206 - what the fruitcake - asorn.org · 6 iofb fungal hyphae and yeast moral of the story the...
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UVEITIS“What the…………Fruitcake?!!!!”
E. Mitchel Opremcak, MD
The Retina Group
The Eye Center of Columbus
Professor of Ophthalmology and Visual Sciences
Ohio State University
Columbus, Ohio
UVEITIS“What the…………Fruitcake?!!!!”
E. Mitchel Opremcak, MD
I have no financial interests or relationships to disclose
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Patient: GW 54 year old WM
CC: Painful LOV OD
HOPI: 9/12/14 One month Hx
severe pain and LOV OD
VA 20/200 and 3+ cell in vitreous
Acute panuveitis and W/U recommended
Lost to F/U and treated elsewhere with STK and prednisone for 6 months
2/17/15 Consult EMO
PMHx: DM (HA1c 17)
Meds: Lantus
ROS: Confused
Presumed Dx? “Severe idiopathic”
uveitis?
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Ocular Exam - GW
VA OD: LP
VA OS: 20/25
SLE OD: Hyperemia, hypopyon, PS, Cataract
SLE OS: WNL
FE OD: No view
FE OS: WNL
Labs: ?
Dx: ?
RX: ?
Ocular Exam - GW
VA OD: LP
VA OS: 20/25
SLE OD: Hyperemia, hypopyon, PS, Cataract
SLE OS: WNL
FE OD: No view
FE OS: WNL
Labs: B scan with vitreous
opacities
Choroidal thickening
Dx: ?
RX: ?
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Ocular Exam - GW
Labs: B scan with vitreous
opacities
Choroidal thickening
HOPI: Back to HOPI “It began after going
ginseng hunting in the woods.”
Dx: ?
Ocular Exam - GW
Labs: B scan with vitreous
opacities
Choroidal thickening
HOPI: Back to HOPI “It began after going
ginseng hunting in the woods.”
I asked if he got hit with a branch and he denied it.
Dx: ?
Ocular Exam - GW
Labs: B scan with vitreous
opacities
Choroidal thickening
HOPI: Back to HOPI “It began after going
ginseng hunting in the woods.”
I asked if he got hit with a branch and he denied it.
His wife said that his friends saw him “get hit in the face real good.”
Dx: ?
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Ocular Exam - GW
Labs: B scan with vitreous
opacities
Choroidal thickening
HOPI: Back to HOPI “It began after going
ginseng hunting in the woods.”
I asked if he got hit with a branch and he denied it.
His wife said that his friends saw him “get hit in the face real good.”
Dx: Endophthalmitis from an organic IOFB
7mm IOFB No CNS lesions
2/18/15 Diagnostic vitrectomy with IO Amphotercin
Heavy growth Candida albicans3/12/15 VA OD NLP
Enucleation
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IOFB Fungal hyphae and yeast
Moral of the Story
The importance of taking a good HOPI
Do not “tough it out” if you poke yourself in the eye with a stick
If you have on a scale a 10/10 eye pain for 6 months with severe LOV…seek help!
Patient: CB 62 year old BM
CC: Decreased VA OU
HOPI: 2/6/15 Two year Hx
decreased VA and “many mistakes driving”
PMHx: HBP and HIV/AIDS
Meds: Lisinopril, Atripla
ROS: Neg
PE: WNL
Presumed Dx? CMV Retinitis?
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Ocular Exam - CB
VA OD: 20/25
VA OS: 20/25
SLE OD: WNL
SLE OS: WNL
FE OD: Disc edema and CWS
FE OS: Disc edema and CWS
FA: ?
Labs: ?
Ocular Exam - CB
Ocular Exam - CB
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Ocular Exam - CB
VA OD: 20/25
VA OS: 20/25
SLE OD: WNL
SLE OS: WNL
FE OD: Disc edema and CWS
FE OS: Disc edema and CWS
FA: Disc edema OU
Labs: ?
Ocular Exam - CB
VA OD: 20/25
VA OS: 20/25
SLE OD: WNL
SLE OS: WNL
FE OD: Disc edema and CWS
FE OS: Disc edema and CWS
FA: Disc edema OU
Labs: BP Normal
Left Homonomous Hemianopia
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MRI - CB
6x7x8 cm Hemangiopericytoma
2 months s/p surgical resection
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Moral of the Story
CWS around the optic nerve are worrisome
Papilledema is more worrisome
Visual fields and MRI are helpful
“It might be a tuma”
Patient: BC 65 year old WF
CC: Decreased VA OU
HOPI: 6/02 Red and pain OU
7/02 and 8/02 CE IOL OU
9/02 Retinal detachments
PMHx: IDDM
Meds: Humulin, Warfarin
ROS: HA
PE: WNL
Presumed Dx? Retinal detachments
following CE IOL?
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Ocular Exam - BC
VA OD: 20/200
VA OS: CF 2 Ft
SLE OD: PC IOL and 1+ Vit Cell
SLE OS: PC IOL and 1+ Vit Cell
FE OD: Inf RD
FE OS: Inf RD
Labs: Mild anemia
Ocular Exam - BC
Ocular Exam - BC
?
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Ocular Exam - BC
What the………….!
Clinical Course - BC
Bilateral RD
Bilateral Vitritis
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Clinical Course - BC
Bilateral RD
Bilateral Vitritis
HA/NA
Vitiligo and poliosis
High end hearing loss
JDMG consult
Clinical Course - BC
Bilateral Exudative RD
Bilateral Uveitis
HA/NA
Vitiligo and poliosis
High end hearing loss
JDMG consult
VKH and AngioidStreaks
STK and return of 20/25 VA 9/08
Ocular Exam - BC
Angioid Streaks and VKH
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VKH Syndrome
940-1010 Ali-ibn-Isa described uveitis with poliosis 1906 Vogt published first case 1926 Harada described a posterior uveitis
with exudative RD associated poliosis and pleocytosis in the spinal fluid 1929 Koyanagi described 6 cases of
iridocyclitis associated with poliosis, vitiligo, and added dysacusia and alopecia 1939 Babel called it V-K-H Syndrome
Histopathology
Granulomatouspanuveitis
Diffuse nodular lesions of epitheliod cells surrounded by lymphocytes and plasma cells
No sparing of choriocapillaris
More scarring
VKH Stages
Prodrome
Meningeal Phase
Ophthalmic Phase
Convalescent Phase
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VKH Stages
Prodrome
Meningeal Phase
Ophthalmic Phase
Convalescent Phase
Autoimmune disease toward pigmented cells
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Vitiligo
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Criteria for VKH
1 – No trauma history
2 – No laboratory evidence for another disease
3 – Bilateral ocular disease
Early manifestations – diffuse choroiditis with RD
Late manifestations – depigmentation or pig clumping
4 – Neurologic/Auditory findings
Menigismus, HA/NA, Tinnitius, Vertigo, CSF pleocytosis
5 – Cutaneous findings
Alopecia, Poliosis or Vitiligo
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Patient: RL 50 year old BF
CC: Decreased VA OS>OD
HOPI: 2 months blurred VA OU
PMHx: 20 year HxIDDM with poor control
Meds: Lantus
ROS: WNL
PE: WNL
Presumed Dx? Unresponsive PDR?
Ocular Exam - RL
VA OD: 20/25
VA OS: 20/70
SLE OD: WNL
SLE OS: WNL
FE OD: PDR
FE OS: PDR and CSDME
Labs: None
Ocular Exam - RL
4/19/10
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Clinical Course - RL
OD: 4/10 PRP
4/11 PRP
8/11 PRP
10/11 PRP
OS: 4/11 Avastin
4/10 PRP
7/10 Focal
8/11 PRP
10/11 PRP
Clinical Course - RL “Unresponsive ”
10/21/11 What the…………….?
Clinical Course - RL “Unresponsive”
10/21/11
Vasculitis with capillary nonperfusion
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Clinical Course - RL “Unresponsive”
10/21/11
Vasculitis with capillary nonperfusion
Labs ESR 72
Lysozyme 27
Chest CT –mediastinallymphadenopathy
Clinical Course - RL “Unresponsive”
10/21/11
Vasculitis with capillary nonperfusion
Labs ESR 72
Lysozyme 27
Chest CT –mediastinallymphadenopathy
Sarcoidosis with DM
Sarcoidosis
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SarcoidosisRx – STK and MTX
Patient: MM 35 year old WF
CC: Sudden decrease VA OD
HOPI: 2/09 High fever
Severe HA
Sudden LOV
PMHx: N/A
Meds: None
ROS: N/A
PE: N/A
Presumed Dx? White Dot
Syndrome?
Ocular Exam - MM
VA OD: 5/09 20/400
APD
Color desaturation
VA OS: 20/20
SLE OD: WNL
SLE OS: WNL
FE OD: White dots
Optic nerve palor
Macular exudates
FE OS: WNL
Labs: ?What the………..?
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White Dot Syndrome
Ocular Exam - MM
VA OD: 5/09 20/400
APD
Color desaturation
VA OS: 20/20
SLE OD: WNL
SLE OS: WNL
FE OD:
FE OS: WNL
Labs: ?
Ocular Exam - MM
VA OD: 5/09 20/400
APD
Color desaturation
VA OS: 20/20
SLE OD: WNL
SLE OS: WNL
FE OD:
FE OS: WNL
Labs: B. henselae IgM 1:400
B. henselae IgG >1:2560
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Clinical Course - MM
Doxycyline 100 mg PO BID
No improvement of VA
Diagnosis Cat Scratch Disease
American college of physicians web site
Cat Scratch Disease
Gram negative bacillus – Bartonella heselae
2000 BC – A 4000 year old molar had Bartonella
Parinaud (1889) – “Granulomatous conjunctivitis and lymph nodes following animal exposure”
1983 – Isolation of the bacillus
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CSD
CSD
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Patient: LB 23 year old WF
CC: Decreased vision OS
HOPI: SLOV 3/27/12
PMHx: N/A
Meds: None
ROS: N/A
PE: N/A
Presumed Dx?Retinal detachment
OS?
Ocular Exam - LB
VA OD: 20/20
VA OS: 20/400
SLE OD: WNL
SLE OS: Mild cell
FE OD: WNL
FE OS:
Ocular Exam - LB
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Ocular Exam - LB
Multiple Evanescent Whit Dot Syndrome - MEWDS
Unilateral (80%)
Young (26 years)
Females
Granular macula
Evanescent white dots
Mild vitritis
“Prolonged enlargement of the blind spot”
AMN
MEWDS – “Granular Macula”
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MEWDs
MEWDS – “Wreath Sign”
Patient: CM 41 year old WM
CC: 10/10 None
REE
HOPI: N/A
PMHx: N/A
Meds: None
ROS: N/A
PE: N/A
Presumed Dx? IRVAN - Idiopathic
retinal vasculitis, aneurysm and neuroretinitis?
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Ocular Exam - CM
VA OD: 20/20
VA OS: 20/20
SLE OD: WNL
SLE OS: WNL
FE OD: Nasal cystic exudation
Subretinal cholesterol
FE OS: WNL
Labs: ?
Clinical Course - CM
What the……………………?
Clinical Course - CM
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Ocular Exam - CM
VA OD: 20/20
VA OS: 20/20
SLE OD: WNL
SLE OS: WNL
FE OD: Nasal cystic exudation
Subretinal cholesterol
FE OS: WNL
Labs: FA
OCT
MRI (brainstem, cerebellum and brain)
Clinical Course - CM
Conservative observation
1/3/11 No change
4/25/11 No change
10/10/11 New loss of peripheral
vision
20/20
Avastin #1
11/21/11 Less SRF
Avastin #2
Diagnosis Juxtapapillary
capillary hemangioblastoma
Von Hippel Lindau
Autosomal dominant
Lost to F/U
Clinical Course - CM
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Clinical Course - CM
IRVAN
Patient: KJ 36 year old WF
CC: Decreased vision OD for several days
HOPI: No pain or redness
PMHx: Negative
Meds: None
ROS: Negative
PE: WNL
Presumed Dx? “Choroiditis?”
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Ocular Exam - KJ
VA OD: 20/50
VA OS: 20/20
SLE OD: WNL
SLE OS: WNL
FE OD: WNL
FE OS: White subretinal lesion
Retinal hemorrhage
SRF
Labs: Negative
Clinical Course - KJ
7/1/08
Clinical Course - KJ
7/29/08
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Clinical Course - KJ
10/21/08
Clinical Course - KJ
11/18/10
Clinical Course - KJ
7/1/08 - Observe
7/29/08 – Prednisone
10/21/08 – CNV and STK
11/18/08 – CNV and Avastin
Diagnosis - ?
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Clinical Course - KJ
7/1/08 - Observe
7/29/08 – Prednisone
10/21/08 – CNV and STK
11/18/08 – CNV and Avastin
Diagnosis – “Two optic nerve syndrome?”
Clinical Course - KJ
7/1/08 - Observe
7/29/08 – Prednisone
10/21/08 – CNV and STK
11/18/08 – CNV and Avastin
Diagnosis – UnifocalHelioid Choroiditis
Unifocal Helioid Choroiditis
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Unifocal Helioid Choroiditis
“Sun-like”
Solitary, 1 DD, elevated, yellow-white choroiditis
Overlying subretinalfluid (heme)
Minimal cells
No systemic disease
Hong PD, Jampol LM . Arch Ophth 115,1007,1997
Patient: JG 19 year old WM
CC: Blurred VA and pain OD
HOPI: LOV for one month
PMHx: Pneumonia 2006 and colon polyp
Meds: PF 1% q1h
ROS: HA, sinus, genital ulcers, “never IV drugs but all others”
PE: Rash on left hand
SHx: House arrest and in jail 10/11
Presumed Dx? Vitritis
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Ocular Exam - JG
VA OD: 20/100
VA OS: 20/20
SLE OD: Limbal flush, 1+ KP and 3+ Vit Cell
SLE OS: WNL
FE OD: Multiple foci retinitis
FE OS: WNL
Labs: ?
Ocular Exam - JG
VA OD: 20/200
VA OS: 20/20
SLE OD: Limbal flush, 1+ KP and 3+ Vit Cell
SLE OS: WNL
FE OD: Multiple foci retinitis
FE OS: WNL
Labs: WNL!
Clinical Course - JG
Suspected IV drug use
Initial started on Bactrimand Prednisone
One week later worse VA to 20/200
Worsening vitritis
?
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Clinical Course - JG
Suspected IV drug use
Initial started on Bactrimand Prednisone
One week later worse VA to 20/200
Worsening vitritis
Diagnostic vitrectomywith ceftazidime and vancomycin.
Clinical Course - JG
Suspected IV drug use
Initial started on Bactrimand Prednisone
One week later worse VA to 20/200
Worsening vitritis
Diagnostic vitrectomyMERSA
Skin rashes and abcess, MERSA in jail, abdominal pain
What the………………….?
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Endogenous Endophthalmitis
Endogenous Endophthalmitis
“My puppy bites my left hand!”
Endogenous Endophthalmitis
Have you ever used IV drugs?
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Endogenous Endophthalmitis
“I use to do IV drugs.”
Endogenous Endophthalmitis
When was the last time you used?
Endogenous Endophthalmitis
Yesterday!
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Exogenous vs Endogenous Endophthalmitis
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Patient: AS 19 year old AS
CC: No complaints
HOPI: REE Had a vit tap negative
10 days on prednisone and Bactrim
PMHx: WNL
Meds: None
ROS: WNL Denied IV drug abuse
PE: WNL
Presumed Dx? “Do not know what
this is.”
Ocular Exam - AS
VA OD: 20/20
VA OS: HM
SLE OD: WNL
SLE OS: WNL
FE OD: WNL
FE OS: 1+ cells
OCT:
FA:
Labs:
Ocular Exam - AS
OCT
What the……………………?
41
Ocular Exam - AS
Clinical Course - AS
12/22/11 Labs
Prednisone pulse
Add Doxycycline
1/6/12 Did not get
labs…”Car broke down.”
Still HM OS
2+ cells in vit
Clinical Course - AS
12/22/11 Labs
Prednisone pulse
Doxycycline
1/6/12 Did not get
labs…”Car broke down.”
Still HM OS
2+ cells in vit
1/11/12 Diagnostic vit
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Clinical Course - AS
12/22/11 Labs
Prednisone pulse
Doxycycline
1/6/12 Did not get
labs…”Car broke down.”
Still HM OS
2+ cells in vit
1/11/12 Diagnostic vit
Culture – Neg
Cytology – Neg
PCR – Neg CMV
HSV
VZV
Toxoplasmosis
What the………!
Clinical Course - AS
12/22/11 Labs
Prednisone pulse
Doxycycline
1/6/12 Did not get
labs…”Car broke down.”
Still HM OS
2+ cells in vit
1/11/12 Diagnostic vit
Culture – Neg
Cytology – Neg
PCR – Neg CMV
HSV
VZV
Toxoplasmosis
Labs – ToxocaraELISA 2.27
Clinical Course - AS
1/12/12 POD1
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Clinical Course - AS
1/19/12 2/2/12
3/1/12
Falciform fold
Toxocara
11/3/11 1/10/12
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Toxocara
Toxocara
Eosinophilic Granuloma
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Toxocara Falciform Fold
Patient: SHT 11 year old WF
CC: Decreased VA OS
HOPI: 4 week history
PMHx: WNL
Meds: None
ROS: WNL
PE: WNL
Presumed Dx? “Multifocal retinitis”
46
Ocular Exam - SHT
VA OD: 20/20
VA OS: 20/40
SLE OD: WNL
SLE OS: WNL
FE OD: WNL
FE OS: Multifocal retinitis
Labs: WNL
Ocular Exam - SHT
6/9/89 What the………………?
Ocular Exam - SHT
6/9/89 DUSN - Raccoon Ascarid
47
Clinical Course - SHT
Laser Photocoagulation
Clinical Course - SHT
Unilateral “Wipe Out Syndrome”
48
Patient: RF 48 year old WM
CC: Decreased VA OU
HOPI: 4/03 1 month Hx
PMHx: IDDM 12 years
HCV (1 year) on IFN (5 months)
HBP
Meds: Insulin and IFN
ROS: WNL
PE: WNL
Presumed Dx? CRVO
PDR
Ocular Exam - RF
VA OD: CF 3 Ft
VA OS: 20/60
SLE OD: WNL
SLE OS: WNL
FE OD: Retinal Heme
FE OS: Retinal Heme
Labs: None
Clinical Course - RF
What the………………………….?
49
Clinical Course - RF
What Rx?
Clinical Course - RF
Interferon Toxicity
D/C Interferon
1/29/08 VA OD: 20/400
VA OS: 20/60
Patient: CH 42 year old BF
CC: Bilateral ocular pain and redness
HOPI: 9/05 Pain and red OU
Rx Prednisone
1/06 Rheum MTX
5/06 Continued pain
PMHx: 60 pound weight gain
New DM and HBP
Meds: Pred, MTX, PF
ROS: Hair loss
PE: Cushings
Presumed Dx? Scleritis OU
50
Ocular Exam - CH
VA OD: 20/40
VA OS: 20/20
SLE OD: Diffuse Ant Scleritis
SLE OS: Diffuse Ant Scleritis
FE OD: WNL
FE OS: WNL
Labs: All WNL
Ocular Exam - CH
Clinical Course - CH
5/06 STK OU
Complex course and medically unresponsive
Additional W/U neg
51
Clinical Course - CH
5/06 STK OU
Complex course and medically unresponsive
Additional W/U neg
7/06 Scleral BiospyCSF
Ocular Wegener’s Granulomatosis
Now cANCA +
IV cytoxan
11/06 Lung lesions
Bx positive
12/06 Oral Prednisone
IV Cytoxan
Clinical Course - CH
5/06 STK OU
Complex course and medically unresponsive
Additional W/U neg
7/06 Scleral BiospyCSF
Ocular Wegener’s Granulomatosis
Now cANCA +
IV cytoxan
11/06 Lung lesions
Bx positive
12/06 Oral Prednisone
IV Cytoxan
New ocular pain and decreased VA OS
What the…………………?
52
Clinical Course - CH
Change Rx Prednisone
Imuran
Cellcept
STK
1/12 Recurrent anterior
and posterior
Pred pulse
STK
Wegener’s Granulomatosis
53
GPA – Granulomatosis with Polyangiitis
Patient: CS 68 year old WF
CC: Blurred VA OU
HOPI: One year Hx of blurred VA
PMHx: SLE “All her life”
RA “Since young”
Meds: Prednisone “All life”
Plaquenil 200mg BID 15 years
ROS: Many
PE: RA
Presumed Dx? RA
SLE
Ocular Exam - CS
VA OD: 20/25
VA OS: 20/25
SLE OD: PC IOL
SLE OS: PC IOL
FE OD: Pig changes
FE OS: Pig changes
Labs: N/A
54
Ocular Exam - CS
VA OD: 20/25
VA OS: 20/25
Color VA: 2/25 plates
SLE OD: PC IOL
SLE OS: PC IOL
FE OD: Pig changes
FE OS: Pig changes
Labs: N/A
OCT: Atrophic
Normal OCT – IS-OS Line
Clinical Course - CS
55
Clinical Course - CS
Clinical Course - CS
Clinical Course - CS
56
New Screening Guidelines for Plaquenil Toxicity
Hydroxychloroquine (Plaquenil) 200 mg PO BID
7 years = 1000 grams
1-7.5% Risk for macular toxicity (0.1%)
Baseline exam
Yearly after 5 years
New Recommendations VA, Color, FP and FA
VF 10-2
One of these three tests OCT (Loss of inner segment/outer segment line)
mERG
FAF
Hydroxychloroquine and the Retina
18,0511 RA/SLE patients on hydroxychloroquine 1,409 at high risk
50% lack a baseline exam
28% lacked regular eye visits
6% had no visits to eye care
35% had no diagnostic testing for toxicity
Nika N, Blachley TS, Edwards, P, et al. Regular examinations for toxic maculopathy in long-term chloroquine or hydroxychloquine users. JAMA Ophthalmol 2014;132(10):1199-1208
57
Melles RB and Marmor MF. The risk of toxic retinopathy in patients on long-term hydroxychloroquine therapy. JAMA Ophthalmol. 2014;132(12):1453-1460
Patient: AS 68 year old Nepalese M
CC: VA loss and pain OD
HOPI: 2 year Hx pain and vision
loss OD
CE IOL OU
Post op RD OD
PMHx: HBP
Meds: None
ROS: WNL
PE: WNL
Presumed Dx? RD OD
Ocular Exam - AS
VA OD: 20/400
VA OS: 20/20
SLE OD: PC IOL
SLE OS: PC IOL
FE OD: ?
FE OS: WNL
Labs: WNL
58
Clinical Course - AS
Clinical Course - AS
Vitreous Cyst
Clinical Course - AS
B scan
Cysticercosis
Tapeworm
Taenia solium
59
Clinical Course - AS
VA 20/30 Post Vitrectomy20/400
Patient: RN 37 year old WM
CC: decreased VA OU
HOPI: 2 week Hx decreased
OS>OD
PMHx: 2001 HIV+
CD4 100
VL 5
Meds: Combivir
ROS: RA
PE: Psoriasis
Presumed Dx? CMV retinitis
Ocular Exam - RN
VA OD: CF
VA OS: CF
SLE OD: 1+ KP and 1+ vit cells
SLE OS: 1+ KP and 1+ vit cell
FE OD: Disc edema
FE OS: Disc edema and retinitis
60
Clinical Course - RN
What the………………….?
Clinical Course - RN
Labs
Famvir 500mg TID
Bactrim DS BID
Labs HIV - Positive
ESR - 60
CRP - 2.7
Toxoplasmosis – Neg
CMV Retinitis?
Clinical Course - RN
Labs
Famvir 500mg TID
Bactrim DS BID
Labs HIV - Positive
ESR - 60
CRP - 2.7
Toxoplasmosis – Neg
RPR - Positive
FTA Abs – Positive
Syphilitic retinitis
61
Clinical Course - RN
RX IV – Penicillin
Weekly BenzathinePenicillin G IM for 3 weeks
Final VA 20/40 OD
20/50 OS
Clinical Course - RN
What the…….?
62
What the…………………?
AIDS and the Eye
Exudative Retinal Detachments s/p ATB for Syphilis
Patient: LB 62 year old WF
CC: Gray vision OS
HOPI: 3/6/12 - Woke up with
pain and LOV OS
3/16/12 Back to normal!
PMHx: WNL
Meds: Symbacort
ROS: HA, ringing and leg swelling
PE: Rash
Presumed Dx? Retinal vasculitis
63
Ocular Exam - LB
VA OD: 20/20
VA OS: 20/70
SLE OD: WNL
SLE OS: WNL
FE OD: WNL
FE OS:
Labs:
Ocular Exam - LB
VA OD: 20/20
VA OS: 20/70
SLE OD: WNL
SLE OS: WNL
FE OD: WNL
FE OS:
Labs: Normal CBC, ESR, CRP
Clinical Course - LB
?
64
Clinical Course - LB
?
Clinical Course - LB
CRAO with plaque break-up
Retinal Vasculitis
65
Retinal Vasculitis
Intra-carotid BCNU
Ocular Exam - MH
VA OD: 20/20
VA OS: 20/70
SLE OD: WNL
SLE OS: Multifocal keratitis
Ocular Exam - MH
VA OD: 20/20
VA OS: 20/70
SLE OD: WNL
SLE OS: Multifocal keratitis
FE OD: WNL
FE OS: Vitreous base snowballs
Labs: WNL
???
66
Ocular Exam - MH
VA OD: 20/20
VA OS: 20/70
SLE OD: WNL
SLE OS: Multifocal keratitis
FE OD: WNL
FE OS: Vitreous base snowballs
Labs: WNL
Ophthalmia Nodosa
Ocular Exam - MH
VA OD: 20/20
VA OS: 20/70
SLE OD: WNL
SLE OS: Multifocal keratitis
FE OD: WNL
FE OS: Vitreous base snowballs
Labs: WNL
Rose Haired Tarantula!
The nevus that got away !
67
The nevus that got away !
?
68
What the…………………!
Patient: DC 11 year old WM
CC: Decreased VA OU
HOPI: 12/8/14 A 5 month Hx of
decreased VA OU and metmorphopsia following a “roller coaster ride”
PMHx: Cystic Hygroma
(Hemangiomatosis)
Permanent trach (2003)
Tracheitis & Pneumonia
Meds: Pred 10 mg
ROS: Unremarkable
PE: Neck tumor/trach
Presumed Dx? Severe Uveitis
Ocular Exam - DC
VA OD: 20/200
VA OS: 20/400
SLE OD: 3+ Cells in A/C and Vit, PSC
SLE OS: 3+ Cells in A/C and Vit, PSC
FE OD: No View
FE OS: No View
Labs: ?
Dx: ?
Rx: ?
69
Ocular Exam - DC
VA OD: 20/200
VA OS: 20/400
SLE OD: 3+ Cells in A/C and Vit, PSC
SLE OS: 3+ Cells in A/C and Vit, PSC
FE OD: No View
FE OS: No View
Labs: ?
Dx: Panuveitis OU
Rx: Pred 60 mg
Ocular Exam - DC
VA OD: 20/200
VA OS: 20/400
SLE OD: 3+ Cells in A/C and Vit, PSC
SLE OS: 3+ Cells in A/C and Vit, PSC
FE OD: No View
FE OS: No View
Labs: Negative!
Dx: Panuveitis OU
Rx: Pred 60 mg
Ocular Exam - DC
12/18/14 OD 20/60
OS 20/70
No cells and poor view of retina
BARN?
Famvir per pedatrician
12/18/14 That night…Endogenous
Endophthalmitis!
Admitted and put on IV Vanc, Gent, Cefaz, Tamiflu and Acyclovir
70
Ocular Exam - DC
1/19/15 VA OD 20/80
VA OS 20/100
No view of retina
1/28/15 Diagnostic and
Therpeutic Vitrectomy OU
Results ?
Ocular Exam - DC
1/19/15 VA OD 20/80
VA OS 20/100
No view of retina
1/28/15 Diagnostic and
Therpeutic Vitrectomy OU
Results Stains – Neg
Cultures – Neg
PCR - Neg
2/5/15
71
Ocular Exam - DC
2/5/15 VA OD 20/40
VA OS 20/100
Photos
Next…. Consult – Augsberger &
Sheilds
Lung Bx and cultures –Positive
Discussed Retina Bx
Started Cipro 500 BID
Progresssive SRF
3/12/15
6/4/15 VA OD 20/60 VA OS 20/200
72
Patient: WB 73 year old WF
CC: Decreased VA OD
HOPI: 6/30/15 1 month Hx
floaters and decreased VA
PMHx: HBP, MI, Anemia, Shingles
Meds: Amlopidine, MTX, Prednisone 10 mg
ROS: Vitiligo, PulmHistoplasmosis
PE: WNL
Presumed Dx? Acute Retinal
Necrosis (ARN)
Ocular Exam - WB
VA OD: 20/30
VA OS: 20/25
IOP: 40/17
SLE OD: PC IOL, 3+ Vit Cells
SLE OS:
FE OD: Retinitis and Retinal Vasculitis
FE OS: WNL
Labs: ?
Dx: ?
Rx: ?
Ocular Exam - WB
VA OD: 20/30
VA OS: 20/25
IOP: 40/17
SLE OD: PC IOL, 3+ Vit Cells
SLE OS:
FE OD: Retinitis and Retinal Vasculitis
FE OS: WNL
Labs: FA
Dx: ARN
Rx: ?
73
Ocular Exam - WB
VA OD: 20/30
VA OS: 20/25
IOP: 40/17
SLE OD: PC IOL, 3+ Vit Cells
SLE OS:
FE OD: Retinitis and Retinal Vasculitis
FE OS: WNL
Labs: FA
Dx: ARN
Rx: Famvir 500 mg TID, Pred 60 mg
Ocular Exam - WB
7/14/15 VA better but worse
retinitis on Rx
Labs: HSV +, Toxo +, RPR +
7/15/15 Diagnostic vitrectomy
Cytology
PCR for HSV, VZV, Toxo, CMV, etc.
Start Bactrim (rash)
7/23/15 – POD 7 On Famvir, Doxy
Prednisone 20 mg
Worse Retinitis!
Ocular Exam - WB
6/15/15 7/14/15
74
Ocular Exam - WB
7/23/15 Vitrectomy Results?
Ocular Exam - WB
7/23/15 Vitrectomy Results?
The lab received and logged the specimen in for cytology but forget to process the PCR!
Ocular Exam - WB
7/23/15 Vitrectomy Results?
The lab received and logged the specimen in for cytology but forget to process the PCR!
We called to do PCR but the specimen had been destroyed!
75
Ocular Exam - WB
7/23/15 Vitrectomy Results?
The lab received and logged the specimen in for cytology but forget to process the PCR!
We called to do PCR but the specimen had been destroyed!
Cytology – No malignancy, lymphocytes and macrophages
Ocular Exam - WB
7/23/15 Vitrectomy Results?
The lab received and logged the specimen in for cytology but forget to process the PCR!
Cytology no malignancy, lymphocytes and macrophages
Ocular Exam - WB
7/30/15 VA 20/30
Worse Retinitis!
On Famvir 500 mg TID
Doxycycline 100mg BID
Prednisone 20 mg
76
Ocular Exam - WB
7/14/15 7/23/15
Ocular Exam - WB
7/30/15 8/20/15
Ocular Exam - WB
7/30/15 What now?
8/20/15 VA 20/30
Better
Still on Famvir 500 mg TID
Doxycycline 100mg BID
Prednisone 20 mg
77
Osurdex
Patient: JW 70 year old WM
CC: Floaters and blurred VA OS
HOPI: Decreased VA 6 months following brain surgery
PMHx: 6/08 Lung infection
6/08 Brain surgery
Meds: IV Bactrim and PO Doxycyline
ROS: Hoarse
PE: N/A
Presumed Dx? Fuch’s
HeterochromicIridocyclitis
Toxoplasmosis-like Scar
Ocular Exam - JW
VA OD: 20/25
VA OS: 20/50
SLE OD: PC IOL
SLE OS: 2 3 + diffuse stellate KP
2 + Vit Cells
FE OD: WNL
FE OS: Large chorioretinitis
Multifocal chorioretinitis
Labs: N/A
What the……..?
78
Clinical Course - JW
Diagnostic and therapeutic vitrectomy
Intaocular antibiotics: Amikacin
Ceftazidime
Cultures: Acid fast bacilli
Continue IV Bactrim
Resolution of vitiritis, inactive chorioretinalscar and return of 20/30 VA
Endogenous Nocardiaendophthalmitis
Silk Route
Fig. 3 Effect of adaptive introgression of Neandertal HLA class I alleles on modern human populations.
L Abi-Rached et al. Science 2011;334:89-94
Published by AAAS
79
Fig. 1 Modern humans acquired HLA-B*73 from archaic humans.
L Abi-Rached et al. Science 2011;334:89-94
Published by AAAS
80
Sooty Mangabey & Bonobo Chimpanzee
Sooty Mangabey(Low SIV & HIV-2) Bonobo (10K)
(SIV Negative)
Face and Female
Chimpanzee – Pan troglodyte
Western Chimps (38K) (SIV Negative)
Nigerian Chimps (6K) (SIV Negative)
Sooty Mangabey, Bonobo and Chimpanzee
Eastern Chimp (98K) (SIV Positive)
Central Chimp (93K) (SIV Positive)
81
Bonobos
Western and Nigerian ChimpsNo SIV Central and Eastern
No SIV
SIV
Air Travel
82
Achoo.Following a sneeze, high-speed video and image processing visualized a waterfall of large droplets (left) and a lingering cloud of small droplets (right) that can spread pathogens
farther.
E Pennisi Science 2014;343:1194-1197
Published by AAAS
Fluid fragmentation from hospital toilets – 80-90 psi (surface tension and detergent) – High speed video 1000 frames per second! C. difficile anyone?
83