 60 year old female with surgical excision of a squamous cell carcinoma from the nose led to herpes zoster reactivation involving the ophthalmic division of the trigeminal nerve with extensive ocular involvement. The ocular sequelae includes diffuse episcleritis, diffuse anterior scleritis, anterior uveitis, trabeculitis and pseudodendritic keratitis. A combination of oral Indomethacin and Acyclovir along with topical Homatropine, Pred Forte, Vigamox, and Dorzolamide led to the successful resolution of this condition.stanberry_herpes
Neurosarcoid: X marks the spotSwanholm2013The modern history of sarcoidosis dates back to 1899 when the Norwegian dermatologist Caesar Boeck coined the term to describe skin nodules that resembled sarcoma. In the past 10 years, more than 5000 articles related to sarcoidosis have been published, yet there are many questions left unanswered. Although etiology and pathophysiology have yet to be identified, we do know that sarcoid most commonly involves the lungs, eyes, and skin. Ocular signs can precede the diagnosis of sarcoid by years and thus it is important to recognize the various clinical ocular manifestations and their high variability. Further, the visual implications of a rare and interesting case of neurosarcoid with granulomas impinging on the optic chiasm will also be presented.swanholm_spot
Treatment and Management of Congenital Asymmetric Bilateral Ectopia LentisTitelbaum2013Congenital ectopia lentis, malposition of the ocular lens, usually manifests as lens subluxation associated with systemic disorders such as Marfan’s syndrome or Homocystinuria. However, congenital ectopia lentis can occur without systemic manifestation, in the form of ectopia lentis et pupillae. Ectopia lentis not caused by trauma and without systemic manifestations is very rare. Initial presentation includes blurry vision due to high myopia and astigmatism that progressively increases but can also include strabismus and amblyopia. It is important to follow these patients very closely as their refraction will change rapidly as the lens continues to subluxate. Once the vision is not correctable by glasses or contact lenses, a lensectomy is necessary and an anterior chamber lens implantation. However, due to the altered structure of the anterior chamber of an eye with ectopia lentis et pupillae, the risk of glaucoma is very high and aphakic contact lens treatment is the treatment of choice. In order to prevent dense amblyopia, early treatment and management of the pediatric patient with bilateral congenital ectopia lentis is necessary to allow for a good visual outcome. This case report reviews the treatment and management of a pediatric patient with bilateral asymmetric congenital ectopia lentis et pupillae.titelbaum_ectopia
Choroidal Metastasis as the Initial Manifestation of Esophageal Carcinoma: A Case Report and Review.TomkinsNathan Whitaker, OD,FAAO2013Although rare, metastases represent the most common intraocular malignancies. Hematogenous dissemination accounts for intraocular involvement and the vascular structure of the choroid makes it the most likely site for involvement. Rarely do metastases involve the iris or retina, and only isolated cases of metastasis to the optic nerve have been reported. Generally, intraocular metastases arise from the breast, lung, prostate and GI system. Herein we report an extremely rare case where choroidal and optic nerve metastasis was the initial manifestation of primary esophageal carcinoma.tomkins_choroidal
When the Brain Sees What the Eyes Don'tTreeceJeffrey T. Joy, OD, FAAO ; Gary Mancil, OD, FAAO2013This poster highlights a case involving a man with advanced macular degeneration who presented with complaints of visual hallucinations causing him great anxiety and depression. Charles Bonnet Syndrome is a complex condition whereby individuals with profound vision loss experience vivid visual hallucinations. Those who suffer from this condition are mentally sound and know their hallucinations are not real, but they are often hesitant to discuss the symptoms for fear of being labeled insane. This can cause stress, anxiety, and depression. Eye care professionals are in a unique position to recognize and diagnose this syndrome and can improve quality of life by reassuring patients that their hallucinations are benign and self-limiting.treece_brain
Ankylosing Spondylitis Uveitis and the Paradoxical Affects of EtanerceptTruong2013Approximately 40% of Ankylosing Spondylitis (AS) patients develop uveitis. This inflammation is acute, unilateral and recurrent. These patients are often placed on strong immunomodulating medications to control for inflammation, which in turn, should prevent uveitis from occurring. Etanercept, a tumor necrosis factor (TNF) inhibitor, has been linked with reported cases of uveitis despite its inflammation inhibiting properties. This poster reviews a case of an acute onset uveitis in an AS patient with impending Etanercept treatment, reviewing why this paradoxical affect occurs and what to do for patients who may have Etanercept related uveitis.truong_uveitis
Glaucoma Among the YouthVazquez2013The practice of optometry isn't solely based on optics and correction of refractive error. It encompasses the ability to diagnose and treat ocular diseases. Glaucoma is the second leading cause of blindness worldwide; therefore time of diagnosis and onset of treatment are critical. This twelve year old patient presented complaining of blurry vision OD for one month. Change of vision was observed after patient used friend's unknown drop for redness. Incoming visual acuity was 2/200 OD and 20/20 OS. Patient pinholed to 20/400 OD. Confrontation fields displayed a nasal defect OD and pupillary testing showed APD. IOPs measured 44mmHg OD and 36mmHg. Posterior findings revealed 0.9 c/d ratio OD and 0.75 OS with rim thinning OU. Initiation of treatment was prompt. Patient was started on Lumigan and Timolol. Patient returned after one month, revealing poor response to Timolol. Patient was switched to Combigan, aiming at higher efficacy for lowering intra-ocular pressures. This case demonstrated two important concepts, the first being that glaucoma isn't an ocular condition that affects only the elderly. Second, it's never too early to begin undergoing comprehensive exams. The ability to diagnose and treat are essential to the valuable role of an optometrist.vazquez_glaucoma
What is antiphospholipid syndrome? Not lupus!WatkinsNathan Whitaker, OD, FAAO2013Antiphospholipid syndrome (APS) is an autoimmune disorder that may cause arterial and or venous thrombosis. It was once believed that APS was a subtype of lupus. It wasn't until the 1990s that APS was recognized as a separate autoimmune disorder. What does this havee to do with optometry? There are many significant ocular complications attributed to APS, including anterior chamber reactions, vitreous hemorrhages, retinal detachments, vein occlusions and artery occlusions. In this review, we discus the pathway of APS, which patients may be at high risk for APS, how to manage a patient with APS, and patient prognosis.watkins_lupus
A Case of the WormsWelkeTheodore H. Fromm MD2013Ocular cysticercosis is a relatively rare parasitic infection in developed countries and is caused by the pork tapeworm Taenia solium. Ocular cysts of the parasite are most commonly found sub-retinal or intra-vitreal. The effects can be detrimental leading to severe vision loss or blindness. This case reviews a 25 year old Indian male that presents with a chief complaint of decreased vision and monocular diplopia. A thorough clinical exam reveals a chorioretinal lesion with a subretinal hemorrhage and a serous retinal detachment. Optical coherence tomography (OCT) and fluorescein angiography (FA) results indicate the need for further testing to rule out a systemic cause. A Complete Blood Count (CBC) with differential, head CT, chest x-ray, and an enzyme-linked immunosorbent assay(ELISA) for cysticercus antibody were ordered. ELISA results for the cysticercus antibody were positive thus indicating a cysticercosis infection.welke_worms
Orbital Adenoid Cystic Carcinoma: A Case Report and ReviewWhitakerSunita Jagani, O.D.2013Adenoid cystic carcinoma (ACC) are rare orbital malignancies, accounting for less than 2% of all orbital tumors. ACC generally occurs in the head and neck, with a particular propensity for the salivary glands. Though slow growing, the tumor can spread to adjacent structures and metastasize to the lungs, brain, and bone. Survival rates with ACC tend to be poor with less than 50% of patients surviving 5 years after diagnosis and only 20% surviving to year 10. Herein, we report the diagnosis and management of this rare malignancy in a 45 year-old female who presented with complaints of sharp, severe, shooting pain in her right eye.whitaker_adenoid
Idiopathic Sclerochoroidal Calcification in a 72 Year-Old MaleWongBrian Kawasaki, O.D.2013Background: Sclerochoroidal calcification is an uncommon ocular condition characterized by multifocal, yellow-white elevated fundus lesions typically located in the superotemporal quadrant along the superior arcades. Sclerochoroidal calcification can be classified as dystrophic, metastatic or idiopathic. Vision threatening complications may arise, such as choroidal neovascular membrane and serous detachment. Case: A 72 year-old Caucasian male presents to clinic for routine examination. Fundus evaluation reveals bilateral, multifocal, yellow-white elevated lesions in the superotemporal fundus. Ultrasound biomicroscopy shows a focal area of hyper reflectivity located at the level of choroid/sclera in both eyes. Optical coherence tomography shows an intact retina with elevated lesions in the choroid. Conclusion: The following lab tests were ordered for the patient to rule out systemic disease: comprehensive metabolic panel; serum magnesium; urinalysis of electrolytes, magnesium, and calcium; parathyroid hormone; and vitamin D. All results are normal, confirming an idiopathic etiology. The patient will be monitored annually with comprehensive eye exams.wong_idiopathic
Advancements in the diagnosis and management of irido-ciliary melanomasWuYi-San Lee, O.D. , Miriam M. Rolf, O.D., FAAO2013Malignant tumors of the iris and ciliary body represent a small portion of all uveal melanomas. Clinical characteristics of iris melanomas include documented growth, pigment dispersion and abnormal vasculature. A predilection for light irides has been found. Advancements in diagnostic procedures have led to improved treatment options with less risk for adverse ocular sequelae. An 81-year-old Caucasian male presented for an initial eye examination. A hyper-pigmented elevated lesion was noted on the patient’s left iris with mild corectopia without ectropion uvea. High frequency ultrasound imaging and a biopsy utilizing the Finger Iridectomy Technique (FIT) later confirmed the lesion’s malignancy. The patient underwent palladium-103 ophthalmic plaque brachytherapy for one week with subsequent tumor regression and preservation of vision. This poster reviews current diagnostic testing and recent advancements for diagnosing iris melanomas. Moreover, treatment and management is discussed.wu_melanomas
Striate MelanokeratosisXuDavid Yang O.D., F.A.A.O.2013Purpose: To describe a case of striate melanokeratosis in an African American patient with low vision. The causes of the corneal pigmentation are likely related to atopic allergic keratoconjunctivitis and lagophthalmos. Case report: A 69-year-old man was admitted to the Western Blind Rehabilitation Center with a history of diabetic retinopathy and advanced glaucoma both eyes. The patient was noted to have brown fragmented corneal pigmentation in a whorl like pattern in both eyes which merged with the Hudson-Stahli line in the right eye. He also had corneal scarring both eyes and pannus in the right eye. The corneal pigmentation pattern on patient's corneas was noted to change during his stay at the blind center and patient was subsequently diagnosed with striate melanokeratosis. Discussion: Striate melanokeratosis is an invasion of the pigment bearing cells from the limbal area into the basal epithelium of the cornea under an intact epithelium. It is proposed that the migration of limbal pigmented epithelium and limbal melanocytes is an attempt to repair compromised corneal epithelium from various corneal insults. Elevation of the pigmented lesions and some corneal opacification from the pigmented striae may contribute to further visual impairment.xu_striate
An Unusual Case of Acute Bilateral Angle Closure AttackAmin2012This was an unusual case of bilateral angle closure attack in which the etiology closely resembled that of Topomax use. A 35 year old Caucasian female was referred for an acute bilateral angle closure attack. Her entering acuities were 20/300 OD and OS. Her habitual refraction was -1.50sph OD and -0.75sph OS. However, she was correctable to 20/20 with a greater myopic refraction. There were no structures visible on gonioscopy and no signs of iris bombe. Her intraocular pressures were 36 OU and the optic nerve head tissue appeared healthy. The patient denied any previous or current use of Topomax. The myopic shift, lack of iris bombe, and poor response to laser iridotomy led to the conclusion that the angle closure attack was secondary to anterior subluxation of the lens from ciliary effusion. In addition, because there was no reported use of Topomax, systemic disease such as Marfan’s was ruled out. The patient was followed closely and stabilized over the course of two months with the use of Atropine 1% BID OU. The cause of the angle closure attack is still unknown.amin_bilateral
Atypical Presentation of Bilateral Posterior StaphylomaArangoAlexandra M. Espejo, OD, FAAO2012Posterior Staphyloma, a hallmark sign of highly myopic eyes, refers to bulging of a weakened sclera at the posterior pole of the eyeball. Literature shows ten types of posterior Staphyloma, Type II (involving the ONH and macula) being the most common. There are few cases reported with Type IV or nasal staphyloma and Type V or inferior Staphyloma. A 43 year old Hispanic female presented for evaluation of blurry vision in the right and left eye for the past year. Ocular history was remarkable for a Lasik procedure ten years ago OU. Best corrected vision was 20/40 OD and OS. Dilated examination revealed an atypical presentation of posterior staphyloma involving the ONH and the nasal and inferior retina. Oblique and tilted insertion was noted OU with peripapillary atrophy. C/D ratios were unable to be established. The macula presented with pigmentary changes and absence of the foveal reflex OU. This case illustrates a grade two chorioretinal changes and a Type IV and V posterior staphyloma that can be attributed to the decreased in vision. We will review the classification of posterior staphylomas as well as appropriate testing and management.arango_staphyloma
Multi-Faceted Management in Monocular Contact Lens Patient with Progressive Keratoconus and Longstanding AmblyopiaAungAndrew McLeod, OD, MS, FAAO (Boston University Medical School, Dept of Ophthalmology)2012Keratoconus is a bilateral, asymmetric, non-inflammatory condition that usually starts in the second decade. Progression is unpredictable and involves thinning and protrusion of the corneal structure while inducing highly irregular astigmatism. This case follows a 35 year-old Caucasian female with severe keratoconus OS, post-penetrating keratoplasy, and longstanding strabismic amblyopia OD. The management of this case discusses attaining the best corrected visual acuity through an irregular cornea, attempting occlusion to resolve diplopia, and adjusting lenses to prevent further lens-induced corneal scarring. Lens types included in this case are: regular and specialty gas permeable, occluder soft, hybrid and piggyback systems.aung_keratoconus
Branch Retinal Artery Occlusion with Contralateral Optic Disc Swelling: Differential Diagnosis and Medical Evaluation.BakerJanice McMahon, O.D. (Illinois College of Optometry)2012Branch retinal artery occlusions (BRAO) are not uncommon in the geriatric population and are usually associated with conditions such as hypertension and diabetes. The occurrence of a BRAO in a patient under the age of 40 is less common. When a BRAO does occur in this age group it is more often associated with cardiac valvular disease, emboli, or conditions associated with hypercoagulable states. This poster highlights the presentation of a visually symptomatic 40-year-old female with a recent onset BRAO. Also of note is the unusual feature of optic disc swelling in the fellow eye. An extensive medical work-up failed to reveal a systemic cause for either finding. The unique features of this clinical case along with the required work-up for patients with BRAO are emphasized in this presentation.baker_arteryocclusion.pptx
An Unusual Presentation of Retinal EmboliBeecumWendy McGonigal, O.D., F.A.A.O.2012Retinal emboli are one of the major causes of amaurosis fugax, transient ischemic attacks, and impending strokes. Retinal plaques are routinely classified as Hollenhorst (cholesterol) or calcific plaques. However, a less commonly seen but significant type of plaque is composed of platelet-fibrin. A 59-year-old male presented with reported episodes of loss of vision in the left eye. The patient denied any other associated symptoms. Upon examination, a ropy, semi-refractile plaque was found in the left eye. Further testing, including fluorescein angiography, lipid profile, carotid doppler, and transesophogeal echocardiography, ruled out other origins of the plaque and suggested that the composition of the plaque was platelet-fibrin. Perfusion through the retinal arteriole holding the fibrin plaque was not hindered, and the patient is being followed closely. In work-up of retinal emboli, platelet-fibrin plaques should be included in the differential diagnoses.beecum_emboli
Cystoid Macular Edema as a Complication of Retinitis PigmentosaBennett2012Cystoid macular edema (CME) is a relatively common complication of retinitis pigmentosa (RP); approximately 20% of RP patients will develop CME. The pathogenesis is unknown, but may be due to a breakdown of the blood-retinal barrier due to chronic low-grade intraocular inflammation. Different treatment strategies have shown variable levels of improvement depending on the defined endpoint (reduced angiographic leakage, decreased macular thickness, or improved visual acuity). Case reports presented in this poster will illustrate different therapeutic approaches, and a literature review will further discuss potential CME management in RP.bennett_rp
Atypical Presentation of Oculopharyngeal Muscular DystrophyBlackMiriam H. Farag2012A 51 year old white female presents with a chief complaint of seeing one and one-half images with the images split horizontally of one month duration. Medical history is significant for oculopharyngeal muscular dystrophy of six year duration. Ocular findings were significant for ptosis, diplopia and enlarged C/D ratios. The patient returned for further evaluation and management. The patient underwent a binocular vision, ptosis and glaucoma evaluation. Oculopharyngeal muscular dystrophy (OPMD) is comprised by the triad of late-onset ptosis, difficulty swallowing and a positive family history. Heredity is primarily autosomal dominant but autosomal recessive cases also occur. The prevalence of the condition is greatest among Bukhara Jews, French Canadians and the French but has been identified in people from more than 30 countries. OPMD is fully penetrant past 70 years of age. The major complications of OPMD are aspiration pneumonia, weight loss and chocking while eating.black_opmd
An Atypical Conjunctival Lesion: When to ReferBollesErin C. Jenewein OD, MS, FAAO2012A 44 year old male presented for evaluation of temporal redness in the right eye, with an uncertain history of progression. The patient had smoked 2 packs of cigarettes a week for the past 32 years, and the patients mother had been diagnosed with cancer. Slit lamp examination revealed a lesion on the temporal limbus involving the cornea with trace rosebengal staining. Possible conjunctival feeder vessels were adjacent to the lesion as was a symblepharon in the lower temporal bulbar conjunctiva. External photography was performed to document size and location. Differential diagnosis included conjunctival intraepithelial neoplasia, squamouscell carncinoma, and atypical pterygium. The patient was referred for biopsy and management. This presentation will discuss the differential diagnosis and management of conjunctival lesions.bolles_cin
Cotton Pickin' Cotton Wool SpotsBuchanan KeeneDr. Loren Bennett, Dr. Matthew Anderson2012Cotton wool spots are superficial white lesions caused by interruption of the axoplasmic flow in the retinal nerve fiber layer. These lesions are nonspecific findings associated with a plethora of systemic and ocular conditions, making a diagnosis of the specific underlying etiology difficult. This case describes a 73 year old white male with a systemic history of Diabetes Mellitus, chronic kidney disease, and hypertension presenting with multiple bilateral cotton wool spots throughout the posterior pole. Fundus photos, differential diagnosis, clinical findings, and management of cotton wool spots will be discussed.buchanan-keene_cotton
Low Vision Management of a Patient with Meige’s SyndromeByron2012Meige’s syndrome is a combination of two forms of dystonia: blepharospasm and oromandibular dystonia. The mechanism of this syndrome remains unclear, and diagnosis is often one of exclusion. This poster presentation discusses a case of a patient with Meige’s syndrome whose visual diagnoses include blepharospasm, convergence insufficiency, and oculomotor dysfunction. Due to these visual problems, this patient had difficulty with safe travelling and with reading. He had a history of treatment with botulinum toxin for blepharospasm, but the effects were short-lived and were by no means a cure for the condition. This case details the steps for devising a low vision rehabilitation plan for a patient with Meige’s syndrome. Devices trialed included reading with monocular occlusion, manual scrolling of print obviating the need for saccades, and an optical character reader.byron_meige
Constricted Visual Field with Deteriorating Night Vision: Atypical Retinitis PigmentosaCarpenterErin M. Fontaine2012A 63-year-old male presented with deteriorating night vision, increased glare sensitivity, and decreased peripheral vision OU. ERG findings strongly suggest moderate rod dysfunction and mild cone dysfunction. Goldmann visual field shows restricted fields of 55 degrees horizontally and 40 degrees vertically. Retinal findings include waxy pale optic nerve and attenuated vessels however, bone spicules and RPE atrophy were not present OU. MRI, carotid Doppler, CT, and extensive labwork were performed with normal results. Testing and evaluation are consistently indicative of Retinitis pigmentosa sine pigmento. Photos, visual fields, ERG, and imaging to be included.carpenter_atypicalrp.ppt
Anterior Segment Irregularities can be Overcome with Scleral Contact Lenses: A Case ReportCarpenterWilliam J. Denton2012A 53-year-old male presents with a history of trauma OS, decreased vision, and dry eye. Anterior segment examination revealed central corneal scarring OS and large nasal and temporal pingueculae OU. Spectacle BCVA was 20/20 OD and 20/50 OS with significant anisometropia. To reduce aniseikonic complications, various types of toric soft contact lenses were trialed. Vision improved to 20/40 OS however symptoms worsened. Scleral lenses provided 20/20 vision with no discomfort. Extensive pingueculae hindered the initial 15.6mm diameter fit. 18.2mm lenses were used to vault over the pingueculae. This case will show how corneal trauma, dry eye symptomology, and pingueculae can be overcome with sclera lens fitting and adjustments. Images/topography included.carpenter_atypicalrp
Using OCT and cSLO to Compare Retinal and Nerve Structure Features Associated With Optic Pits in Different Locations.CarusoRobert Dunphy, O.D.2012Optic disc pits vary in size, shape, depth, location and associated pathology. Pits generally present unilaterally as round, grey excavations in the temporal disc. Temporal presentation carries the highest risk for associated serous maculopathies. We present a 33 year-old man with an optic pit and associated complex macular schisis of both the retinal ganglion and photoreceptor cell layers barely detectable on clinical exam. We contrast temporal pits with associated macular schisis and inferior pits without associated retinopathy via digital photography, IR cSLO, RF cSLO, fundus autofluorescence and SDOCT to demonstrate the different retinal abnormalities associated with temporal pits.caruso_oct
Wow! That's Flat!Chao2012Post LASIK keratectasia is a progressive deformation of the cornea that may lead to central or inferior corneal steepening, increased myopia, and corneal thinning. Some patients eventually need corneal grafts. PY, 47 year old Caucasian female with s/p LASIK OU developed post-LASIK ectasia in her left eye after 4 years. Patient then underwent Penetrating Keratoplasty OS 1 year later. PY presented to our clinic for specialty contact lens fit for the left eye. Topographical map of the post surgical cornea indicated a very flat cornea. This case will discuss the surgical factors that may lead to such flat cornea and what various contact lens options that we can use to rehabilitate post PK patients.chao_flat.ppt
One and a Half Syndrome as the Presenting Clinical Sign of Multiple SclerosisChengBrian R. Hall, O.D., F.A.A.O.2012One-and-a-half syndrome is a neurological disorder that presents with abnormal extraocular muscle movements characterized by an internuclear ophthalmoplegia combined with a horizontal conjugate gaze palsy. This condition is secondary to a lesion in the midbrain and is often accompanied by an up-gaze nystagmus. We report the case of a 17-year-old African American female who presented with complaints of constant diplopia and decreased vision. Brain MRI revealed numerous T2/FLAIR hyperintense signal abnormalities in the subcortical, deep, and periventricular white matter of the frontal, parietal, and temporal lobes as well as several U fiber lesions and Dawson’s finger lesions, sufficing McDonald criteria for multiple sclerosis.
Gottleib Prism Prescribed in a Select Number of Veterans with Hemianopsia to Enhance Visual FieldsChronisterDenise T. Wilcox, O.D., Ph.D., Janet Meyers, O.T., V.T., and Muriel Savage, M.S.2012This is a case study that showed patients subjectively responded to Gottleib prisms rather than traditional Fresnel prism therapy for field enhancement. These are the first case reports, to our knowledge, that has been presented where patients were switched from traditional therapy to Gottleib systems. All 3 patients with hemianopic visual field loss secondary to occipital stroke responded favorably to switching from traditional Fresnel prism for field enhancement to Gottleib systems. Two of the patients were ambulatory and one patient was wheel chair bound. Two patients had worn the Fresnel prism system at least 3 years prior to switching to the Gottleib system and a third patient had worn the traditional Fresnel system over 20 years prior to switching. After training in a stationary position by the vision therapist and while traveling with the orientation and mobility specialist, all three patients expressed satisfaction with the Gottleib system and felt they had enhanced visual fields using the subjective methodology.chronister_prism
An Interesting Case of Hereditary Benign Intraepithelial DyskeratosisChuiBarnie Lim, O.D., F.A.A.O.2012Hereditary benign intraepithelial dyskeratosis (HBID) is a rare inherited ocular surface disorder associated with oral mucosal changes primarily seen in descendents of the Haliwa-Sponi Native American Tribe of North Carolina. We report a case of a 47-year-old Puerto Rican female, a descendent of the Taíno Tribe in the Carribbean, who presented to the clinic with a complaint of dry eyes. Slit lamp exam revealed a white, granular subpeithelial opacity at the inferior-nasal limbus of the left cornea that was suspicious for intraepithelial neoplasia. Excisional biopsy of the corneal lesion was performed and a pathological study was consistent with HBID. The patient was informed of the benign nature of the condition and the possibility of similar findings in her children.
Chronic Dacryoadenitis in a 65 Year Old African American Female with an Elevated ESRChunDominick Opitz O.D. FAAO2012A 65 year old African American female presented to the Illinois Eye Institute complaining of right eyelid pain starting 3 days ago. She reported that her left eye presented in the same manner one week ago but had resolved without any treatment. She recalls that this eyelid pain had occurred once before 5 years ago in the left eye. Her last medical exam was greater than 10 years ago. She is unaware of any medical conditions she may have. Though the patient was only complaining about her right eye, this patient presented with an S-shaped ptosis in both eyes. It was apparent upon gross observation and palpation that the patient was presenting with acute dacryoadenitis. Upon palpation of the left lacrimal gland, it was evident she had a history of chronic dacryoadenitis in the left eye given her fibrotic, hardened, and enlarged lacrimal gland. Recurrent dacryoadenitis raises suspicion for an underlying autoimmune systemic etiology including Sarcoidosis. A CBC with differentials was completed; all values were within normal limits except the patient’s Westergreen sedimentation rate. The patient never returned for her medical follow up but this case serves as an example of a probable autoimmune etiology manifesting with inflamed lacrimal glands.chun_dacryoadenitis
Vitreopapillary Traction Causing Optic Nerve Head ElevationCody2012An incomplete posterior vitreous detachment with persistent adherence to the retinal tissue can lead to traction at various areas of the vitreoretinal interface. Macular involvement, which may induce a variety of conditions including epiretinal membrane formation, is a common occurrence. Residual attachment at the optic nerve, leading to vitreopapillary traction is more rarely discussed. This case report involves a 73 year old white male who presented for an annual exam with no ocular complaints. Examination the previous year was remarkable only for incipient cataracts. Visual acuity was stable in the OD, reduced 2 lines in the left eye. Fundus examination revealed the presence of epiretinal membranes OS>OD with elevated, blurred optic disc margins in the OS appearing to be disc edema. This case will discuss peripapillary vitreoretinal traction as well as the clinical testing needed to differentiate other etiologies of disc edema. Macular and retinal nerve fiber layer OCT scans, fundus photography and visual fields will be used to describe this unusual presentation of vitreoretinal traction and aid in a discussion of the condition.cody_vitreoretinal
Let's Talc About DrugsConyerDr. Loren Bennett2012Talc retinopathy is an ophthalmic finding in long term intravenous drug users, presenting as microemboli of the retinal vasculature concentrated around the macula. Careful case history is critical for the diagnosis since patients are rarely symptomatic and may not volunteer a history of substance abuse. This case discusses a 57 year old African American male with a systemic history that included history of Hepatitis C, chronic obstructive pulmonary disease, degenerative joint disease, and polysubstance abuse of unknown duration. Dilated fundus exam revealed multiple refractive yellow-white peri-macular deposits bilaterally. Further investigation documented a urine screening in the past year positive for cocaine and opiates, as well as, drug seeking behavior.conyer_drugs
Diagnosis and Management in Posterior Uveitis: A Case Report Differentiating MEWDS vs Other White Dot SyndromesCowart2012A 56 YO WF presented to our neuro-ophthalmology clinic after referral for NAION OS>OD. At initial presentation the patient complained of central blurry vision OS for 3 days. The patient was noted to have optic nerve edema OS>OD with trace vitreous cell OS. Retinal findings were unremarkable. MRI and blood work were ordered at this time. MRI and blood work returned unremarkable. The patient was sent to the retina clinic for consultation. Upon presentation to the retina clinic the patient was noted to have unilateral mild vitreous cell, white dots in the retina along with a placoid lesion at the macula OS. No abnormalities including optic nerve swelling were noted OD. A diagnosis of MEWDS was given and the patient was placed on Prednisone 60mg daily. Within 2 weeks vision improved from CF@ 5 feet to 20/25 OS. The patient returned 6 weeks later complaining of decreased vision OS. Best corrected VA’s at this time were 20/200 @ 1 foot. Prednisone was increased to 100mg daily. This patient is currently being treated in our clinic. Included in this case report are photos, visual fields, optic nerve OCT, and fluorescein angiograms used in the diagnosis and treatment of this patient.cowart_mewds
When Lightning Strikes: A Case ReportDasinger2012Background: An 18-year-old female was struck by lightning while walking home from school, resulting in a traumatic brain injury (TBI). She spent weeks in the hospital with a poor prognosis but was eventually released to a rehabilitation facility. Case Summary: Despite two eye examinations post-incident with normal findings, the patient’s mother insisted that underlying visual problems were delaying recovery. In relearning to walk and reaching for objects, she noticed that her daughter had depth perception deficiencies. The TBI produced an 18Δ alternating exotropia, absence of stereopsis, figure ground dysfunction, accommodative dysfunction, and 10° monocular visual fields. Conclusions: Our treatment included yoked prism and active vision therapy in an effort to restore fusion. At follow-up examination, her visual fields are expanding (70° OS, 50° OD) and mobility training has improved.dasinger_testosterone
When All Else Fails…Testosterone: A Dry Eye Case ReportDasinger2012Background: An 89-year-old white female was referred by her optometrist for a dry eye evaluation. Despite using multiple artificial tears, Restasis, and punctual occlusion, she was still symptomatic. Case Summary: Entrance Schirmer testing was 7mm OD and 10mm OS with a 4 second tear break-up time (TBUT) OU. Initial treatment with topical loteprednol offered only minimal relief and did not improve Schirmer testing or TBUT OU. Conclusions: Final treatment included testosterone cream applied to both eyelids twice daily. After one month of treatment, the patient reports significant improvement and Schirmer testing increased to 30mm OD and 27mm OS.dasinger_testosterone
OMG, is it OMD? Clinical Assessment and Management of Ocular Motor DysfunctionDehesaVadim Guy, O.D.2012Ocular motor dysfunction (OMD) is a sensorimotor anomaly of the ocular motor system which limits the patient’s ability to perform accurate, effective ocular pursuits, saccades and fixational eye movement patterns. OMD is a frequently encountered condition for optometrists, yet is commonly overlooked during exams. Some of the most common signs/symptoms of OMD are: difficulty visually tracking objects, loss of place, and omission of words/lines while reading. If not recognized and treated properly, OMD can have a devastating effect on reading and learning. We present a series of cases of patients with OMD with uniquely different clinical presentations, signs, and symptoms. The treatment and management of each case will also be discussed.dehesa_omg
Unilateral Wipe-Out Syndrome: Reopening a Forgotten Can of WormsDehesaBarry Frauens, OD, FAAO; Margi Patel, optometic student2012Diffuse unilateral subacute neuroretinitis DUSN is an ocular infectious disease caused by subretinal migration of a nematode, resulting in profound vision loss. Typical late stage disease changes include multiple chorioretinal atrophic lesions, retinal vessel narrowing and disc pallor. We present a case of an 11 year old African American female patient who presented with complaints of unilateral severe vision loss for many years in the left eye from an unknown etiology. No explanation was ever given as to what caused the vision loss. Upon examination, diffuse retinal pigmented epithelial disruption throughout the posterior pole and peripheral retina was found, along with optic nerve atrophy and macular scaring. This patient presents with the typical latestage disease findings of diffuse unilateral subacute neuroretinitis.dehesa_unilateral
Incomplete Eyelid Closure Secondary to Left Facial Nerve Paralysis Reveals Squamous Cell Carcinoma of the MandibleDelGiodiceAttefa Sultani O.D., F.A.A.O.2012Facial nerve paralysis is a relatively common neurologic condition. The rate of incidence in the general population is estimated to be 2-15%, with 75-90% attributed to Bell’s palsy (idiopathic facial nerve paralysis). Facial nerve paralysis involving a history of pain, associated cranial nerve involvement and recalcitrant behavior, should be investigated with computed tomography (CT) and laboratory testing to exclude associated systemic pathology. A 72 year old white male presented with a chief complaint of painful, progressive left facial droop with associated incomplete left eyelid closure, hearing deficit and shortness of breath. Physical examination revealed an immobile, hard, painful mass along the left mandible. CT imaging and biopsy of the neck confirmed the diagnosis of stage IV squamous cell carcinoma (SCC). Facial nerve paralysis secondary to malignancy has a low prevalence rate. A careful history, review of systems, physical examination and CT imaging, increases the likelihood of an accurate diagnosis.delgiodice_facial
Idiopathic Neuroretinitis: A Case Study and Differentials DiscussionDerewyankoJulie Rodman2012Posterior uveitis is an entity attributed to both infectious and noninfectious agents. We present an atypical case of idiopathic posterior uveitis in an otherwise healthy, black 15 year old female. Clinical presentation includes bilateral diffuse conjunctival injection, vitreous cells, peripheral creamy placoid chorioretinal lesions, bilateral disc edema, and macular pucker. Due to the numerous etiologies of neuroretinitis, it is important that ophthalmic physicians are able to diagnose these conditions using both clinical evaluation and supporting ancillary testing. Differentials discussed here are syphilis, sarcoidosis, lyme disease, toxoplasmosis, tuberculosis, acute posterior multifocal placoid pigment epitheliopathy, multiple evanescent white dot syndrome, and multifocal choroiditis. After extensive laboratory and serologic testing, this patient was diagnosed with a rare, bilateral idiopathic posterior uveitis.derewyanko_idiopathic
The Low Vision Management of a Patient with Septo-Optic DysplasiaDesaiNicole Hooper, O.D.2012Septo-optic dysplasia (SOD) is a congenital malformation affecting 1 in 10,000 births. It can be characterized by a combination of optic nerve hypoplasia (ONH), pituitary hypoplasia and midline neuroradiological abnormalities, such as the absence or partial absence of the septum pellucidum. Many of these patients will also present with endocrine deficits. In most cases ONH will present with nystagmus and an often asymmetric, broad spectrum of visual impairment is observed. This poster will discuss SOD and the low vision management of a 9 year old male who was diagnosed with SOD and consequently suffers from severe visual impairment due to ONH.desai_dysplasia
Haemolacria: A Case Report of Bloody TearsDillivan2012Haemolacria is a rare phenomenon of bloody tears that is typically benign, unilateral and selflimiting however, there are deadly etiologies that exist. A patient presented with an acute onset of haemolacria. Patient medical history revealed coronary artery disease, uncontrolled hypertension, warfarin usage, and noncompliance with his blood pressure medications. Patient was referred to urgent care for laboratory testing and to address his hypertension. Spontaneous resolution of the haemolacria occurred after his blood pressure was controlled and his anticoagulant therapy evaluated. A diagnosis of haemolacria secondary to anticoagulant therapy andor uncontrolled hypertension was made. This presentation will provide a detailed case report and explore historical etiologies of this rare ocular disorder.dillivan_haemolacria
At the CrossroadsDingley201227 year old mixed race male presents initially (August 2011) with a vague chief complaint of mild blurry vision, "like he was flashed by a camera and never recovered". BCVA is 20/25+ OD, 20/25- OS. Refraction is essentially emmetropic. No apparent pathology noted on anterior segment exam or in the fundus. OCT of macula is unremarkable. Patient returns 1 week later for follow-up visual field which reveals a bitemporal inferior quadranopsia. MRI, CT, and blood work rules out mass, aneurysm, and infection. However, MRI reveals demonstrated multiple focal lesions and an abnormal FLAIR signal at the optic chiasm, consistent with a demylinating disease. Patient diagnosed with chiasmal neuritis secondary to Multiple Sclerosis. Chiasmal neuritis is an extremely rare form of retrobulbar optic neuritis. Treatment is not well established, but is usually treated as a optic neuritis. Patient was given Methylprednisolone 1000 MG for 5 days and later began Copaxone. Patient has been slowly recovering color vision and visual field has been improving over the past 4 months, but BCVA remains 20/25 OD, OS.dingley_crossroads
Not Your Average Retinal Lesion...EnemuohRichard A. Bell, O.D.2012Choroidal Osteoma is a benign ossifying tumor within the choroid that can result in mild to severe vision loss secondary to CNVM formation and subsequent subretinal fluid. This poster will illustrate visual evaluation of this condition with use of auxiliary diagnostic instrumentation in an 83 year old male presenting for a routine eye exam. It will also include discussion of epidemiology, pathophysiology, differential diagnosis, clinical presentation, and management.enemuoh_osteoma
Argon Laser Iridoplasty, New and ImprovedFalcoDr. Alan Kabat2012When laser peripheral iridotomy is contraindicated or ineffective, Argon Laser Peripheral Iridoplasty (ALPI) may be a viable option. In recent years, ALPI has become more clinically effective with fewer adverse reactions. ALPI eliminates appositional angle closure resulting from mechanisms other than pupillary block. By placing focal laser burns in the peripheral iris, stromal contracture is induced resulting in subsequent opening of the angle. It is beneficial for acute angle closure and relieves appositional angle closure that is due to plateau iris syndrome. It is helpful in lensrelated angle closure and can also be used before argon laser trabeculoplasty to widen the angle. The location, duration, power and spot size of the laser are all critical elements to ensure success of the procedure.falco_argon
Aqueous Misdirection Syndrome: Idiopathic or the Result of an Incorrectly Placed IOLFarha2012A 61 year old Caucasian male underwent seemingly uncomplicated extracapsular cataract extraction in his left eye. Over the next few days, the patient returned with fluctuating intraocular pressures, changes in his anterior chamber depth, and changes in the intraocular lens (IOL) position. Nd:YAG laser iridotomy, posterior capsulotomy, transpupillary laser to disrupt the anterior vitreal hyaloid face and surgical repositioning of an incorrectly placed IOL were performed. This presentation reveals a unique case of malignant glaucoma, or aqueous misdirection syndrome, in a patient who does not possess the common risk factors. Anterior segment photographs document our findings and a discussion provides details into if the incorrect placement of the IOL could have caused the misdirection of the aqueous.farha_misdirection
Herpes Simplex Virus Reactivation Triggered by PUVA TherapyFleming2012Psoralen and ultraviolet light A PUVA therapy for the treatment of dermatologic conditions can cause cataracts, pingueculas, and reoccurrence of herpes simplex virus in the eye secondary to the ultraviolet exposure. Only found in humans, the herpes simplex virus HSV is a DNA virus classified as type 1 or 2. The primary ocular infection of HSV1 usually occurs in children up to age five. The virus enters a latent state until reactivation occurs by a trigger such as ultraviolet light, stress, surgery, or suppression of the immune system. A 60 yearold man with a normal eye examination one week prior returned to the office 3 days after his first PUVA therapy session with an acute onset of HSV keratitis.fleming_herpes
Severe Bilateral Visual Field Constriction in a Patient with Arnold-Chiari Malformation Type 1.FontaineChristian W. Jordan2012We will present a case study of a 48-year-old male veteran with Arnold-Chiari Malformation with secondary visual symptoms. We will include both MRI and CT imaging of the brain and orbits -- as well as visual field, fundus photography and ocular coherence tomography. We will present a general neurologic overview of the Arnold-Chiari Syndrome and its subsets, discussing its effects on the visual pathway, associated ocular sequellae and masquerading differential diagnoses.fontaine_chiari
Emerging Treatments for Coats’ Disease Diagnosed in AdulthoodGalloAmy Jill Quan, O.D., F.A.A.O.2012Coats’ Disease is an idiopathic condition defined by peripheral retinal vascular telangiectasia with exudative retinopathy. Most cases are unilateral, predominately affecting young males. Less commonly, it is diagnosed in adulthood, usually with similar features, a slower rate of progression, and a limited area of fundus involvement. Historically, treatment options for Coats’ patients have included ablation of abnormal retinal vessels, either by laser photocoagulation or cryotherapy, and if necessary, surgery for retinal detachment. More recently, it has been suggested that Coats' may be associated with increased ocular levels of VEGF, and a few case studies have shown combining intravitreal bevacizumab with laser photocoagulation is an effective treatment choice for patients with the condition. We present a case of unilateral, adult onset Coats’ disease in a 53-year-old Asian male, who, despite prior laser treatments, has persistent active telangiectasia and exudative retinopathy. The emerging role of anti-VEGF agents will be discussed.gallo_coats
Spinocerebellar Ataxia Type 7 with Atrophic MaculopathyGardnerMichael S. Petrik, MSc2012Spinocerebellar ataxia type 7 (SCA7) has been historically the only inherited ataxia that involves ocular abnormities among all the neurodegenerative ataxias. This unique subtype of progressive ataxia exclusively involves macular dystrophy and retinal photoreceptor abnormalities. Classical ocular abnormalities of SCA7 have been recently well documented and recognized, but there exists are wide variety of atypical retinal presentations. Furthermore, recent studies have shown ocular abnormalities in other sub-types of this progressive neurogenic disorder. In this poster we present one case of atypical macular variation from a clinical perspective and review the diagnosis for this condition for documentation purposes. The case of a 61-year-old Cherokee Indian male with SCA7 with decreased vision loss and atypical maculopathy and is presented. Fundus photography and optical coherence tomography (OCT) were used to diagnose and record the overall progression of the disease in this patient. SCA7 (and other select sub-types) should be considered in cases of early atypical dry age-related macular degeneration (ARMD), macular holes and pseudoholes, and epiretinal membranes to differentiate them from other macular conditions and their respective treatments.gardner_ataxia
Eyelid Lesion as a Presenting Symptom of Primary Large B-Cell Lymphoma of the OrbitGarlandNathan H. Neville, O.D., M.S.2012A 71-year old white male presented with a 2-week duration of right eye pain, swelling and the sensation of a bump growing underneath his upper eyelid. Diagnosed with meibomitis, he was prescribed lid hygiene, artificial tears and Erythromycin ointment. He walked in 15 days later to report enlargement of the bump and difficulty opening his eye. Four months later he died from complications of treatment for diffuse large B-cell lymphoma. Initially detected in the orbit, it rapidly progressed in an uncharacteristic way to the sinuses, scalp, neck, lymph nodes and spinal cord. MRI results and images as well as pathology reports to be discussed in this interesting, rare presentation of Atypical Primary Large B-Cell Lymphoma of the Orbit.garland_lymphoma
Combined Branch Retinal Artery and Central Retinal Vein Occlusion: Ocular Findings, Pathogenesis and Systemic AssociationsGentryRichard Zimbalist O.D., Jessica Young2012Retinal vascular occlusions characteristically affect either the venous or arterial system independently in a population over 50 years from cardiovascular disorders such as hypertension, hypercholesterolemia, and carotid artery disease. Both vascular systems are rarely affected simultaneously. Venous and arterial occlusions typically present with sudden, unilateral vision loss and variable visual field defects. Combined occlusions in younger patients may be the initial sign of a more serious systemic condition. Systemic etiologies to be considered include autoimmune, infectious, pharmacologic, hypercoaguable, hyperviscosity and other hematologic disorders. This case describes a 48 year old African American female with multiple risk factors associated with a simultaneous branch retinal artery and central retinal vein occlusion. A review of ocular pathology and literature outlines a potential vascular etiology of combined occlusions. Corroborative testing includes digital retinal imaging, fluorescein angiography, visual field testing and pertinent bloodwork.gentry_brao
Third Nerve Palsy due to Non-Hemorrhagic Pituitary ApoplexyGiardinaAlicia M. Greene, O.D.2012Background: Pituitary apoplexy is a medical emergency resulting from a stroke of the pituitary gland. Case Report: A 61 year-old man presents with a left, pupil-involved third nerve palsy, severe headache, left facial weakness, and left leg weakness. The brain MRI showed a heterogeneous pituitary macroadenoma with asymmetric lateral extension. The diagnosis of pituitary apoplexy was concluded based on the MRI findings and the acute presentation. No overt hemorrhaging was seen, indicating ischemic infarction. The patient received a transphenoidal resection of apoplectic tissue and was treated with steroids. Conclusions: This life-threatening differential for a third nerve palsy should be considered in cases with headache and pupil involvement.giardina_pituitary
A “Rare” Case of Progressive Type 2A Idiopathic Juxtafoveal TelangiectasiaGibbons2012Type 2A idiopathic juxtafoveal telangiectasis (IJFT) is often undiagnosed due to its funduscopic similarities to mild diabetic retinopathy. IJFT is classified by five stages ranging from no visible biomicroscopic anomalies to parafoveal CNV. This case presents a 66 year old patient with Type 2A IJFT with an involuted CNV in the left eye, and capillary dilatation in the right eye. A collection of fundus, HD-OCT, and IVFA photos will highlight the importance of optical coherence tomography and fluorescein angiography in the diagnosis and management of juxtafoveal telangiectasis. Ancillary testing such as HD-OCT and IVFA can be helpful in management of IJFT due to its progressive nature, as well as differentiation between IJFT and diabetic retinopathy.gibbons_telangiectasia
Sympathomimetic Diet Pills Cause CN VI Palsy Secondary to Pontine MicrohemorrhageGoldenbergErin Draper, O.D., Kelly Malloy, O.D.2012The use of sympathomimetic amphetamine-like anorexiants carries a significant risk for developing side effects. The FDA recalled the popular weight loss combination drug Phentermine - Fenfluramine (Phen-Fen) in 1997 because of a high incidence of cerebrovascular accidents, valvular heart disease, and pulmonary hypertension. Although the combination drug is no longer available, one of its components, Phentermine, is still widely used for weight loss treatment. This case report describes an isolated CN VI palsy secondary to multiple intracerebral microbleeds including a pontine hemorrhage in a young, otherwise healthy, woman taking a combination of Phentermine - Phendimetrazine as a part of her weight loss program.goldenberg_sympathomimetics
The Case of the Mysterious Black Dot!?HainesJulie Rodman, O.D.2012Acute macular neuroretinopathy (AMNR) is a rare condition that tends to occur in young women and produces transient or permanent visual disturbances. The pathophysiology of AMNR is unknown, the causes are uncertain, and there is no specific treatment for the condition. The clinical diagnosis of AMNR is made on the distinctive lesions of AMNR which appear as sharply defined, confluent, non-elevated wedge-shaped lesions at or near the macula, which seem to point toward the macula. Patients will complain of multiple or single paracentral scotoma in one or both eyes. A diagnostic feature of AMNR is the correspondence of the lesions with the shape and location of the scotoma described by the patient on amsler grid. We present the case of a 25-year-old white female who presented complaining of a grayish scotoma superior to center of fixation of 6 months duration. Ocular disturbances coincided with the onset of a virus. She was able to accurately describe the scotoma on amsler grid. Flourescein angiography, biomicroscopy and optical coherence tomogroaphy assisted in identifying the lesion as AMNR.amnr_presentation
Where’s the Leakage Coming From?HarderKelly R. Thompson, OD, FAAO2012A 73-year-old male presents with reduced visual acuity, OD. Fundus exam revealed an epiretinal membrane, vessel tortuosity, clinically significant macular edema, and a gray scar temporal to the fovea, OD. His medical history was positive for diabetes, Barrett’s esophagus, atrial fibrillation, and controlled hypertension. The aim of this poster is to increase awareness and to avoid possible misdiagnosis of idiopathic juxtafoveol retinal telangiectasia. This poster will describe the various types of retinal telangiectasias, treatment options, and how to distinguish them from secondary telangiectasias. This presentation will include fundus photography, fluorescein angiography, and OCT images.harder_juxtafoveal
A Unique Clinical Presentation of Giant Cell ArteritisHardeyCorinne N Casey, OD2012Giant cell arteritis (GCA) is an inflammatory condition of the elderly that can present with a spectrum of systemic, neurologic, and ophthalmic manifestations. The most common ocular finding in GCA is anterior ischemic optic neuropathy, yet there are a number of other possible presentations. Therefore, it is critical to include GCA as a differential for new vascular and neuro-ophthalmic conditions presenting in high-risk patients. An 87 year old white male presented with complaints of new onset diplopia, headache, and general malaise. Examination revealed a partial CN VI palsy. The most common causes of a CN VI palsy include: ischemia due to diabetes, hypertension, or atherosclerosis; trauma; or idiopathic. However, given the patient’s age, constitutional symptoms, and headache, further workup was necessary to rule out GCA. Elevated Westergren ESR and C-reactive protein, and decreased hematocrit level, raised further suspicion for GCA. Prompt treatment with oral prednisone was initiated, and subsequent temporal artery biopsy confirmed active cranial arteritis. Considering the grave risk of vision loss and fatality from GCA, it is imperative to recognize the array of possible clinical manifestations, and readily identify high-risk patients warranting further workup by a multidisciplinary team.hardy_gca
Juvenile Glaucoma: An Advanced Case and ReviewHarris2012Juvenile glaucoma accounts for a small percentage of primary open-angle glaucoma (POAG) cases worldwide. To maximize functional vision and visual field, timely diagnosis and treatment of juvenile glaucoma are paramount. This poster will present a case report of an unsuspecting 19 year-old Black male with an advanced case of juvenile glaucoma. This poster will also highlight the relevant etiological factors, clinical signs, and therapeutic considerations for juvenile glaucoma patients.harris_mylastnerve
Adult-Onset Vitelliform Maculopathy Treatment and Low Vision ManagementHodgesWendy M. McGonigal O.D., F.A.A.O.2012Adult-Onset Vitelliform Maculopathy initially presents in adulthood as bilateral subtle and often asymptomatic macular lesions which are often misdiagnosed as early Age Related Macular Degeneration. Retinal findings may ultimately progress to visually debilitating and blinding geographic atrophy; therefore, standard of care in advanced cases should include a referral to a low vision specialist who can improve visual function and increase quality of life for affected patients by prescribing devices that will enhance contrast sensitivity and central vision. This case offers a comprehensive overview of the medical intervention and low vision management of an 80-year-old Caucasian male diagnosed with Adult-Onset Vitelliform Maculopathy.hodges_vitelliform
Anterior Scleritis: A Case Presentation Exploring the Underlying Etiology in a Patient with Ulcerative ColitisHodgesWendy McGonigal, O.D., FAAO2012Anterior scleritis is characterized by an inflammatory response of ocular tissues, spreading from deep scleral to more superficial episcleral and conjunctival layers. Comprising 98% of scleritis cases, anterior scleritis runs the gamut of severity from one self-limiting episode to many, with the potential of becoming visually debilitating. Specific systemic conditions, such as ulcerative colitis, have been linked to an increased incidence of ocular inflammation; thus, managing the predisposing cause of scleritis might prevent a subsequent recurrence. This case explores the underlying etiology of anterior scleritis in a 44-year-old African American male with a previous diagnosis of ulcerative colitis and concurrent elevated angiotensin-converting enzyme lab levels.hodges_scleritis
Rapid Myopic Progression Secondary to the Formation of an Oil-Droplet CataractHodges2012A 59 year old white male presented for an examination complaining of gradual blurred vision accompanied by intermittent diplopia. He had been seen by multiple doctors and had undergone extensive testing including a binocular vision workup and an MRI. Over time, the patient experienced a 7.00 D shift in myopia OD. The etiology of this dramatic shift was finally correlated to an oildroplet cataract, an elusive cataract frequently missed by practitioners, leading to extensive referrals and testing that tax the patient and creates undue fiscal waste. This presentation will discuss the signs, symptoms, pathophysiology, methods for identification, and treatment of oildroplet cataracts, as well as review the unique difficulties in diagnosis that practitioners face when encountering this clinical condition.hodges_oildrop
Hyperhomocysteinemia as an Etiology for Central Retinal Vein OcclusionsHodges2012Central Retinal Vein Occlusions are an uncommon disorder in the retinal vasculature leading to significantly reduced vision and other unwanted manifestations including macular edema and possibly glaucoma. Laboratory testing is pertinent to discover the underlying cause so that appropriate management may ensue. This poster will discuss a 55 year old white male who presented with a CRVO with no apparent etiology but was found to have hyperhomocysteinemia after appropriate blood work. An in-depth discussion of homocysteine and its metabolic role in vascular functions leading to abnormalities such as CRVO will be the prime focus for this poster. The secondary focus will include systemic abnormalities a patient might experience when diagnosed with hyperhomocysteinemia.hodges_crvo
The Relationship Between Hypertriglyceridemia and Idiopathic Choroidal Neovascular Membrane – A Case ReportHoffmanPatti Fuhr, O.D., Ph.D. and Leo Semes, O.D.2012A 54 year-old patient presented with a complaint of a black spot in his right eye’s central vision which had gradually worsened over the last 10-14 days. He also complained of decreased vision and micropsia in the affected eye. His medical history was significant poorly controlled type 2 diabetes and hypertriglyceridemia, hypogonadism, acid reflux, degenerative joint disease, hemorrhoids, Barrett’s esophagus, and obesity. Of particular interest to this case was the fact that over the last year and a half, this patient’s fasting triglyceride serum levels ranged from 467 to as high as 1694 mg/dL. Presenting acuities were 20/200-1 OD and 20/25 OS. Dilated fundus examination of the right eye revealed a small perifoveal intraretinal hemorrhage and a 1 DD area of central intraretinal edema. A gray subretinal membrane was also noted in the central subfoveal retina. A florescein angiography and OCT were performed and an active central CNVM was diagnosed of unknown origin. The patient was treated with intravitreal Avastin and scheduled to return monthly for the next four months. This case report discusses how hypertriglyceridemia may contribute to the pathogenesis of idiopathic CNVM.hoffman_idiopathic
Vogt Koyanagi Harada (VKH) Syndrome and the Role of Low Vision Rehabilitation: A Success StoryHoffmanAngela Ryan, CLVT, OTR/L2012A 55 year-old African American female was referred by her Ophthalmologist for a low vision evaluation. She had a more than 20 year history of Vogt Kayanagi Harada (VKH) Syndrome which had caused her to be legally blind. She presented to the clinic with complaints of difficulty reading, seeing her cell phone, and trouble with glare. Due to the complexity of the patient's ocular and systemic condition, it proved to be a difficult yet surprisingly successful low vision rehabilitation program. This case report will discuss VKH and its ocular complications as well as the indication for and benefits of low vision rehabilitation.hoffman_vkh
Visual Functions in Multiple SclerosisHuber2012Multiple sclerosis (MS), a chronic inflammatory disease affecting the central nervous system, has multiple ocular sequelae. In addition to optic neuritis, MS has been shown to affect contrast, stereopsis, nerve fiber layer thickness, and visual fields in patients with and without other ocular disturbances. In patients without a history of MS-related complications, these abnormalities may not be elicited in a clinical exam. Consideration of the entire visual system allows clinicians to gain greater understanding of potential difficulties in patients with MS and make appropriate recommendations. This case report demonstrates how MS can affect the eye in a patient with a history of unilateral optic neuritis and bilateral abnormal visual functions.huber_visualfunctions
Post-Operative Pulsatile Proptosis After Cataract Surgery: Signs of Carotid Artery Disease?HumesPaul Ernest, M.D.2012There are few symptoms of carotid artery disease that are not immediately debilitating, pulsatile proptosis is one of these. A pulsating exophthalmos of the orbit, characterized by engorged, tortuous episcleral blood vessels, dilated pulsating conjunctival arteries, and a distinct "whooshing" noise or sensation of pulsation. It is a rare external sign of carotid artery disease. Cataract surgery is the most common elective surgical procedure in America, pulsatile proptosis is an unexpected finding upon post examination. A 74 year old woman presented for a one day post cataract surgery examination, with a main complaint of an intermittent pulsing feeling in the operated eye and mild pain. Pre- and post-surgery blood pressure were abnormally high, additionally a faint bruit was present on the ipsilateral carotid. The patient was rushed to the emergency room after consultation with PCP for an emergent MRA and carotid doppler, confirming carotid stenosis of 65% on the ipsilateral side and 55% on the contralateral. Treatment was immediately initiated for hypertension and consultation for carotid endarterectomy or angioplasty with stent was scheduled. This case highlights how astute post operative examination can reveal previously hidden, life threatening systemic diseases.humes_pulsatile
Unilateral Sectoral Iris and Choroid HeterochromiaHuttoAlexandra M. Espejo, O.D., F.A.A.O., Victoria M. Trieu B.S.2012Sectoral iris heterochromia is a unilateral or bilateral condition, where the iris presents with variable pigmentation. The condition is more frequently acquired, but has also been reported as congenital.A 50 year old male of AfroCaribbean descent presented with unilateral, superior sectoral iris heterochromia with corectopia and transillumation defects associated with areas of iris atrophy. Cornea was unremarkable. Dilated fundus exam revealed heterochromia of the superior choroid macularsparing. Visual function and fields appeared unaffected. Gonioscopy revealed heavy pigment in the inferior angle of the affected eye, with absence of peripheral anterior synechiae. Glaucoma testing was performed due to angle appearance, slightly elevated pressures, asymmetric CD ratios and family history of unexplained blindness. The patients family history revealed iris heterochromia, with an autosomal dominant hereditary pattern. The condition in this case appears to be hereditary. Very few cases of iris heterochromia combined with choroid involvement have been reported. We will review possible differential diagnosis and appropriate testing.hutto_heterochromia
Phacolytic GlaucomaKarst Morris2012With the advancement and availability of modern cataract surgery, phacolytic glaucoma has become an uncommon condition in regions where healthcare is easily accessible. This secondary glaucoma occurs when a hypermature cataract releases lens particles through an intact capsule. Macrophages and lens proteins obstruct the trabecular meshwork causing a rapid increase in intraocular pressure. This poster presents the case of a 66-year old female who was discharged from the emergency room to our clinic with a preliminary diagnosis of acute angle closure glaucoma. Slit lamp examination revealed diffuse conjunctival injection, an edematous, hazy cornea, an unreactive 8mm pupil and a hypermature cataract. The anterior chamber appeared deep with a faint pseudohypopyon; gonioscopic views of the angle were obscured by corneal edema. IOP was measured at 52mm Hg and was unresponsive to oral and topical medications. The patient was diagnosed with phacolytic glaucoma and underwent extracapsular cataract extraction one week later.karstmorris_phacolytic
Orbital Pseudotumor: A Case ReportKinney2012Orbtial pseudotumor is a non-neoplastic inflammatory process within the orbit. It is the third most common intraorbital disease accounting for 8-11% of orbital lesions. Treatment options include oral steroids, radiation, immunomodulators, or surgery. This case details a 34-year-old patient who presented complaining of a hard mass under his left lower lid for the past four months. Upon examination, the diagnosis was made of a left intraorbital mass, which was confirmed by MRI. Pathology of the mass was found to be orbital pseudotumor. Following excision, constant post surgical vertical diplopia ensued which was managed with prism spectacles. This poster reviews the clinical features and management options of orbital pseudotumor.kinney_pseudotumor
Structural Integrity of the Retina in Vitreomacular Traction SyndromeKress2012Vitreomacular Traction Syndrome VMT is a condition arising from persistent hyaloid traction of the macula as a result of incomplete vitreous detachment. The appearance of VMT on retinal exam can be easily overlooked. Better visualization of the vitreoretinal interface and structural integrity of the retinal layers using OCT has expanded our understanding VMT. This poster will discuss a case of VMT with intact visual acuity in light of an alarming retinal appearance on OCT. This poster will also discuss the role of VMT in specific maculopathies, such as cystoid macular edema CME, macular hole MH, and epiretinal membrane ERM formation, and treatment options for each given visual integrity and retinal appearance using OCT evaluation.kress_vmt
EDI-OCT Assisted Diagnosis of Age-Related Choroidal AtrophyLambertJustin H. Townsend, MD2012An 81 year old Caucasian female presented with progressive nyctalopia and central vision loss to the level of 20/30 OU. Clinical exam and imaging confirmed no signs of age-related macular degeneration; laboratory analysis, fluorescein angiography, and electroretinography ruled out common etiologies of nyctalopia and central vision loss. Imaging of the choroid with enhanced depth imaging spectral-domain optical coherence tomography (EDI-OCT) revealed thinning of the choroid at the foveal region in both eyes, confirming the diagnosis of age-related choroidal atrophy. This presentation contains the patient’s choroidal imaging and discusses the significance of choroidal atrophy in central vision loss and the utility of EDI-OCT in the diagnosis of age-related choroidal atrophy.lambert_choroidal
Venous Sinus Thromboses Secondary to Depo-Provera InjectionLeeKelly Malloy, OD, FAAO; Erin Draper, OD2012Introduction: Papilledema is an ocular emergency requiring emergent imaging and cerebral spinal fluid analysis. Venous sinus thrombosis (VST) is one cause of papilledema, and can be caused by hypercoagulable states or hormonal medications. The likelihood of thrombosis may be greater with injectable forms of birth control due to higher hormonal concentrations. Case Report: A 27-year-old woman presents with a 3-month history of severe headaches and intermittent diplopia, beginning shortly after receiving her first injection of Depo-Provera birth control medication. Examination shows bilateral cranial nerve VI palsy and florid papilledema. Prompt hospitalization reveals multiple cerebral venous sinus thromboses, including the superior sagittal sinus, right transverse and sigmoid sinuses, and right internal jugular vein. Hypercoagulable work-up was negative, and the thromboses were ultimately attributed to the single Depo-Provera shot. The patient reported significant improvement in her symptoms shortly after beginning treatment with Heparin and Diamox. Conclusion: In the setting of papilledema, it is imperative to ascertain a patient’s systemic history in terms of hormonal medications, past pregnancies, and/or hypercoagulable states. The treatment for VST differs from that for pseudotumor cerebri in that anticoagulants are required. Correspondingly, the work-up for papilledema must include not only MRI, but also MRV to evaluate for thrombosis.lee_venous
“Herpes Zoster Ophthalmicus as the Presenting Sign of AIDS: A Case Report”Leong2012Herpes Zoster Ophthalmicus can present in a variety of ways affecting essentially any ocular tissue along the ophthalmic nerve dermatome. Most common presentations involve the skin and anterior segment. However it may also involve the optic nerve, retina and central nervous system. The incidence of Herpes Zoster (HZ) increases as varicella zoster virus (VZV) cell-specific immunity (CMI) decreases. This decline occurs naturally with age or may be a result of an immunosuppressive state or illness. Immunosuppression may be secondary to medical treatment with systemic corticosteroids or due to systemic illness such as malignancy, human immunodeficiency virus (HIV) or acquired immunodeficiency syndrome (AIDS). It has been reported that the relative risk of an HZ infection is at least 15 times greater in men with HIV than in men that are immunocompetent. Therefore when a young patient presents with HZO, additional blood work to rule out systemic immunosuppression is warranted. Presented here is a case report of a 23-year old African American male with HZO uveitis and keratitis due to previously undiagnosed AIDS.leong_zoster
What’s Telling in Vitelliform Lesions: Diagnostic and Time Progression Analysis of Adult Vitelliform Macular Degeneration with Serial Fundus Photography and Optical Coherence TomographyLoweJarett Mazzarella, OD, FAAO2012Adult vitelliform macular degeneration (AVMD) can be a difficult diagnosis to make when the characteristic egg-yolk like lesions are not present. There are several other differential diagnoses that should be ruled out, including Best’s disease, age-related macular degeneration, and other classical pattern dystrophy presentations. A 58 year old white male presented with a chief complaint of gradual blur at distance over the past year, OD worse than OS. Best corrected acuity was 20/40 OD, 20/30 OS. Dilation only revealed pigmentary changes in the macula, which is a non-specific finding and can be misidentified with several other etiologies. This case presentation will go over the differential diagnoses of AVMD, highlighting the subtle differences that can be seen clinically and through ancillary testing. Fluorescein angiography, serial fundus photography and optical coherence tomography will be interpreted and discussed in context of obtaining the correct final diagnosis of AVMD and monitoring its clinical course and progression over time.lowe_vitelliform
To Float or Not to Float? Graft Detachment - a Possible Complication of DSAEKLuuBrian S. Kawasaki, O.D., M.B.A., FAAO2012Background Corneal endothelial diseases are often treated with Descemets stripping automated endothelial keratoplasty DSAEK. The endothelium is removed and replaced with a donor tissue. DSAEK can have complications such as graft detachment or rejection.Case report A 66yearold male with advanced Fuchs dystrophy underwent DSAEK procedure in the left eye. The patient reported increasingly blurred vision of his left eye at his one week postoperative visit. Upon evaluation, a detached graft was observed and he was sent back to his surgeon for a refloat procedure. Conclusion Patient returned with a successful reposition of graft with suture fixation, significant visual improvement, and no further complications. Patient will be monitored closely during the postoperative period.luu_dsaek
Ocular Manifestations of Erectile Dysfunction Medications: Getting More Than You Bargained ForMarkKimberly Mark, O.D. (Optometry Resident), Ania Hamp, O.D., Edward Chu, O.D.2012Non-Arteritic Ischemic Optic Neuropathy (NAION) secondary to erectile dysfunction (ED) medications is a rare yet relevant clinical finding. Risk factors include hypertension, nocturnal hypotension, diabetes, hyperlipidemia, cardiovascular co-morbidities, ED medications, “disk at risk”, and elevated IOP. ED medications can contribute to arterial hypotension and potentially alter blood flow to the nerve leading to NAION. We will review the current research and present a detailed account of a patient with disc edema and sectoral hemorrhages associated with recent ED medication use. With the increased utilization and popularity of these medications, it is imperative that patients are educated, particularly those at greatest risk for developing ocular sequelae.mark_naion
Bilateral Arteritic Anterior Ischemic Optic NeuropathyMatsonLane Fujimoto, O.D.2012Arteritic anterior ischemic optic neuropathy AION is a disease of the optic nerve head seen in patients over the age of 50. With few exceptions, arteritic AION is caused by giant cell arteritis. Early diagnosis and prompt treatment with corticosteroids are essential for preventing potentially devastating visual loss from this disease. Arteritic AION is an ocular emergency. Optometrists need to be able to recognize and diagnose this condition quickly in order to initiate critical corticosteroid treatment. The purpose of this poster is to report a case of bilateral arteritic AION and to review the diagnosis and treatment of the disease.matson_aion
A Nonsurgical Approach to Recurrent PterygiumMcGonigalJanis L. Holt, M.D.; Chynni H. Clark, O.D.2012Pterygium are an extremely common conjunctival and corneal degeneration. Most pterygia do not require surgical treatment; however, they may be removed for cosmetic reasons, changes in vision, or discomfort. The most common complication of surgical excision is recurrence. Recurrent pterygia may be far more aggressive than the original occurrence, particularly in the face of untreated ocular surface disease. Several reports have documented the effectiveness of 5-fluorouracin (5-FU) in the treatment of recurrent pterygia. More recently vascular endothelial growth factor inhibitors have been employed in the treatment of recurrent pterygia. This case demonstrates the use of combined 5-FU and ranibizumab in halting the progression of recurrent pterygia and dramatically improving the appearance in a 59-year-old Caucasian male.mcgonigal_pterygium
Valsalva Retinopathy: An Important Differential in Evaluation of Retinal HemorrhageMcNulty2012A case report will be presented of a 20 year old female who presented to the emergency room with recent onset blurry vision in one eye. An optometry consult and dilated fundus examination revealed a macular hemorrhage in the left eye. The patient’s history revealed recent valsalva maneuver caused by constipation. A diagnosis of valsalva retinopathy was made, and no treatment was indicated except for observation. Follow-up examination showed partial resolution of the hemorrhage. The patient refused further follow-up, but stated via telephone that her vision had returned to normal by 2 months after initial presentation. This case illustrates the importance of valsalva retinopathy as a differential diagnosis in the evaluation of retinal hemorrhage. This condition is largely benign and self-resolving, and does not necessarily require a retina consult.mcnulty_valsalva
The Mystery of the Bloody Tears: A Case ReportMikhailIvan Garcia, MD2012BACKGROUND: Hemolacria, or blood stained tears, is an uncommon clinical occurrence, which may present a challenge for the examiner to determine the cause. It can be caused by traumatic, surgical, neoplastic or systemic etiologies. Thus, it requires thorough examination and blood workup to rule out potentially serious underlying etiologies and ensure proper and timely management as necessary. CASE REPORT: a 76 year old Hispanic female presented with a chief complaint of bloody tears OS x 3 years mostly at night time. Tears are followed by intermittent blurry vision. Initial examination did not reveal any ocular abnormalities. On return visit, pt presented with active blood stained tears. A more thorough ocular examination revealed an extruded scleral buckle. CONCLUSION: very careful examination is essential in determining the etiology of hemolacria. Idiopathic hemolacria is a diagnosis of exclusion and thus close physical examination, blood workup and further testing is required to rule out possible serious etiologies before dismissal of this finding.mikhail_bloodytears
Digging Deeper: The Use of Ancillary Testing in the Diagnosis of a Choroidal HemangiomaMisko2012A 29 year old female presented to Nova Southeastern University The Eye Care Institute for a comprehensive eye examination secondary unexplained ocular pain OD. The patient was diagnosed in 2004 with Glaucoma OU. No family history of Glaucoma or retinal disorders were reported. The patients medical history was significant for Hodgkins Lymphoma. Baseline Humphrey Visual Field revealed a defect OD inconsistent with optic nerve head appearance. Visual Field OS was clear. Dilated fundus examination revealed a redorange fundus OD. Optical coherence tomography and Bscan ultrasonography revealed temporal retinal elevation OD. Diagnosis of choroidal hemangioma was supported with optical coherence tomography and fundus photos. Management options and systemic associations are discussed.misko_hemangioma
An Atypical Presentation of Elschnig PearlsMonarrezPaul Vejabul, OD and Theresa Chong, OD2012A ninety year old white male with severe visual impairment in the right eye and total blindness in the left eye presents with severe pain and irritation in the left eye. His discomfort is secondary to dry eye and ocular surface issues, however an interesting secondary finding is an overgrowth of posterior capsule cells (Elschnig Pearls) filling the anterior chamber of his left eye. This developed relatively within the last eighteen months since his last eye exam. He was unable to notice either a change in vision or change in physical appearance of his left eye because of his poor visual status. Great anterior segment photos were taken in office.monarrez_elshnig
Poked in the Eye...Now What?Nelson2012Patient MM, a 59 year old white male, was referred by his corneal specialist on July 6, 2011 for a contact lens examination. His chief concern was blurry vision in his left eye. In June 2009, his left cornea perforated as a result of peripheral ulcerative keratitis and vigorous eye rubbing. An eccentric lamellar corneal transplant was performed in March 2010 followed by cataract surgery in March 2011. Upon examination, best corrected spectacle acuity was 20/25 in the right eye and 20/40 in the left eye. Topography maps revealed inferior corneal steepening and thinning in both eyes. The patient was fit with a mini-scleral lens with 15.6mm diameter, 7.34mm base curve, and -6.00 D power. This lens provided appropriate central clearance, a soft landing on the sclera, and no conjunctival vessel blanching. However, the lens had significant bearing over the eccentric graft. The lens was customized by widening the optic zone from 8.6mm to 9.0mm, flattening and narrowing the second curve from 7.70mm/1.7mm to 8.04mm/1.5mm and steepening and widening the third curve from 8.7/0.9mm to 8.3/1.9mm. This lens achieved clearance across the eccentric graft without creating excessive central clearance. Currently, the patient is able to wear the lens 14-15 hours per day with 20/20- vision.nelson_poked
Acute Onset Esotropia Secondary to Sudden Withdrawal from Methadone Maintance TreatmentNevilleElizabeth M. Garland O.D.2012Prescription opiate abuse has become a serious public health issue in the US. A 34 year-old- white male was referred from the ER for double vision. One year prior he became addicted to pain medications following burns to his face and hands during an on the job electrical explosion. To control his narcotic dependency he was undergoing daily high-dose Methadone Maintance Treatment (MMT). The sudden onset diplopia occurred spontaneously after self-administered complete detox from methadone. Ocular examination revealed nystagmus and constant esotropia. Neurological work up was negative; STAT neuroimaging was unremarkable for pathology. Patient was reevaluated four weeks later; the esotropia had resolved and single binocular vision was present. This poster will review ocular manifestations of methadone and prescription narcotic abuse.neville_methadone
A WEBINO Case: A New Multiple Sclerosis Diagnosis for an Older African American FemaleNguyenAshley Scheurer, OD, Leonard Messner, OD, FAAO2012Internuclear ophthalmoplegia (INO) is an ocular motor abnormality found among patients with localizing brainstem disorders. Lesions can be bilateral or unilateral affecting the medial longitudinal fasciculus pathway. This deficit results in an adduction weakness in the ipsilateral eye and nystagmus in the contralateral abducting eye. INO presence is suggestive of vascular disorders, infectious disease, trauma, or most commonly multiple sclerosis (MS). Magnetic resonance imaging (MRI) of the brain is the primary diagnostic tool used to assess MS risk and development. A 56 y/o black female presented with a sudden onset of horizontal diplopia. She had bilateral adduction deficit, primary gaze exotropia, and abnormal convergence indicative of wall-eyed bilateral INO. She reported no vascular medical history or recent trauma. MRI revealed white matter lesions concentrated along the periventricular zones consistent with the autoimmune demyelinating disease.nguyen_webino
Atypical Melanoma Masquerading as a Benign NevusNguyenJoan Sears, OD, FAAO2012Pigment epithelial detachments are a rare association of choroidal nevi. Additionally, most nevi do not progress to melanomas, especially without first demonstrating multiple risk factors. A 68-year-old white male presented for yearly dilated monitoring of a moderately- sized choroidal nevus located between his optic disc and macula. To date it had clinically appeared flat and stable. His current presentation, however, revealed a subtle central elevation that was very difficult to perceive via fundus biomicroscopy. OCT revealed a centrally-located pigment epithelial detachment. Fluorescein angiography later produced findings pathognomonic for a choroidal melanoma, including the classic double circulation pattern. Pathogenesis, treatment, and prognosis will be discussed in this unique presentation of an especially benign appearing malignance.nguyen_melanoma
Effects of Inhaled Fluticasone on Intraocular Pressure, and Central Corneal Thickness, in Asthmatic Children Without Family History of GlaucomaOsuagwuMuslim M. ALSAADI, Turki M. ALMUBRAD2012Purpose: To report the effects of Fluticasone Inhaled corticosteroid on Intraocular pressure (IOP) and central corneal thickness (CCT) of asthmatic children without family history of glaucoma, aged 5 to 15 years. Subjects & Methods: Triplicate measurements of intraocular pressure and Central corneal thickness were obtained randomly by a hand-held noncontact tonometer and a noncontact specular microscope respectively over a 12 weeks period. Ninety-three children who participated in this study were grouped into 2. Group one: 69 asthmatic children with no family history of glaucoma who have been on inhaled fluticasone propionate 250µg/daily for at least 6 months. Group two: 24 age-matched control subjects. Results: The mean age of the subjects enrolled in this study was 8 ± 2.4 and 9 ± 2.9 years (Group 1 & 2 respectively). Average IOP measurements obtained in group 1 (asthmatic) subjects (14 ± 3.3mmHg, mean ± SD) was not significantly different (P = 0.3626) from that obtained in group 2 (control) subjects (14 ± 2.9 mmHg). The IOP in group 1 and 2 subjects ranged from 10 to 24 mmHg and 11 to 22 mmHg respectively. Mean CCT obtained in the asthmatic children (531 ± 30.1 µm) was also not significantly different (P = 0.1625) from that obtained in the control subjects (519 ± 47.0 µm). Conclusions: Fluticasone in its regular dose used over a period of at least 6 months, was shown not to have any significant effect on central corneal thickness and intraocular pressure in children between 5 and 15 years old, without a family history of glaucoma. There was a significant correlation between level of IOP and CCT of asthmatic children.osuagwu_asthma
A Pediatric Scare: The Rare Clinical Case of Coats DiseasePateErin Hardie, BS2012While leukocoria is most commonly associated with Retinoblastoma, other ocular pathologies can be the cause of this threatening sign. In this case, Coats disease was the culprit for a presentation of unilateral sensory exotropia, vision loss, and leukocoria. A 4yearold African American male presented with concern over an eye turn and no other acknowledgment of vision loss in the left eye. This case presentation highlights the diagnosis, treatment, and management of Coats disease a rare, congenital condition of the retinal vasculature resulting in massive lipid exudates and telangiectatic blood vessels that often requires laser therapy. This case presentation reviews alternative causes of leukocoria in young children and reiterates the importance of thorough dilated eye exams in the pediatric population.pate_coats
Standardized A-Scan Examination with the 30-Degree Test: A Useful Tool in Identifying Pseudo-Papilledema from Papilledema in ChildrenRandhawaJulie Marsh, OD, Carlo J. Pelino, OD, FAAO2012The diagnosis of pseudotumor cerebri can be complicated in a young child. In the presence of neurological symptoms and indistinct optic nerve margins, raised intracranial pressure should be suspected. Standardized A-scan combined with a 30 degree tilt test can be used to differentiate between increased cerebrospinal fluid and pseudo-papilledema. Increased nerve diameter is categorized as non-compressible, when due to a tumor, or compressible when due to increased subarachnoid fluid. A case report of a nine year old is discussed and how the combined A/B-scan ultrasound with 30 degree testing avoided further neuro-imaging. The A-scan technique along with the 30 degree testing is reviewed and how it takes advantage of the optic nerve anatomy in diagnosing optic nerve diseases.randhawa_abscan
The ABCs of CVIRay2012Cortical visual impairment is the most common cause of acquired bilateral visual impairment in the pediatric population of developed countries. It is defined as decreased visual acuity in the absence of ocular pathology in patients with structurally normal afferent visual pathways. Etiologies include perinatal hypoxia and prematurity, but children can also acquire CVI through infection and head trauma. Due to improved survival rates for preterm infants and traumatic brain injury patients, CVI is becoming more common. The purpose of this report is to enhance the optometrist’s insight to better care for children with CVI and better educate their often inquisitive parents using the “ABCs of CVI” (Assessments and Associations, Behavior, Clinical Care, Developmental Concerns, Environmental Modifications, and Future Implications).ray_cvi
Occlusive Vasculitis of Unknown Etiology in a 63 Year Old Immunocompetent MaleRichardJames Aylward, OD2012Retinal vasculitis is an inflammation of the vasculature resulting in arterial sheathing leading to retinal infarcts and ischemia and phlebitis leading to hemorrhaging, exudation and edema. Phlebitis is commonly seen with Behcet’s disease, tuberculosis, sarcoidosis, multiple sclerosis, Eales’ disease and human immunodeficiency virus (HIV). Arteritis is associated with systemic vasculopathies such as systemic lupus erythematosus, polyarteritis nodosa and Wegener’s granulomatosis and ocular diseases such as acute retinal necrosis and idiopathic retinal vasculitis, aneurysms and neuroretinitis (IRVAN). In this case, a 63 year old white male presents with a vasculitis and secondary artery occlusion and associated vitritis. Medical history was remarkable only for a new diagnosis of diabetes, well controlled hypertension and colon cancer. Extensive laboratory testing was negative for blood disorders, inflammatory or infectious disease and HIV or autoimmune disease. Conservative treatment was initiated. At two weeks after the initial presentation, the inflammation and ischemia have started to improve. No further diagnostic studies such vitreous sampling and retinal biopsy have been performed given the improving clinical picture and patient’s excellent vision.richard_occlusive
The Pouting Punctum and its Disagreeable Dacryolith - A Case of CanaliculitisRodmanKimberly Reed, OD, FAAO2012A 43 year old female presented with a 4 month history of tearing, discharge and swelling in the left upper eyelid. She had been previously treated with various topical modalities without resolution. The left eye revealed swelling in the region of the upper canalicular area, with moderate mucopurulent discharge draining from the punctum. A clinical diagnosis of chronic canaliculitis was made, and inoffice expression was attempted. A large dacryolist was expressed, along with copious mucopurulent discharge. The patient initially reported resolution however, symptoms subsequently worsened, and the patient was referred for surgical intervention. Canaliculitis is an inflammation of the proximal lacrimal drainage system that is frequently misdiagnosed as bacterial conjunctivitis or blepharitis. Ultimately, surgery may be required to achieve full resolution.rodman_canaliculitis
A Sticky Situation: A Case of Doyne Honeycomb Retinal Dystrophy in a 28-year-old PatientRogersMatthew Simpson, O.D.2012Background: Doyne Honeycomb Retinal Dystrophy (DHRD) is an inherited macular dystrophy that results from a defective metabolic process in the retinal pigment epithelium (RPE). Case Report: A 28-year old Caucasian male with reduced distance vision OU that was worse at nighttime presented for a comprehensive eye exam. BCVA was 20/20 OU. Fundoscopic examination revealed multiple small drusen surrounding the fovea with larger coalescent drusen extending temporal into the posterior pole OU. Mild RPE changes were also observed OD. Macular OCT revealed numerous densities at the level of the RPE, consistent with drusen OU. There was no clinical evidence of CNVM OU. Clinical findings were consistent with DHRD. Conclusion: This case report will review the etiology, possible differential diagnoses and management of Doyne Honeycomb Retinal Dystrophy.rogers_doyne
Sjrogren’s Syndrome Associated Severe Dry Eye Relieved with the Jupiter Scleral Contact LensRoy2012A 54 yr old Caucasian female presents with blurred vision OD, OS and severe dry eye symptoms secondary to Sjogren’s syndrome. She reports no relief after a trial of Restasis, punctual occlusion, frequent artificial tear use and ointment at night. A Jupiter scleral contact lens covers the compromised ocular surface to significantly reduce dry eye symptoms, and allows for improved vision, comfort and overall quality of life. This modality should be a viable option for the growing number of severe dry eye sufferers.roy_scleral
Acute Onset Cranial Nerve Six Palsy in the Adult PopulationScheurer2012Cranial nerve six palsy results from a disruption of signal along CN VI. It causes an acquired horizontal diplopia induced by the inability of the affected eye to abduct. An acute presentation in the adult population most often results from vasculopathic disease, trauma or surgery, idiopathic and less commonly multiple sclerosis. In this case report a 40 year-old black female presents with complaint of diplopia for 2 days. Ocular examination revealed a marked abduction deficit consistent with left cranial nerve six palsy. Further complaints of intermittent paresthesias along the right leg prompted referral for neurological workup, resulting in the diagnosis of multiple sclerosis. This presentation highlights the clinical evaluation and management for acute CN VI palsy presenting in the adult population.scheurer_cn
Vitreo-Macular Traction - The Wrong Kind of AttractionSchinasKimberly K. Reed, OD, FAAO2012The increasing availability of posterior segment OCT has permitted a much broader understanding of diseases of the choroid, retina, and vitreous. Vitreomacular adhesion VMA andor traction VMT is a recognized factor in several conditions, including macular hole formation, cystoid and diabetic macular edema, and proliferative diabetic retinopathy, among others. A 64 year old male presented complaining of decreased, distorted vision OD for the past 36 months. His ocular and medical history was noncontributory. Preliminary testing was normal. Best corrected VAs were 2050 OD, 2020 OS. Metamorphopsia was noted centrally on Amsler grid OD. Slight elevation with macular mottling was noted OD and OCT confirmed VMT with a stage 2 macular hole. The patient was referred to a retinal specialist. Images and outcome for the patient will be presented. Risk factors for the development of VMT and VMA as well as review emerging surgical and nonsurgical management options will be presented.schinas_traction
An Unknown Culprit: A Case Presentation of a Metallic Intraocular Foreign BodyStaskal-Brecht2012A 42 year old male presented with pain, blurry vision, photophobia, and multiple black spots in vision OD after an unknown injury to the eye earlier that day. His systemic health and previous ocular history were unremarkable. Entering visual acuities were 20/400 OD and 20/20 OS. Pupils were equal and reactive to light, extraocular muscles were smooth and full, and confrontations were hand-motion OD, FTFC OS. Slit lamp examination revealed a temporal sub-conjunctival hemorrhage with a 3mm conjunctival laceration OD. The cornea had a small 0.2mm abrasion at the temporal limbus without seidel’s sign and mild corneal edema temporal OD. Anterior chamber showed significant cells and flare OD. Fundus examination revealed a hazy vitreous media with a 3DD area of commotio retinae temporally and a small, round, refractile mass stationary in the mid-peripheral vitreous OD. The patient was diagnosed with a ruptured globe s/p trauma and intraocular foreign body OD. The patient was sent for an emergency pars plana vitrectomy and foreign body removal. This case presentation details the ocular findings, additional testing and proper management of a patient with a metallic intraocular foreign body.staskal-brecht_foreignbody
Unilateral Macular Hemorrhage Secondary to Autoimmune Hemolytic Anemia in Systemic Lupus Erythematosus: Case Report and OverviewSultaniMichael DelGiodice O.D., F.A.A.O.2012This presentation exhibits a case report and review of anemias, hemolytic anemia in particular, and associated ocular findings. Systemic and ocular findings of systemic lupus erythematosus and the association with autoimmune hemolytic anemia are also discussed. A 35-year-old Hispanic female with unilateral macular hemorrhage presents with minimal decrease in vision. After an extensive evaluation to rule out other causative pathology, this patient was diagnosed with retinal ischemia and unilateral macular hemorrhage secondary to autoimmune hemolytic anemia in systemic lupus erythematosus. Presented are clinical data of a case of unilateral macular hemorrhage secondary to autoimmune hemolytic anemia in a patient with systemic lupus erythematosus and literature review of both autoimmune hemolytic anemia and the ocular manifestations of systemic lupus erythematosus.sultani_anemic
Doc... Is That a Tooth on the Eyeball?Sunner2012A 7-year-old Hispanic male presents with “a growth on the right eyeball since birth.” The parents report the growth has increased in size and turns purple upon rubbing. Symptoms include blurry vision, swelling of the eye, and itchiness. Examination reveals large orbital mass (lipodermoid), significant astigmatism, dense amblyopia, and larger cupping in the right eye. Anterior transconjunctival orbitotomy was performed to remove the mass and in hopes of reducing astigmatism, thus making the treatment prognosis better for amblyopia. Photographs were taken pre-op, intra-op and post-op. The specimen was sent for a pathology report. Following the removal of a lipodermoid, careful examination of ocular motility and tear production is warranted. Although a lipodermoid may present as an individual entity, caution must be exercised as it is associated with systemic conditions such as Goldenhar Syndrome.sunner_tooth
Rare Calcium Lid Deposits Associated with End Stage Renal Disease Secondary to GlomerulosclerosisTibbittsKatherine D. Sanford, O.D.2012Background: Numerous anterior segment conditions are associated with end stage renal disease including conjunctival hyperemia, dry eye syndrome, pingueculae, and episcleritis, with corneal and conjunctival calcifications being the most common. We give a case report of a rare calcium lid deposit that can occur when serum calcium concentrations are elevated from chronic kidney failure. Case Report: A 55 year old black/male presented to our clinic as a consult by his PCP for evaluation of diabetes. The patient reported a history of Focal Segmental Glomerulosclerosis and a kidney transplant secondary to this condition in 2004. His PCP reported a long history of fluctuating calcium levels as well as recent episodes of elevated parathyroid hormone and serum calcium. The most recent PCP report stated that calcium levels were again regulated and under close monitoring Ocular Findings: Slit lamp examination revealed multiple calcium lid deposits lining the mucocutaneous junction of the upper and lower lids of both eyes. All other anterior or posterior segment findings were unremarkable. Conclusion: We present this case report as an informative discussion into the signs of anterior segment disease for patients suffering from chronic renal failure. Only three other cases are found in literature regarding these calcium lid deposits.tibbitts_calcium
Uveal Effusion Syndrome: Ocular Ramifications and Likely EtiologiesTibbittsDr. James A. Williamson, OD2012Background: Uveal Effusion Syndrome (UES) is an uncommon condition that often has devastating outcomes. Many of these include choroidal detachments that lead to exudative retinal detachments and residual leopard spotting of the retina that can significantly affect acuity and retinal function. Many theories are available regarding its cause. More recent opinions range from thickened sclera that impedes scleral protein permeability and compression of vortex veins to others that discuss possibilities of choroidal vessel inflammatory processes. We give a case report of a patient with worsening retinal findings in relation to UES as well as a discussion on current theories regarding its etiology. Case Report: A 65 year old white/male presented to our clinic as a new patient by definition. This patient had been seen in 2005 with findings of retinal folds of unknown etiology and was lost to follow-up. The patient returned in 2011 for a diabetic exam with complaints of subtle visual changes over multiple years for which he did not seek treatment. Ocular Findings: Fundus examination revealed linear streaks of RPE hyperplasia with surrounding fibrovascular changes. Obvious folding of the retina was seen that emanated from the macula and radiated outward into equator. Conclusion: We present this case report as an informative discussion into the possible etiologies of UES.tibbitts_effusion
Acanthamoeba Keratitis: A Case Report and ReviewTolud2012Acanthamoeba keratitis is a rare, sight threatening, corneal infection frequently associated with ocular trauma, exposure to contaminated water and contact lens wear. Early clinical findings are typically subtle presenting as a keratitis or a pseudodendritic lesion. The characteristic ring infiltrate or perineuritis tend to occur later in the disease process, which makes it difficult to diagnose early. Current treatment involves long-term use of multiple topical anti-ameobic agents as acathamoeba is highly resistant to treatment. This report examines a case of a 23yo CL wearer who presented to our clinic with symptoms of photophobia and eye redness for two months prior and was subsequently diagnosed with acanthamoeba keratitis. We review our treatment approach as well as current and emerging diagnostic and treatment modalities for this entity.tolud_acanthamoeba
Anterior Chamber Emulsification of Silicone OilTorbitBrad Sutton, OD, FAAO2012Silicone oil tamponade is a commonly used surgical intervention for the repair of significant or complicated retinal detachments. If the oil is not eventually removed from the eye, a host of secondary complications can occur. One of these complications is silcone oil emulsification with deposition in the anterior chamber. This poster will present such a case.torbit_silicone
Stroke with Retrograde Ganglion Cell DamageTorbitDebra McConnaha OD2012A 54 year old Caucasian man presents with a stable, right homonymous heminopsia secondary to an arterial venous malformation rupture at age 10. External and internal ocular health was normal. Upon dilation, healthy optic nerve rim tissue was found in both eyes with a c/d ratio of .6/.6 OD, OS. However, OCT shows significant RNFL loss. Further investigation did not suggest the patient has glaucoma or any other retinal/ONH condition. OCT findings reveal temporal RNFL loss that matches the nasal VF defect. It is believed that the stroke damaged axons in the occipital cortex that originated in the LGN. Damage to those axons has apparently led to retrograde damage of their synaptic partner retinal ganglion cells as evidenced by the OCT scan. This poster will include visual field and OCT findings, differential diagnosis, management/treatment options as well as a review of the literature on retrograde ganglion cell damage after a stroke.torbit_stroke
Holy Hypoxia!?: An Extreme Case of Contact Lens Induced Corneal EdemaTruittChris Wroten, O.D.2012A 23 year-old Caucasian male presents with pain, redness, tearing, and blurry vision reduced to finger counting at 2 feet OS (with correction). Examination reveals severe, diffuse corneal edema with epithelial disruption, stromal haze, endothelial folds, and bullae. Despite an initial pachymetry measurement of 1035 microns, the patient regains 20/20 vision within two weeks of treatment initiation. This poster presents an extreme case of corneal edema, secondary to contact lens overwear, with a review of treatment and management options including new pachymetry technology and the use of anterior segment optical coherence tomography (OCT) to follow resolution. Digital anterior segment photography is included.truitt_hypoxia
Cystoid Macular Edema Associated with Prostaglandin Analog UseTurner2012This is a clinical case study of cystoid macular edema occurring in a pseudophakic patient who was being treated for ocular hypertension with a prostaglandin analog. Supplementary data and ancillary testing are included. Cystoid macular edema is an ocular disorder caused by an accumulation of fluid in the macula that can result in decreased visual acuity. This case report reviews the treatment and management of patients with cystoid macular edema, and incorporates a discussion of symptoms, clinical findings, etiologies, differential diagnoses and treatment and management options as they are related to this unique case presentation.turner_cystoid
Flipping Out: A Conjunctival ConundrumTylerKelly Meehan, OD -- Midwestern University College of Optometry2012A granuloma is a relatively small nodular inflammatory lesion that may be caused by infectious or noninfectious agents. These localized ocular changes most commonly develop from palpebral conjunctival tissue, seen as a small lesion on lid eversion resulting in foreign body sensation. A white male presented to the clinic with an irritated OD that had changed significantly in the previous day. The patient stated the lesion OD had flipped outside the lid after approximately two weeks of puffiness and increasing size. Overnight the lesion began to bleed.The patient had a history of ear pain on the left side and a stye OS six weeks prior. The patient had used an OTC stye medication and warm compresses followed by a prescription for Amoxacillin PO x 14 days. Afterwards the patient developed swelling OD for which he presented. Unaided VA was 2025 OD, OS with normal preliminaries in both eyes. General observation showed a large growth protruding over the right eyelid. Biomicroscopy revealed a large vascularized, lobed and stalked lesion with diffuse staining of the conjunctiva. Additionally, the OS had a thickened, painless lesion of the lower lid. The cornea was intact OU without NaFl staining. Differentials for atypical conjunctivallid lesions will be discussed as well as potential prognoses. Images of the presented lesion will be provided.tyler_flipping
Diplopia: Double Vision and Diabetes, Or Is It?WelkeErin M Draper, OD, FAAO, Kelly Malloy, OD, FAAO, Diplomate2012A 38 year-old African-American woman with a history of uncontrolled diabetes presents with an acute onset of diplopia. Her ocular history is remarkable for previous episodes of diplopia. Upon examination an internuclear ophthalmoplegia(INO) with a skew deviation is diagnosed. Because an INO in a younger diabetic patient is atypical, a further work-up is warranted. The results of an MRI reveal findings that are consistent with multiple sclerosis. A neurological consultation is necessary and treatment is initiated.welke_diplopia
Ocular Manifestations of Multiple MyelomaWhitakerLauren Stirling, O.D., Resident, Hospital-Based Optometry, Tuscaloosa VAMC2012Multiple myeloma is a rare malignancy which results in a myriad of symptoms and clinical presentations. In affected individuals, uncontrolled proliferation of plasma cells results in the formation of bone marrow tumors. Consequently, a variety of organ and system dysfunctions ensue which ultimately shorten the lifespan. Although rare, ocular manifestations of multiple myeloma may occur at any point in the disease process and can affect virtually every ocular structure. Herein, we review the etiology, epidemiology, diagnosis and management of this subset of patients.whitaker_multiple
Circumscribed Choroidal Hemangioma: A Case Report and ReviewWhitakerCarrianne Starnes, O.D. - Resident Hospital-Based Optometry2012Choroidal hemangioma is a rare vascular hamartoma which presents in both diffuse and discrete forms. These congenital tumors may be discovered during a routine eye examination or if a patient develops visual symptoms. Subjective complaints are most often secondary to an accompanying serous retinal detachment. Herein, we review the diagnosis and management of choroidal hemangioma in a 62 yearold male who presented with complaints of decreasing vision in his right eye of two years duration.whitaker_hemangioma
Small Nerve, Big Problem?WongJulie Rodman, OD, FAAO and Deborah Amster, OD, FAAO, COVD2012Optic nerve hypoplasia (ONH) is a congenital abnormality characterized by small optic discs. Visual symptoms are variable and may be mild to severe, potentially including visual field abnormalities. ONH can occur in isolation or in association with other central nervous system abnormalities. We present two patients with ONH that vary in degree of symptomatology. Case one presents a 38-year-old healthy female with history of refractive surgery and decreased vision in the right eye vision since birth. Visual field testing reveals a dense arcuate defect in the right eye. Case two presents a 4-year-old healthy boy with history of blindness in the right eye and behavioral problems. Krimsky testing reveals a 20-25 prism diopter constant right exotropia. In both cases fundus examination is notable for small optic nerves with a “double ring sign” (small nerve surrounded by a pale peripapillary halo). In patients with ONH, endocrinologic evaluation and neuroimaging of brain are recommended to rule out endocrinopathy and structural brain abnormalities, including absence of the septum pellucidum, and agenesis or thinning of the corpus callosum. This poster will review ocular manifestations of ONH and its systemic associations.wong_smallnerve
The Longterm Ocular and Visual Sequelae of Hypertensive Encephalopathy: A Low Vision Case ReportYeeMana Sharma, Kara Gagnon, O.D., F.A.A.O, Nancy Shenouda-Awad, O.D., F.A.A.O, Christine Burke, O.D., F.A.A.O2012Hypertensive encephalopathy is a neurological dysfunction of the brain typically caused by severe and acute hypertension. Here we report a case of longstanding bilateral optic neuropathy secondary to hypertensive encephalopathy resulting from malignant hypertension. Fundoscopic examination revealed elevated optic nerves with generalized pallor. Optical coherence tomography showed a loss of retinal nerve fiber layer (RNFL) without active edema. In addition to hypertensive encephalopathy, we consider additional differential diagnoses, including papilledema, papillitis, optic disc drusen, and anterior ischemic optic neuropathy. We review the ocular findings and visual sequelae of hypertensive encephalopathy in this patient, who presented with intact central vision but severe visual field constriction. Using this case example, we discuss low vision evaluation and management of legal blindness resulting from hypertensive encephalopathy.yee_encephalopathy
Lab Values: The High, the Low and What They Really MeanYee2012Blood tests are a valuable diagnostic tool. There are over 130 tests available to health care providers. While some lab tests are routinely ordered by general practitioners, others are mostly ordered by specialists and subspecialists. The presentation will focus on some specific blood tests, their values and what they may indicate. Some of these labs are commonly ordered by the eye community, while others are ordered by primary care. This discussion will also include a few labs that are most often obtained in hospital base facilities. As eye care providers in outpatient clinics andor private practice, we do not typically encounter some of these lab values. However, it is worthwhile to gain a better understanding of these labs, their values and their potential complications.yee_lab
The “Art” of Low Vision: Vision Rehabilitation in a Case of Concurrent Glaucoma and Wet Age-Related Macular Degeneration (ARMD)YeeKara Gagnon, O.D., F.A.A.O, Nancy Shenouda-Awad, O.D., F.A.A.O2012When ocular pathology results in low vision, the loss of vision can typically be characterized as either peripheral visual field constriction (as in glaucoma, diabetic retinopathy, retinitis pigmentosa) or central scotoma (as in macular degeneration, maculopathies). Occasionally however, these ocular pathologies can coexist. Simultaneous reduction of both central and peripheral vision can result in severe impairment of functional vision. Coping with such a disability is a significant challenge. In this low vision case study, we report on a professional artist diagnosed with wet ARMD and end-stage glaucoma in both eyes. Techniques for evaluating and maximizing visual acuity and functional vision in the coincident central scotoma and small-fielded patient are reviewed. We also discuss unique devices, recommendations, and adaptations for low vision artists, including optical magnification, digital/video magnification, head-borne and mobile devices, lighting, tinting, and suggestions for intermediate visual demands.yee_artlowvision
Toxic Optic Neuropathy Associated with Short-Term Linezolid Use in a Patient with MRSA-Related PneumoniaZabalaAndre Stanberry, OD2012Case Report: A 72-year old white male presented with decreased vision in both eyes after taking oral linezolid for two weeks. Before diagnosed with MRSA-related pneumonia, prior treatment included multiple antibiotics including IV ethambutol. Linezolid was discontinued, and his vision was restored one month later. Conclusion: Multiple cases of linezolid-related optic neuropathies have been reported in the literature with long-term use. There are only three cases, including this report, of patients associated with short-term usage. Drugs such as ethambutol or vincristine, which have been shown to cause toxic optic neuropathy, may enhance the toxicity of linezolid therefore causing linezolid-related optic neuropathy within only a few weeks of treatment.zabala_linezolid