Grand Rounds in Grand Rounds in Eye CareEye Care

FROM THE LIDS TO FROM THE LIDS TO THE MESHWORKTHE MESHWORK

Lee W. Carr, O.D.Lee W. Carr, O.D.

Jeff D. Miller, O.D.Jeff D. Miller, O.D.

28 y.o. White female28 y.o. White female

C/O: “I had a big stye on my lid, and now C/O: “I had a big stye on my lid, and now it’s really swollen up, and it hurts really it’s really swollen up, and it hurts really bad.”bad.”

No known health problemsNo known health problems No medications, currentlyNo medications, currently Allergic to penicillinAllergic to penicillin No other known allergiesNo other known allergies

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

good and it really started to hurt.”good and it really started to hurt.”

Currently…Currently…

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

The ExamThe Exam

VA’s (sc): OD: 20/20 OS: 20/20VA’s (sc): OD: 20/20 OS: 20/20 Pupils: PERRLA, brisk OUPupils: PERRLA, brisk OU Motilities: full, unrestricted OD + OSMotilities: full, unrestricted OD + OS Conf Fields: full, OD + OSConf Fields: full, OD + OS SLE: quiet and clear cornea and anterior SLE: quiet and clear cornea and anterior

chamberchamber EXTERNAL: EXTERNAL: OD: quiet, WNLOD: quiet, WNL

OS: extensive lid OS: extensive lid swellingswelling

Assessment: Preseptal vs Assessment: Preseptal vs Postseptal CellulitisPostseptal Cellulitis

Re-checked EOM’s. Full, unrestrictedRe-checked EOM’s. Full, unrestricted Took patient’s temperature: 97.5 degreesTook patient’s temperature: 97.5 degrees Pulse & BP: 74 bpm; 122/78Pulse & BP: 74 bpm; 122/78 Questioned patient regarding current or recent Questioned patient regarding current or recent

sinusitissinusitis Evaluated nasal passages with transilluminator Evaluated nasal passages with transilluminator

lightlight Attempted sinus transilluminationAttempted sinus transillumination Attempted combined scan ultrasoundAttempted combined scan ultrasound Discussed monitor/empiric therapy or CT Discussed monitor/empiric therapy or CT

evaluation options with patientevaluation options with patient

ManagementManagement Rx: azithromycin (z-pack x 2)Rx: azithromycin (z-pack x 2)

Take 2 (250mg) tablets twice per day for two Take 2 (250mg) tablets twice per day for two days;days;Then reduce to 1 tablet per day until all tablets Then reduce to 1 tablet per day until all tablets are goneare gone

Rx: tramadolRx: tramadolTake 1 (50mg) tablet qid x 2 daysTake 1 (50mg) tablet qid x 2 days

Requested tetanus booster via Adult MedRequested tetanus booster via Adult Med RTC: 24 hours to re evaluate motilities,RTC: 24 hours to re evaluate motilities,

other findingsother findings

DILATED FUNDUS EXAMDILATED FUNDUS EXAM

All findings considered benign and WNLAll findings considered benign and WNLfor OD and for OSfor OD and for OS

54 year old male54 year old male

Yearly eye examYearly eye exam C/O OD blurry for the last 3-4 weeksC/O OD blurry for the last 3-4 weeks Has happened before but intermittentHas happened before but intermittent Refr. Hx: hyperopic/astigmat/presbyopeRefr. Hx: hyperopic/astigmat/presbyope Medical Hx: Type II DM, HTN, elevated Medical Hx: Type II DM, HTN, elevated

cholesterolcholesterol Meds:Metformin,HCTZ,Toprol-XL, Meds:Metformin,HCTZ,Toprol-XL,

Zetia,VitaminsZetia,Vitamins

The ExamThe Exam

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

Additional TestingAdditional Testing

Lissamine GreenLissamine Green Cirrus OCT of Macula OUCirrus OCT of Macula OU TopographyTopography Pachymetry OD 530 OS 509Pachymetry OD 530 OS 509

Additional History: always sleeps with Additional History: always sleeps with ceiling fan on highceiling fan on high

Cirrus SD OCTCirrus SD OCT#####

Topography OUTopography OU

Working DiagnosisWorking Diagnosis

Irregular topography OD secondary Irregular topography OD secondary

to Dry Eyeto Dry Eye Suspect corneal thickness OS > ODSuspect corneal thickness OS > OD

(Ocular HTN/Glaucoma suspect?)(Ocular HTN/Glaucoma suspect?)

REC: D/C ceiling fan if possible, AT’s upon REC: D/C ceiling fan if possible, AT’s upon waking and throughout day, various samples waking and throughout day, various samples given, consider “gel” HSgiven, consider “gel” HS

RTC 3-4 weeks progress evaluation RTC 3-4 weeks progress evaluation

F/U ExamF/U Exam

Patient states mild improvement some days better than Patient states mild improvement some days better than othersothers

Using Soothe XP with some successUsing Soothe XP with some success C/O of Mild itchingC/O of Mild itching

VA cc OD 20/25- OS 20/20VA cc OD 20/25- OS 20/20 Cornea eval trace SPK OD, clear OSCornea eval trace SPK OD, clear OS Everted Lids: clear however, lids very “flaccid”Everted Lids: clear however, lids very “flaccid” Lids everted w/o any particular effort or techniqueLids everted w/o any particular effort or technique

Additional HistoryAdditional History

At this point the spouse offered some At this point the spouse offered some information through a question information through a question

““We’ve stopped the ceiling fan however, We’ve stopped the ceiling fan however, he has just recently started using a CPAP he has just recently started using a CPAP for sleep apnea. Will that dry his eyes out for sleep apnea. Will that dry his eyes out more?”more?”

Working Diagnosis ChangedWorking Diagnosis Changed

FES, Sleep Apnea, and GlaucomaFES, Sleep Apnea, and Glaucoma

Several ocular disorders have been found in association with Obstructive Several ocular disorders have been found in association with Obstructive Sleep Apnea or OSA: FES, optic neuropathy, glaucoma, NAION, and Sleep Apnea or OSA: FES, optic neuropathy, glaucoma, NAION, and papilledema.papilledema.

5-15% of OSA pts. have FES5-15% of OSA pts. have FES 96% of FES pts. have OSA (collagen in esophagus / pharynx similar to 96% of FES pts. have OSA (collagen in esophagus / pharynx similar to

tarsal plate – results in esophageal collapse)tarsal plate – results in esophageal collapse) 57% of NTG pts. Have sleep apnea symptoms57% of NTG pts. Have sleep apnea symptoms Glaucoma – 2% of general population, 7+% of OSA patientsGlaucoma – 2% of general population, 7+% of OSA patients Multiple studies have shown over 70% of NAION pts. have OSAMultiple studies have shown over 70% of NAION pts. have OSA Trigger: failure of AUTOREGULATION Trigger: failure of AUTOREGULATION (all NAION pts. Should be advised to be evaluated for OSA)(all NAION pts. Should be advised to be evaluated for OSA)

www.slideshare.net/rhodopsin/sleep-apnea-and-the-eye Rick Trevino, O.D.Rick Trevino, O.D.

GDX GDX

Evidence of Ischemia’s Role Evidence of Ischemia’s Role in Glaucomain Glaucoma

Overwhelming evidence indicates high IOP Overwhelming evidence indicates high IOP contributes to the development of glaucomacontributes to the development of glaucoma

As many as 80% of Ocular HTN’s don’t develop As many as 80% of Ocular HTN’s don’t develop glaucomaglaucoma

What about NTG? – about 30% of glaucoma What about NTG? – about 30% of glaucoma patients appear to have normal IOP yet go on to patients appear to have normal IOP yet go on to have their nerves collapse and deterioratehave their nerves collapse and deteriorate

The Key? – AUTOREGULATION The Key? – AUTOREGULATION

ManagementManagement

Continue to treat Ocular surface diseaseContinue to treat Ocular surface disease

Continue to monitor for GlaucomaContinue to monitor for Glaucoma

Encourage patient to have continued f/u Encourage patient to have continued f/u care with PCP discussed OSA and care with PCP discussed OSA and potential neurovascular, cardiovascular potential neurovascular, cardiovascular sequela as well as glaucoma and ION sequela as well as glaucoma and ION

66 y.o. White female66 y.o. White female

Referred in from Low Vision Service and Referred in from Low Vision Service and Rural Eye Program clinic for evaluation for Rural Eye Program clinic for evaluation for ectropion repair—right lower lidectropion repair—right lower lid

History of longstanding Bell’s Palsy, right History of longstanding Bell’s Palsy, right side (“at least 14 years ago”)side (“at least 14 years ago”)

Hx: Hx: Type 2 diabetes, on insulinType 2 diabetes, on insulinHypertensionHypertension

Ocular HistoryOcular History

General OphthalmologistGeneral Ophthalmologist Pan retinal photocoagulation OU (2002)Pan retinal photocoagulation OU (2002)

Retinal SpecialistRetinal Specialist PRP and grid (2002)PRP and grid (2002) Vitrectomy, OD, (2003)Vitrectomy, OD, (2003)

Low Vision Service (2003)Low Vision Service (2003) VA: OD: 10/400 OS: 20/150VA: OD: 10/400 OS: 20/150

Hx (continued):Hx (continued):

Corneal SpecialistCorneal Specialist Exposure keratitis management (2005)Exposure keratitis management (2005) Cataract surgery, OD, (2005)Cataract surgery, OD, (2005) Lateral tarsorrhaphy, OD, (2005)Lateral tarsorrhaphy, OD, (2005) Recommendation: Cataract surgery OSRecommendation: Cataract surgery OS

Retinal SpecialistRetinal Specialist More PRP (2006)More PRP (2006) Cataract surgery, OS, (2006)Cataract surgery, OS, (2006)

Low Vision ServiceLow Vision Service VA: OD: 10/100 OS: 10/350VA: OD: 10/100 OS: 10/350

Hx (continued):Hx (continued):

Retinal SpecialistRetinal Specialist PRP, OU, (2007)PRP, OU, (2007) Anti-VEGF, OU (2007)Anti-VEGF, OU (2007) Vitrectomy and Retinal Detachment Repair, Vitrectomy and Retinal Detachment Repair,

OS, (2007)OS, (2007)

Low Vision ServiceLow Vision Service VA: OD: 6/80 OS: HM at 2 feetVA: OD: 6/80 OS: HM at 2 feet

Specialty Care Exam (4/22/08)Specialty Care Exam (4/22/08)

““I was advised to get my eye lid fixed I was advised to get my eye lid fixed again.”again.”

““No pain; I’ve gotten used to it.”No pain; I’ve gotten used to it.” ““Sometimes I forget to use my artificial Sometimes I forget to use my artificial

tears, but not often.”tears, but not often.” Mx: insulin, Fosthopace, Systane, Thera-Mx: insulin, Fosthopace, Systane, Thera-

tears, Erythromycin ophthalmic ointment tears, Erythromycin ophthalmic ointment (prn use)(prn use)

VA: VA: OD: 20/400 at 4 feetOD: 20/400 at 4 feetOS: Light ProjectionOS: Light Projection

Ext: Severe right face droop—full facial palsyExt: Severe right face droop—full facial palsySignificant edema below right lower lid.Significant edema below right lower lid.Mild ectropion, right lower lidMild ectropion, right lower lidGrossly incomplete lid closure, OD.Grossly incomplete lid closure, OD.Mild red eye reaction OD—wateryMild red eye reaction OD—wateryBlue tinge to right lower lidBlue tinge to right lower lidSolid nodule palpable within edematous right Solid nodule palpable within edematous right lower lidlower lid

Assessment: Atypical for ectropionAssessment: Atypical for ectropion

Consult with our clinical Consult with our clinical ophthalmologistophthalmologist

Additional Hx obtained: Patient last seen by her Additional Hx obtained: Patient last seen by her primary care physician in January, 2008. He primary care physician in January, 2008. He recommended eye lid evaluation.recommended eye lid evaluation.

In late November, 2007, the PCP had removed a In late November, 2007, the PCP had removed a “skin lump” from outer canthus, right lower lid.“skin lump” from outer canthus, right lower lid.

Pathology report identified basal cell carcinoma.Pathology report identified basal cell carcinoma. At March, 2008 exam, PCP expressed concern At March, 2008 exam, PCP expressed concern

to patient that residual tumor may exist, and to patient that residual tumor may exist, and again recommended eye lid surgery.again recommended eye lid surgery.

Lesson LearnedLesson Learned

PATIENT EDUCATION IS CRITICALPATIENT EDUCATION IS CRITICAL This patient thought that the This patient thought that the

recommendation for ectropion repair and recommendation for ectropion repair and the recommendation for evaluation of the the recommendation for evaluation of the right lower lid for residual basal cell right lower lid for residual basal cell carcinoma were “one-and-the-same”carcinoma were “one-and-the-same”

ManagementManagement

Assessment: Probably deep basal cell Assessment: Probably deep basal cell carcinoma spread—potentially orbital carcinoma spread—potentially orbital invasion.invasion.

Plan: Made immediate referral to Plan: Made immediate referral to oculoplastic surgeon--Tulsaoculoplastic surgeon--Tulsa

22 y/o male 22 y/o male college studentcollege student

Presented with c/o mild decreased vision Presented with c/o mild decreased vision OD associated with scratchy FB sensation OD associated with scratchy FB sensation and photophobiaand photophobia

Reports is being treated for a “stye” on his Reports is being treated for a “stye” on his OD upper lid with lid scrubs and tobradex OD upper lid with lid scrubs and tobradex drops for 1 week – no improvement – in drops for 1 week – no improvement – in fact, getting worsefact, getting worse

OD red, questions allergy to drops? OD red, questions allergy to drops?

The ExamThe Exam

Healthy young male no systemic Healthy young male no systemic conditions, no meds p.o.conditions, no meds p.o.

VA sc OD 20/30 OS 20/20VA sc OD 20/30 OS 20/20

All entrance visual skills normalAll entrance visual skills normal

SLE:SLE:

Assessment / Treatment Assessment / Treatment

Herpetic lid lesion and HSKHerpetic lid lesion and HSK

D/C TobradexD/C Tobradex

Begin Viroptic q1h ODBegin Viroptic q1h OD

Begin 400mg Acyclovir p.o. 5 x dayBegin 400mg Acyclovir p.o. 5 x day

Herpes Simplex KeratitisHerpes Simplex KeratitisThe Leading Cause of Corneal The Leading Cause of Corneal

Blindness in the USBlindness in the US

Ocular Herpes SimplexOcular Herpes Simplex Each year in the U.S. 25 million people have flare-ups Each year in the U.S. 25 million people have flare-ups of facial Herpes (95% of population exposed by age 6yrs)of facial Herpes (95% of population exposed by age 6yrs)

1/3 of the population worldwide has had HSV infection 1/3 of the population worldwide has had HSV infection

700,000 have developed HSV-related ocular disease in the US700,000 have developed HSV-related ocular disease in the US

20,000 – 50,000 new cases/yr 28,000 reactivations/yr 20,000 – 50,000 new cases/yr 28,000 reactivations/yr

Rarely is this bilateral however, has been seen bilaterally in children Rarely is this bilateral however, has been seen bilaterally in children

After the first corneal infection, 25% re-occur with in 2 yearsAfter the first corneal infection, 25% re-occur with in 2 years

It is the most common cause of infectious blindness in the Western It is the most common cause of infectious blindness in the Western World World

Ocular Herpes SimplexOcular Herpes Simplex After the second infection odds of further recurrences After the second infection odds of further recurrences greatly increasesgreatly increases 40% of these patients have more than one recurrence40% of these patients have more than one recurrence

Infectious Epithelial keratitisInfectious Epithelial keratitisNeurotrophic KeratopathyNeurotrophic KeratopathyNecrotizing Stromal KeratitisNecrotizing Stromal KeratitisImmune Stromal Keratitis (ISK)Immune Stromal Keratitis (ISK)EndotheliitisEndotheliitis(Keratouveitis or trabeculitis)(Keratouveitis or trabeculitis)

One of the leading indications for PK in the US One of the leading indications for PK in the US

Diagnostic PearlsDiagnostic Pearls

Evaluate lid margin and lash follicles closelyEvaluate lid margin and lash follicles closely Look for a follicular vs. papillary responseLook for a follicular vs. papillary response Look for more of a serous vs. mucous dischargeLook for more of a serous vs. mucous discharge Don’t forget decreased corneal sensitivityDon’t forget decreased corneal sensitivity Cotton wisp test (check before staining!)Cotton wisp test (check before staining!) Multiple raised epithelial defects vs. mediumMultiple raised epithelial defects vs. medium to large classic dendritesto large classic dendrites

Be careful with steroids on garden variety eye Be careful with steroids on garden variety eye inflammationinflammation

Oasis Medical Inc.

909-305-5400

Treatment - Oral AntiviralsTreatment - Oral Antivirals

Valacyclovir hydrochloride Valacyclovir hydrochloride Trade name – Valtrex Trade name – Valtrex

Acyclovir Acyclovir Trade name – ZoviraxTrade name – Zovirax

Both inhibit viral DNA replication by Both inhibit viral DNA replication by interfering with viral DNA polymerase interfering with viral DNA polymerase

Acute PhaseAcute PhaseDosages and PrecautionsDosages and Precautions

Valtrex 500mg 1 p.o. bid x 7 days ($88)Valtrex 500mg 1 p.o. bid x 7 days ($88)

Zovirax 400mg 1 p.o. 5 x a day Zovirax 400mg 1 p.o. 5 x a day for 10-14 days (14 days $20)for 10-14 days (14 days $20)

Contraindicated in patients with Contraindicated in patients with kidney disease, liver disease, and kidney disease, liver disease, and immunosuppressed patients (HIV)immunosuppressed patients (HIV)

Acute PhaseAcute PhaseTreatment - Topical AntiviralsTreatment - Topical Antivirals

Trifluridine ophthalmic drops Trifluridine ophthalmic drops Trade name – Viroptic ($125, generic $95)Trade name – Viroptic ($125, generic $95) 1 drop q1h (8 times a day)1 drop q1h (8 times a day)

Vidarabine ophthalmic ointment (Vidarabine ophthalmic ointment (UNAVAILABLE EXCEPT BY SPECIALORDERUNAVAILABLE EXCEPT BY SPECIALORDER)) Trade name – Vira-A ung (5 times a day)Trade name – Vira-A ung (5 times a day) Effective against strains unresponsive toEffective against strains unresponsive to Viroptic and AcyclovirViroptic and Acyclovir

What about steroids to decrease scarring? What about steroids to decrease scarring?

Treatment of Ocular Treatment of Ocular Herpes SimplexHerpes Simplex

HEDS –Herpes Eye Disease Study HEDS –Herpes Eye Disease Study (Archives of Ophthalmology,121,Dec.03’)(Archives of Ophthalmology,121,Dec.03’)

Longterm use of oral Acyclovir greatly Longterm use of oral Acyclovir greatly reduces the recurrence of HSKreduces the recurrence of HSK

400mg daily, 400mg daily, compliance is mandatorycompliance is mandatory Patients who stopped early – re-infectedPatients who stopped early – re-infected 12 months vs. 18 months vs. Indefinitely12 months vs. 18 months vs. Indefinitely

DiagnosisDiagnosis

We’ve all heard “Herpes Zoster We’ve all heard “Herpes Zoster the Great Imposter” however, the Great Imposter” however,

Ocular Herpes Simplex can be Ocular Herpes Simplex can be cunning as well cunning as well

PearlsPearls

Consider superficial wipe with weck cell sponge or cotton Consider superficial wipe with weck cell sponge or cotton tip applicator with HSKtip applicator with HSK

Remember subsequent epithelial infections are not as Remember subsequent epithelial infections are not as irritating or painfulirritating or painful

Family and friends watch for “red eye”Family and friends watch for “red eye” Do not miss multiple doses of oral Acyclovir can lead to Do not miss multiple doses of oral Acyclovir can lead to

reactivationreactivation Think of it as BC or a daily VitaminThink of it as BC or a daily Vitamin If nonresponsive try Vira-A ung If nonresponsive try Vira-A ung

LeiterRX.com – 800-292-6773LeiterRX.com – 800-292-6773 Be cautious with steroids!!Be cautious with steroids!!

60 y.o. white male60 y.o. white male

POAG diagnosed 3 years previouslyPOAG diagnosed 3 years previously IOPIOP DisksDisks 24-2’s24-2’s GDXGDX

(+) Family History(+) Family History MotherMother

Significant field lossSignificant field loss Managed with Timoptic .5%Managed with Timoptic .5%

Baseline IOP consistently around 21mmHgBaseline IOP consistently around 21mmHg

C.E.O. of major academic C.E.O. of major academic institutioninstitution

Engaged in major capital fundraising Engaged in major capital fundraising campaigncampaign

Anticipating program’s 100 year Anticipating program’s 100 year anniversary celebration weekanniversary celebration week

Prominent lecturer on CME circuitProminent lecturer on CME circuit Professionally, very activeProfessionally, very active Personally, Physically, very activePersonally, Physically, very active

Initial TreatmentInitial Treatment

Timoptic .25%Timoptic .25% Rx: 1gt OD + OS, once per day, a.m.Rx: 1gt OD + OS, once per day, a.m.

IOP OD: 20 and OS: 19IOP OD: 20 and OS: 19 Rx: 1gt OD + OS, twice daily, a.m. + p.m.Rx: 1gt OD + OS, twice daily, a.m. + p.m.

IOP OD: 19 and OS: 19IOP OD: 19 and OS: 19

Patient complains of difficulty with daily Patient complains of difficulty with daily early-morning joggingearly-morning jogging

Timoptic discontinuedTimoptic discontinued

Xalatan treatment initiatedXalatan treatment initiated Rx 1 gt OD + OS at night, prior to sleepRx 1 gt OD + OS at night, prior to sleep

IOP OD: 16 OS: 15IOP OD: 16 OS: 15 Complaint of “red eye reaction”Complaint of “red eye reaction” Daily dosing schedule alteredDaily dosing schedule altered

Rx 1 gt OD + OS at dinner timeRx 1 gt OD + OS at dinner time

““Red eye reaction” complaint persistsRed eye reaction” complaint persists

Xalatan discontinuedXalatan discontinued

Travatan initiatedTravatan initiated ““Red eye reaction” complaint intensifiesRed eye reaction” complaint intensifies

Argon Laser Trabeculoplasty Argon Laser Trabeculoplasty discussed with patientdiscussed with patient

Selective Wavelength Laser Selective Wavelength Laser Trabeculoplasty mentioned to patientTrabeculoplasty mentioned to patient

S.L.T. performed OD + OSS.L.T. performed OD + OS

Inferior 180-degreesInferior 180-degrees IOP at 2 months: OD 21 OS 21IOP at 2 months: OD 21 OS 21

Second S.L.T. performedSecond S.L.T. performed

Superior 180-degreesSuperior 180-degrees IOP at 1 month: OD: 16 OS: 15IOP at 1 month: OD: 16 OS: 15 IOP stable at 15 – 18 at this timeIOP stable at 15 – 18 at this time

52 y/o Female52 y/o Female

““I want to have LASIK”I want to have LASIK” Previous CL wearer (monovision) started Previous CL wearer (monovision) started

to have comfort issues and previous doc to have comfort issues and previous doc told her to go to glasses – “hates them!”told her to go to glasses – “hates them!”

Med Hx: menapausal, mild controlled HTNMed Hx: menapausal, mild controlled HTN C/O VA is blurry with glasses in distance C/O VA is blurry with glasses in distance

OD > OSOD > OS

The ExamThe Exam

VA cc OD 20/40 OS 20/25VA cc OD 20/40 OS 20/25 Pupils, EOM’s, CVF normal OUPupils, EOM’s, CVF normal OU BVA OD -3.00-75 x 040, 20/30-BVA OD -3.00-75 x 040, 20/30-

OS -4.00-1.00 x 025, 20/25-OS -4.00-1.00 x 025, 20/25- SLE: Lids and lashes clear, A/C deep and SLE: Lids and lashes clear, A/C deep and

quiet, 1+NS OU, quiet, 1+NS OU, See corneal photosSee corneal photos Internal: .25 C/D OU, Macula and periphery Internal: .25 C/D OU, Macula and periphery

clear OUclear OU

Corneal photoCorneal photo

Corneal photoCorneal photo

?? LASIK Candidate ???? LASIK Candidate ??

Is a patient with Fuch’s Dystrophy a Is a patient with Fuch’s Dystrophy a candidate for LASIK?candidate for LASIK?

Is a patient with Cogan’s (MDF) Dystrophy Is a patient with Cogan’s (MDF) Dystrophy a candidate for LASIK?a candidate for LASIK?

Fuch’s Endothelial DystrophyFuch’s Endothelial Dystrophy

Females 3:1Females 3:1 Autosomal DominantAutosomal Dominant Slowly progressive formation of guttate lesions Slowly progressive formation of guttate lesions

between the corneal endothelium and between the corneal endothelium and Descemet’s membraneDescemet’s membrane

Guttate are thought to be abnormal elaborations Guttate are thought to be abnormal elaborations of basement membrane and fibrillar collagen of basement membrane and fibrillar collagen from distressed or dystrophic endothelial cellsfrom distressed or dystrophic endothelial cells

So does performing laser on the corneal stroma So does performing laser on the corneal stroma effect this condition in any way? effect this condition in any way?

Refractive Surgery and Fuch’sRefractive Surgery and Fuch’s

Incisional refractive surgery, AK, RK, Incisional refractive surgery, AK, RK, LASIK and ALL-LASER LASIK, is LASIK and ALL-LASER LASIK, is contraindicated in Fuch’s patients (?)contraindicated in Fuch’s patients (?)

Surface Ablation, PRK, LASEK, Epi-LASIK Surface Ablation, PRK, LASEK, Epi-LASIK are relative contraindications are relative contraindications

It is estimated that there is 3-8% of It is estimated that there is 3-8% of endothelial cell loss during laser ablationendothelial cell loss during laser ablation

DSEK or DSAEKDSEK or DSAEK

DDescemet’s escemet’s Stripping tripping EEndothelial ndothelial KKeratoplastyeratoplasty

DDescemet’s escemet’s SStripping tripping AAutomated utomated EEndothelial ndothelial KKeratoplastyeratoplasty

Impressively mild post-op Impressively mild post-op Minimal corneal edema or anterior Minimal corneal edema or anterior

corneal compromisecorneal compromise Rapid rehab with minimal to no astig.Rapid rehab with minimal to no astig.

DSAEK VIDEODSAEK VIDEO

Cogan’s DystrophyCogan’s Dystrophy

MDF, ABMD, EBMD, Microcystic Epithelial MDF, ABMD, EBMD, Microcystic Epithelial DystrophyDystrophy

Nonprogressive but fluctuating in courseNonprogressive but fluctuating in course F > MF > M 1/3 of patients have RCE1/3 of patients have RCE Irregular Astigmatism common cause of Irregular Astigmatism common cause of

VA lossVA loss VA loss does not match clinical picture via VA loss does not match clinical picture via

slit lamp examslit lamp exam

Cogan’s DystrophyCogan’s Dystrophy

Pathophysiology: Corneal epi adheres to Pathophysiology: Corneal epi adheres to underlying BMunderlying BM

Faulty BM – thickened, multilaminar, Faulty BM – thickened, multilaminar, misdirected into epi: “maps & fingerprints”misdirected into epi: “maps & fingerprints”

Deeper epi cells don’t migrate to the Deeper epi cells don’t migrate to the surface: “dots, intraepithelial microcysts”surface: “dots, intraepithelial microcysts”

Epi cells ant. To the BM difficulty forming Epi cells ant. To the BM difficulty forming hemidesmosomes results in RCEhemidesmosomes results in RCE

Cogan’s DystrophyCogan’s Dystrophy

Treatments: AT’s, Muro 128 gtts and ungTreatments: AT’s, Muro 128 gtts and ung 2005 only prospective study to date no 2005 only prospective study to date no

difference between AT”s and NaCldifference between AT”s and NaCl Irregular Astig. CL fix? RGP vs. SoftIrregular Astig. CL fix? RGP vs. Soft Superficial KeratectomySuperficial Keratectomy Polish BM w/ diamond burr or alger brushPolish BM w/ diamond burr or alger brush ASP for erosions or post Keratectomy, consider ASP for erosions or post Keratectomy, consider

donut approach and spare visual axisdonut approach and spare visual axis PTK or PRK if going for refractive correctionPTK or PRK if going for refractive correction Not great LASIK candidatesNot great LASIK candidates

Cogans DystrophyCogans Dystrophy

For decreased VA w/ suspect irregular For decreased VA w/ suspect irregular astigmatism look at placedo disc vs. astigmatism look at placedo disc vs. topographytopography

Consider Silicone Hydrogels however, Consider Silicone Hydrogels however, beware most of these patients have some beware most of these patients have some degree of dry eye and are more likely to degree of dry eye and are more likely to have torsion marks / RCEhave torsion marks / RCE

Daily vs. EW? Poor dexterity in elderlyDaily vs. EW? Poor dexterity in elderly