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

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

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

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

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

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

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

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

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

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

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

15. Cirrus SD OCT
#####

16. Topography OU

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

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

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

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

23. GDX

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

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

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

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

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

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

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

31. VA: OD: 20/400 at 4 feet OS: Light Projection
Ext: Severe right face droop—full facial palsy Significant edema below right lower lid. Mild ectropion, right lower lid Grossly incomplete lid closure, OD. Mild red eye reaction OD—watery Blue tinge to right lower lid Solid nodule palpable within edematous right lower lid
Assessment: Atypical for ectropion

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

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

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

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

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

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

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

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

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

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

47. Oasis Medical Inc.

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

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

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

51. Treatment of Ocular Herpes Simplex
HEDS –Herpes Eye Disease Study (Archives of Ophthalmology,121,Dec.03’)
Longterm use of oral Acyclovir greatly reduces the recurrence of HSK
400mg daily, compliance is mandatory
Patients who stopped early – re-infected
12 months vs. 18 months vs. Indefinitely

55. Diagnosis
We’ve all heard “Herpes Zoster the Great Imposter” however, Ocular Herpes Simplex can be cunning as well

60. Pearls LeiterRX.com – 800-292-6773
Consider superficial wipe with weck cell sponge or cotton tip applicator with HSK
Remember subsequent epithelial infections are not as irritating or painful
Family and friends watch for “red eye”
Do not miss multiple doses of oral Acyclovir can lead to reactivation
Think of it as BC or a daily Vitamin
If nonresponsive try Vira-A ung
LeiterRX.com –
Be cautious with steroids!!

61. 60 y.o. white male POAG diagnosed 3 years previously
IOP
Disks
24-2’s
GDX
(+) Family History
Mother
Significant field loss
Managed with Timoptic .5%
Baseline IOP consistently around 21mmHg

62. C.E.O. of major academic institution
Engaged in major capital fundraising campaign
Anticipating program’s 100 year anniversary celebration week
Prominent lecturer on CME circuit
Professionally, very active
Personally, Physically, very active

63. Initial Treatment Timoptic .25% IOP OD: 20 and OS: 19
Rx: 1gt OD + OS, once per day, a.m.
IOP OD: 20 and OS: 19
Rx: 1gt OD + OS, twice daily, a.m. + p.m.
IOP OD: 19 and OS: 19
Patient complains of difficulty with daily early-morning jogging

64. Timoptic discontinued
Xalatan treatment initiated
Rx 1 gt OD + OS at night, prior to sleep
IOP OD: OS: 15
Complaint of “red eye reaction”
Daily dosing schedule altered
Rx 1 gt OD + OS at dinner time
“Red eye reaction” complaint persists

65. Xalatan discontinued Travatan initiated
“Red eye reaction” complaint intensifies

66. Argon Laser Trabeculoplasty discussed with patient
Selective Wavelength Laser Trabeculoplasty mentioned to patient

67. S.L.T. performed OD + OS Inferior 180-degrees
IOP at 2 months: OD OS 21

68. Second S.L.T. performed Superior 180-degrees
IOP at 1 month: OD: OS: 15
IOP stable at 15 – 18 at this time

69. 52 y/o Female “I want to have LASIK”
Previous CL wearer (monovision) started to have comfort issues and previous doc told her to go to glasses – “hates them!”
Med Hx: menapausal, mild controlled HTN
C/O VA is blurry with glasses in distance OD > OS

70. The Exam VA cc OD 20/40 OS 20/25 Pupils, EOM’s, CVF normal OU
BVA OD x 040, 20/30-
OS x 025, 20/25-
SLE: Lids and lashes clear, A/C deep and quiet, 1+NS OU,
See corneal photos
Internal: .25 C/D OU, Macula and periphery clear OU

71. Corneal photo

72. Corneal photo

74. ?? LASIK Candidate ??
Is a patient with Fuch’s Dystrophy a candidate for LASIK?
Is a patient with Cogan’s (MDF) Dystrophy a candidate for LASIK?

75. Fuch’s Endothelial Dystrophy
Females 3:1
Autosomal Dominant
Slowly progressive formation of guttate lesions between the corneal endothelium and Descemet’s membrane
Guttate are thought to be abnormal elaborations of basement membrane and fibrillar collagen from distressed or dystrophic endothelial cells
So does performing laser on the corneal stroma effect this condition in any way?

76. Refractive Surgery and Fuch’s
Incisional refractive surgery, AK, RK, LASIK and ALL-LASER LASIK, is contraindicated in Fuch’s patients (?)
Surface Ablation, PRK, LASEK, Epi-LASIK are relative contraindications
It is estimated that there is 3-8% of endothelial cell loss during laser ablation

78. DSEK or DSAEK Descemet’s Stripping Endothelial Keratoplasty
Descemet’s Stripping Automated Endothelial Keratoplasty
Impressively mild post-op
Minimal corneal edema or anterior
corneal compromise
Rapid rehab with minimal to no astig.

79. DSAEK VIDEO

80. Cogan’s Dystrophy MDF, ABMD, EBMD, Microcystic Epithelial Dystrophy
Nonprogressive but fluctuating in course
F > M
1/3 of patients have RCE
Irregular Astigmatism common cause of VA loss
VA loss does not match clinical picture via slit lamp exam

83. Cogan’s Dystrophy
Pathophysiology: Corneal epi adheres to underlying BM
Faulty BM – thickened, multilaminar, misdirected into epi: “maps & fingerprints”
Deeper epi cells don’t migrate to the surface: “dots, intraepithelial microcysts”
Epi cells ant. To the BM difficulty forming hemidesmosomes results in RCE

84. Cogan’s Dystrophy Treatments: AT’s, Muro 128 gtts and ung
2005 only prospective study to date no difference between AT”s and NaCl
Irregular Astig. CL fix? RGP vs. Soft
Superficial Keratectomy
Polish BM w/ diamond burr or alger brush
ASP for erosions or post Keratectomy, consider donut approach and spare visual axis
PTK or PRK if going for refractive correction
Not great LASIK candidates

85. Cogans Dystrophy
For decreased VA w/ suspect irregular astigmatism look at placedo disc vs. topography
Consider Silicone Hydrogels however, beware most of these patients have some degree of dry eye and are more likely to have torsion marks / RCE
Daily vs. EW? Poor dexterity in elderly