“Highlights in Optometry: how optometrist change people’s lives”
The 2024 EastWest Eye Conference Poster Session
Chair: Dawn J. Goedde, O.D., F.A.A.O
OSU College of Optometry
Abstracts:
#1
Title: Assessment of Lid Wiper Staining, Tear Film Osmolarity, and Ocular Surface Inflammation Following Complete Ocular Surface Lavage with an Irrigating Eyelid Retractor: A Case Report
Authors:
Cory J. Lappin, OD, MS, FAAO; Phoenix Eye Care and The Dry Eye Center of Arizona
Srinivas Kondapalli, MD; Everett & Hurite Eyecare Specialists
Category:
Ocular Disease
Abstract
Background:
Lid wiper epitheliopathy (LWE) is characterized by disruption to the surface epithelium of the lid wiper region which is found posterior to the mucocutaneus junction of the upper and lower eyelid and is responsible for spreading the tear film over the ocular surface and removing debris. LWE is a clinical sign in the form of staining with ophthalmic vital dye associated with contact lens wear and dry eye. Symptoms of LWE include foreign body sensation, irritation, and grittiness.
Case Discussion:
A 34-year-old female presented with a year long history of bilateral eye irritation. Pertinent examination findings included diffuse conjunctival staining of the inferior lid wiper and palpebral conjunctiva (Figure 1a) and a decreased tear break up time and tear lake. Staining with lissamine green dye strips was performed twice and the patient examined three minutes after the second installation. Her tear osmolarity was 328 mOsm/L and 332 mOsm/L (ScoutProTM, Trukera Medical, Temecula, CA) in the right and left eye, respectively. MMP-9 via point of care testing (InflammaDry®, QuidelOrtho, San Deigo, CA) was found to be mildly positive (Figure 2a).
Upon discussion and agreement, the patient elected to proceed with a complete ocular surface lavage facilitated by an irrigating eyelid retractor (Rinsada®, Wildwood, PA). 10 mL and 5 mL of sterile, non-preserved 0.9% normal saline was used to rinse the fornices of the upper and lower eyelid, respectively.
The patient immediately noted improvement in her symptoms. Repeat testing done 3 hours post lavage was notable for an improvement in tear osmolarity (303 mOsm/L and 305 mOsm/L in the right and left eye, respectively) and an improvement in MMP-9 point-of-care testing (Figure 2b).
Most notably, there was an improvement in LWE based on staining patterns of the patient’s inferior lid wiper (Figure 1b), as there was improvement in horizontal length of staining as well as sagittal height staining post treatment.
Conclusion:
LWE is a clinical sign of dry eye disease and contact lens discomfort due to lid-to-surface friction. The mechanical shearing forces of the blink coupled with tear film instability are thought to contribute to LWE. As such, performing a high-pressure ocular surface lavage may stabilize the tear film and reduce this microtrauma. The symptomatic relief demonstrated by our patient coupled with improved LWE staining and reduced tear osmolarity suggests this high-pressure ocular surface lavage may be of clinical value for patients with dry eye disease and contact lens intolerance.
#2
Title: Managing Recurrent Corneal Erosions in a Pediatric Patient with Epidermolysis Bullosa
Authors: Erik Whitney, OD, Kelsey Carriere, OD, FAAO, Melissa Rice, OD, FAAO
Cincinnati Children’s Hospital Medical Center
Category: Pediatrics
Background
The purpose of this case report is to describe management of recurrent corneal erosions in a pediatric patient with epidermolysis bullosa (EB) using bandage contact lenses. EB is a group of rare inherited connective tissue diseases that cause extensive blistering of skin and mucosal membranes and ocular manifestations including recurrent corneal erosions. Signs and symptoms of corneal involvement include acute-onset eye pain, epiphora, blurry vision, and redness. Lubricating agents are often prescribed to minimize ocular sequelae, but this case demonstrates that extended-wear bandage contact lenses offer an alternative to improve quality of life and preserve vision in patients suffering from EB.
Case Discussion
An 11-year-old Caucasian male was referred to CCHMC contact lens clinic for management of recurrent corneal erosions secondary to recessive dystrophic EB. After years of alternative pharmacologic management (MURO-128 ophthalmic solution, various lubricating agents, and multiple courses of antibiotics and steroids) to manage acute abrasions and an increasing trend of erosion incidents, the patient was referred to the contact lens clinic to trial bandage contact lenses.
At presentation, the patient reported no blurriness, pain, or other eye concerns following healing of the recent abrasion. Slit lamp exam revealed mild anterior stromal scarring in both eyes (OU) with 0.5mm of inferonasal neovascularization in the right eye (OD). After completing regimens of Vigamox, bacitracin, and fluorometholone for the recent abrasion, the patient continued habitual usage of MURO-128 and Puralube ointments.
Despite the patient’s high anxiety, Air Optix Night & Day contact lenses were successfully inserted and dispensed. Prophylactic Vigamox (moxifloxacin) ophthalmic drops were prescribed twice daily OU. Puralube ointment was discontinued to avoid coating contact lenses and blurring vision. To help maintain lubrication, the patient was prescribed Celluvisc every two hours and MURO-128 ointment at bedtime OU. Extensive education was provided on risks vs. benefits of extended-wear contact lenses, which would be replaced monthly indefinitely barring complications. To date, the patient has successfully worn extended-wear contact lenses for five years with no adverse effects.
Conclusion
Epidermolysis bullosa is a debilitating condition with potential for painful recurrent corneal erosions and severe scarring. Providers often exhaust lubricating options including artificial tears, ointments, autologous serum, and punctal plugs to reduce recurrent keratopathy and corneal scarring. Extended-wear bandage contact lenses offer a unique alternative to alleviate pain, reduce corneal involvement, and maintain high visual acuity. Patients must remain compliant with prophylactic antibiotic drops and be monitored closely to avoid contact lens-associated complications.
#3
Title: Bilateral Myelinated Retinal Nerve Fiber Layer with High Myopia and Amblyopia
Author: Elizabeth Nickell, OD
University Hospitals Rainbow Babies & Children’s Hospital
Categories: Binocular vision/pediatrics and ocular disease
Abstract
Background:
The purpose of the case is to describe a presentation of bilateral myelinated retinal nerve fiber layer (MRNFL) in a pediatric patient. Typically, retinal ganglion cells become myelinated as they pass posteriorly through the lamina cribrosa, but rarely, in about 1%, of cases, they can become myelinated prior to the lamina cribrosa. Even more rarely, bilateral MRNFLs occur in just under 7% of those cases. It is believed that there is an abnormal migration of oligodendrocyte cells into the retina prior to the development of the barrier function of the lamina cribrosa. The effect on vision of MRNFLs is highly variable, ranging from no effect to light perception, depending on the degree and location of myelin present.
Case Presentation:
A 14-year-old African American male presented to clinic for his annual eye exam. His past medical history includes bilateral MRNFL, high myopia, nystagmus, esotropia, and anisometropia. His vision was 20/150 OD and 20/40 OS which has been stable for many years. His refractive error was -16.00 OD and -9.25 OS. He exhibited a latent horizontal nystagmus in both eyes. He has a history of large angle esotropia that was corrected surgically and now remains orthophoric. Fundus findings were notable for a myelinated nerve fiber layer in both eyes, in the right eye extending off the inferotemporal arcade and in the left eye extending 360 off the optic nerve. He has a posterior staphyloma in both eyes
There is an association of MRNFLs with high myopia, amblyopia, strabismus, and nystagmus. The myopia is axial in nature, and the degree of myelination usually correlates to the level of myopia. This is thought to occur though a similar process to form deprivation, where the myelinated nerve fibers blur the retinal image thus stimulating axial elongation. While there are some reports of successful amblyopia treatment in patients with MNFLs, these successes are typically only seen in cases with lower refractive errors (mean spherical equivalent of -8.00D or less) and with normal foveal contour.
Conclusion:
This is a rare case presentation of bilateral MNFL’s with bilateral high myopia and amblyopia. Overall, bilateral MNFLs are a rare condition with a very wide range of effects on vision. There should be a guarded prognosis for any successful amblyopia treatment in these patients, and the structural integrity of the macula should be assessed for any abnormalities prior to initiating treatment.
#4
Title: Check and Balance: When Cancer Therapy with Immune Checkpoint Inhibitors Causes Bilateral Intermediate Uveitis
Author: Hayley Samson, OD, MS
Cincinnati Eye Institute
Category: Ocular Disease
Background: Checkpoint inhibitors are common immune modulators used in the treatment of cancer, often in adjunct to chemotherapy. Pembrolizumab (Keytruda) specifically targets PD-1 receptors, which upregulate T cell function, increasing inflammation. Treatment must involve discussion with the patient’s oncologist, as continuing with use of pembrolizumab may outweigh the ocular side effects. In addition, other possible etiologies must be ruled out. This case describes ocular side effects found in a patient currently receiving pembrolizumab for breast cancer.
Case Presentation: A 54-year-old Caucasian female presented to Cincinnati Eye Institute with complaints of blurred vision, flashes, and floaters starting 1-2 weeks previous. She reported she is currently under treatment for breast cancer, and recently completed her last chemotherapy session with concurrent use of Keytruda. Her VA was mildly reduced at 20/20-3 OD and 20/25+1 OS. Anterior segment and IOP were unremarkable, save for 1+ PEE noted OU. There was no cell or flare. Posterior segment evaluation revealed 2+ vitreous cells OU, with no other notable findings. OCT showed mild vitreous opacities in both eyes. She was referred to be seen at CEI’s retinal clinic for further evaluation, and presented similarly with a VA of 20/20-3 OD, 20/25-3 OS, no AC reaction, 3+ vitreous cells, and few vitreous opacities noted with OCT, OU. A FANG was also performed, and no leakages or abnormalities were noted in both eyes. As the patient was currently being treated for breast cancer, discussion with the patient’s oncologist was initiated to discuss subsequent action and to confirm continuation of pembrolizumab. The patient denied IV drug use and reported no history of STDs. To rule out other potential infectious causes, bloodwork was ordered including toxoplasma gondii IgG, IgM, and PCR testing, QuantiFERON-TB Gold+, and T pallidum screening cascade. The patient returned 2 weeks later with improved symptoms, VA of 20/30-3 OD, 20/20-1 OS, and 1-2+ vitreous cells in strands. The lab results are currently pending, but as the intermediate uveitis has been resolving it was decided to hold off on treatment and continue monitoring.
Conclusion: Management of ocular conditions caused by systemic medications can be a complex process, and often involves coordination of care. In the case of an intermediate uveitis related to immune modulators like pembrolizumab, it is essential to discuss findings with the patient’s oncologist to determine the best course of action to maintain sufficient cancer treatment while minimizing patient symptoms and side effects.
#5
Title: Progressive OCT-Angiography Non-Perfusion as a Marker for Conversion from Nonischemic to Ischemic Central Retinal Vein Occlusion
Author: Chloe M. Foster, O.D. The Ohio State University College of Optometry (Class of 2024), Cincinnati VA Ocular Disease Residency 2024-2025
Category: Ocular Disease
Background:
Central retinal vein occlusion (CRVO) can be broadly defined as nonischemic or ischemic, which can have a dramatic divergence of clinical course. The purpose of this case report is to describe a case of ischemic CRVO conversion that was preceded by a progressive enlargement of non-perfusion on optical coherence tomography angiography (OCT-A). Early aggressive management of pre-proliferative CRVO and neovascular glaucoma are necessary. OCT-A may serve as a non-invasive early indicator of high risk CRVO eyes.
Case Discussion:
A 75-year-old male patient was diagnosed with a CRVO OS onset June 2023. Associated macular edema was serially treated with antiVEGF therapy using 2 mg aflibercept (Eylea). He then presented overdue in August 2024 with a complaint of a red, photophobic and painful eye, 14 weeks after his last aflibercept injection. Evaluation in the optometry clinic revealed a visual acuity of count fingers 2 feet in the affected eye. Slit lamp examination revealed 3+ circumlimbal injection, diffuse NVI at the pupillary margin, and an anterior chamber reaction with 1-2+ cells and 1+ flare. Gonioscopy disclosed patches of NVA in all quadrants. The intraocular pressure measured 14 mmHg OS despite the florid iris and angle neovascularization. OCT of the macula showed significantly worse edema. He was treated using 1% prednisolone acetate QID OS for the AC reaction as well as repeat Eylea for his diffuse edema. Serial review of previous OCT-A scans revealed progressive posterior pole capillary dropout between June 2023 to January 2024 prior to the onset of neovascularization.
Conclusion:
OCT-A can be used as a non-invasive additional tool to help identify progressive ischemia that might allow for earlier identification of proliferative disease following CRVO, particularly when fluorescein angiography (FA) is not otherwise available. Worsening OCT-A perfusion over time can serve as an indication for more frequent follow-up to monitor for worsening disease. Earlier detection can help prevent sight-threatening complications, including anterior and posterior segment neovascularization, neovascular glaucoma, or vitreous hemorrhage. While this patient did not have a prior FA, the rapid progression of capillary dropout seen on OCT-A suggested worsening ischemia. OCT-A may serve as an effective non-invasive tool to identify CRVO eyes at risk for severe neovascular complications.
#6
Title: Management of Subretinal Hemorrhage After Non-Penetrating Firework Trauma
Author: Nicholas Keinath, OD
Cincinnati Eye Institute
Category: Ocular Disease
Background
Firework-related ocular injuries are common, with severity ranging from minor abrasions to catastrophic trauma. This case report describes a subretinal hemorrhage with multiple small choroidal ruptures secondary to a non-penetrating firework injury.
Case Presentation
A 21 year old caucasian male presented to clinic complaining of blurred vision, pain, and a new floater in the right eye since a firework accident 5 days earlier. The patient reported that a mortar tube had exploded, sending debris flying in a wide radius and striking him in his right eye. The patient initially presented to the emergency department, where a CT scan revealed no intraocular or intraorbital foreign body. Uncorrected visual acuity was 20/70-2 OD and 20/20-2 OS, with pinhole acuity in the right eye improving to 20/20-2. External examination of the right eye revealed mild periorbital ecchymosis and a resolving upper lid laceration. Anterior segment findings included fine keratic precipitates with 2+ cell in the anterior chamber. Fundus examination revealed a superior subretinal hemorrhage with adjacent small choroidal ruptures and vitreous hemorrhage. Macular OCT showed normal foveal contour with no perimacular subretinal fluid. Given the peripheral nature of the hemorrhage and relatively small adjacent choroidal ruptures, no surgical intervention was implemented. The patient was started on Prednisolone QID OD and Atropine QID OD and advised to forego strenuous activity. At follow-ups on days 4 and 10, the subretinal hemorrhage was resolving and the choroidal ruptures remained stable.
Conclusion
While many retinal firework injuries necessitate extensive surgical repair, this case exemplifies the potential for conservative management. The distinction between a surgical and non-surgical case is ultimately deferred to the expertise of a vitreoretinal surgeon. However, by identifying certain high-risk retinal findings and pertinent negatives, optometrists may better educate patients on their condition and help alleviate their concerns.
#7
Title: Combined therapy for myopia management in a 10-year-old
Author: Kelsey Blalock, OD, Michelle J. Buckland, OD, MS, Douglas Widmer, OD, MS
Category: Pediatric Optometry
Background: Recent studies estimate that approximately 41.6% of the United States population is myopic. With high amounts of myopia comes increased risks of retinal detachments, glaucoma, myopic macular degeneration, and other ocular pathologies. For this reason, myopia management has become an increasingly emphasized part of pediatric optometry. Current treatment options include low-dose atropine, multifocal soft contact lenses, and orthokeratology lenses. One option for multifocal contact lenses is MiSight dailies, an FDA-approved center-distance design. Patients can opt for monotherapy or a combination of the listed therapies. Outside of the United States, myopia management spectacles are available. This case report is designed to demonstrate the initiation of combined therapy for myopia management.
Case Presentation: A 10-year-old white female presented in July 2024 for a MiSight contact lens fit follow-up. The patient has been on 1 drop 0.05% atropine nightly in both eyes since June 2023. Since starting this treatment, the patient has noted the following side effects: mild photophobia in the sun and mild blur after extended periods of near work. In June 2024, it was recommended that additional myopia control measures be added to the patient’s treatment plan given that her axial length had increased since the last follow-up 6 months prior. Her axial length measurements increased 0.48 mm and 0.35 mm in the right and left eye respectively between June 2023 and June 2024. Her refractive error increased asymmetrically over the course of the year (-1.25 D, -0.50 D changes in the right and left eye respectively) without corresponding keratometry changes to explain this difference. Due to this progression and a positive family history of myopia and retinal detachments, the patient’s family is very motivated to minimize the patient’s amount of myopia.
#8
Title: Bilateral Macular Hole Development in Adult-Onset Vitelliform Macular Dystrophy
Author: Sidney Parks, OD, MS
The Ohio State University College of Optometry, Cincinnati VA Ocular Disease Residency
Category: Ocular Disease
Background:
The purpose of this case presentation is to highlight an uncommon presentation of bilateral macular hole development in a patient with late stage Adult-Onset Foveomacular Vitelliform Macular Dystrophy (AOFVD). Late stage AOFVD results in outer retinal atrophy that may predispose these eyes to macular hole formation. Adult Vitelliform Macular Dystrophy is retinal disorder that has four well defined stages with distinct presentations. However there are rare occurrences of macular dystrophy, confounded by onset of vitreomacular traction, that can lead to macular hole development and further devastation of the visual capabilities of an already compromised macula. As vitelliform lesions progress and overlying photoreceptors and outer retinal layers degrade, a macular hole can develop with severe visual consequences, as there is typically minimal improvement from surgical interventions. OCT can aid in the detection of risk factors that can lead to the development of a macular hole and allow for better prediction of long term visual outcome. This case follows the development of bilateral lamellar macular holes in a patient with AOFVD .
Case:
A 74 year old patient with Adult Vitelliform Macular Dystrophy presented with symptoms of the disappearance of words and increased difficulty while reading. OCT revealed apparent lamellar holes which had developed in both eyes, overlying the patient’s already present vitelliform lesions. The patient was referred for retinal evaluation and was started on topical steroids and intraocular pressure lowering drops. After no improvement the patient was given a series of 3 intravitreal Avastin injections with no improvement. Over this time the patient’s macular atrophy worsened and they experienced a rapid decline in vision in both eyes. On review of OCT prior to the development of the lamellar holes, the patient had apparent vitreomacular traction causing an intraretinal cyst which likely aided in the evolution of the holes.
Conclusion:
Severe vision loss in AOFVD is typically the result of macular atrophy from neovascular membrane complication. However, late stages of AOFVD increase the risk of macular hole. There is limited literature reporting surgical outcomes in AOFVD with surgical repair of macular hole. A thorough assessment of OCT presentation allows a measured approach to management of patients with complex presentations of vitreomacular interface disorders.
#9
Title: Unilateral Granulomatous Uveitis in an ANA/ANCA positive patient
Author: Jack Baumer, OD
Cincinnati Eye Institute
Category: Ocular Disease
Background: The purpose of this case report is to describe the presentation of a unilateral granulomatous anterior uveitis in an ANA/ANCA positive patient. Anterior Uveitis is an inflammation of the anterior portion of the uveal tract (iritis/iridocyclitis). The nature of the inflammation is typically categorized in two ways: granulomatous or non-granulomatous. Granulomatous uveitis typically presents with mutton-fat keratic precipitates (KP’s) accompanied by cells/flare in the anterior chamber, as well as potential iris nodules or synechiae. They typically have a more chronic onset compared to non-granulomatous etiologies which are more acute in nature. It is often associated with patients who have a systemic history of Sarcoidosis, Tuberculosis, Syphilis, VKH, or Lyme disease.
Case Presentation: A 26-year-old Hispanic female presented to the Cincinnati Eye Institute Urgent Department in July 2024 with complaints of pain, hazy vision, photophobia, and redness in her left eye for the past 5 days. The patient reported that she went to the ER over the weekend where she was given Ciprofloxacin antibiotic eye drops to use every 2 hours but said that they were not helping. Slit lamp examination revealed a mild-moderate corneal edema with subsequent mutton-fat KP’s on the inferior aspect of the endothelium, grade 2+ cell in the anterior chamber, and posterior synechiae present from 5-10 o’clock with fibrin present on the nasal edge of the pupil. No posterior involvement was found upon dilation. The patient was diagnosed with an anterior granulomatous uveitis and started on Pred Acetate every 2 hours while awake and cyclopentolate twice a day until follow-up. Given the granulomatous nature of the inflammation, blood work was ordered. The results came back positive for ANA and ANCA panels, which are more suggestive of Lupus or an ANCA systemic vasculitis. Results were negative/normal for ESR/CRP, ACE, CCP, HLA B-27, Serum Lysozyme, RF, and T. Pallidum Screening Cascade.
Conclusion
While Granulomatous Uveitis can commonly present in patients with certain systemic conditions predicted by the literature, it can also occur idiopathically or in patients with other forms of inflammatory markers.
#10
Title: The Lowdown on Sagging Eye Syndrome
Author: Molly Papio, OD; Doug Widmer, OD, MS, FAAO
Ohio State University College of Optometry
Category: Binocular Vision
Abstract
Background: First described in 2009, Sagging Eye Syndrome (SES) is a leading cause of double vision in older adult populations. This disease presents as both a horizontal and vertical strabismus and is also seen with a bilateral ptosis and deep superior lid sulcus. It can be caused by age-related degeneration the ligaments connecting the EOMs and results in inferior sag of the lateral rectus. Sagging Eye Syndrome can be treated with prism lenses in order to alleviate the diplopia or strabismus surgery in to approve ocular alignment for the patient. This poster aims to describe this newly understood binocular vision condition and its presentation in elderly adults.
Case Presentation: An 80-year-old white male presented to the Binocular Vision Clinic for a complaint of double vision when looking in the distance that has been worsening for the last year. His diplopia onset gradually and has not affected his near vision. The patient had previously been treated for diplopia with prism, and his entering spectacles had a total of 9 D vertical prism. These helped with his diplopia initially but are no longer sufficient in the distance.
Cover test revealed a constant alternating esotropia and incomitant right hypertropia at distance, and an exophoria with no strabismus at near. Double Maddox rod testing showed right excyclotorsion. On anterior segment evaluation, the patient had a slight bilateral ptosis with a high lid crease and deep superior sulcus.
With prism demonstration, the patient appreciated increased vertical prism and the addition of BO prism to his current lenses. The patient preferred updated prism over surgical intervention at this time.
Conclusion: In older adult populations, Sagging Eye Syndrome is an important consideration for causes of double vision. Although it is newly understood, this binocular vision condition provides great insight into the mechanism for some cases of age-related diplopia and understanding the presentation can help aide in the proper management of these patients.
#11
Title: Don’t Worry about the Doily
Author: Stephanie M. George, OD, MS; David L. Bejot, OD
The Specialty Eye Institute
Category: Ocular Disease
Background: Age-related macular degeneration (AMD) is one of the leading causes of blindness in the world. Risk factors such as family history, smoking, UV exposure, among others contribute to the development of AMD, and the risk of progression from dry/non-exudative to wet/exudative AMD is higher if the fellow eye has wet AMD. Clinical features of wet AMD are diverse and may include subretinal or sub-RPE hemorrhage, intraretinal or subretinal fluid, and/ or gray-green subretinal neovascular membrane. Patients often experience central vision loss, metamorphopsia, and scotomas. Care must be taken to address challenges of monocular status in those with AMD. Few monocular patients experience visual hallucinations, known as Charles Bonnet Syndrome. In these cases, patients typically experience simple or complex hallucinations. In the absence of neurological deficits, patients should be educated and reassured on the condition.
Case Discussion: An 83-year-old Caucasian female presented for an evaluation after noticing the appearance of a “doily” in her vision intermittently for one week that was more noticeable at night. Best corrected visual acuity (BCVA) was NLP OD (stable) and 20/70 OS. Several months prior, the patient’s BCVA was 20/30 OS. She has a history of wet macular degeneration and aqueous misdirection OD and intermediate dry macular degeneration OS. Posterior examination showed stable 2+ soft drusen with retinal pigment epithelium changes and no subretinal blood OS. The OCT-macula showed a large pigment epithelial detachment with surrounding subretinal fluid that was subclinical upon fundus examination. Due to the patient’s intact cognitive function, reassurance was given on the visual hallucinations. However, the patient was immediately referred to the retinal specialist given her monocular status, and the following day, she was given an intravitreal injection of Eylea.
Conclusion: While the appointment was scheduled due to the patient’s visual hallucinations, the subretinal fluid and possible conversion to wet macular degeneration was the most imminent concern. Since the subretinal fluid was subclinical, OCT analysis was important in accounting for the discrepancy in vision compared to previous visits. Here, we highlight the significance of reduced BCVA in a monocular patient whose complaints did not align with the primary diagnosis.
#12
Title: Retinal Complications of Cocaine Use
Author: Olivia L. Bittner, O.D. University of Alabama at Birmingham School of Optometry (Class of 2024), Cincinnati VA Ocular Disease Residency 2024-2025
Category: Ocular Disease
Background: The purpose of this case report is to describe a presentation of a retinal hemorrhage in a patient with long-term cocaine abuse and to discuss ocular effects of cocaine use. Abuse of cocaine can be presented in vasospastic events such as arterial and venous occlusions, retinal hypoperfusion, preretinal or intraretinal hemorrhages, embolic phenomena, and maculopathies. Cocaine use is also associated with an enlarged venous caliber and an increase in arterial branching. The proposed pathophysiology of vascular changes associated with cocaine are the vasospastic events and/or immediate elevated blood pressure following its use. These events cause a decrease in retinal profusion leading to micro or macro vascular changes. Many ocular presentations of cocaine abuse may have similar presentation of other vascular etiologies, thus careful investigation is required after presentation to confirm diagnosis.
Case Presentation: A57 year old white male new patient presented on July 31, 2024 for a complete eye exam. Upon dilated fundus examination, an incidental finding of a disc hemorrhage on the inferior temporal rim of the left eye was discovered. The artery underlying the hemorrhage had focal sclerosis. Both optic nerves were well perfused with small cup-to-disc ratios and distinct margins. No posterior vitreous degeneration was noted on examination. Mild to moderate tortuosity was noted on ocular vasculature and there was an increased sclerosis surrounding vessels near optic disc. Valsalva retinopathy was ruled out secondary to unremarkable patient history. The patient’s most recent blood pressure reading was 121/65 mmHg and most recent hemoglobin A1c was 5.5%. The patient denied a history of hypertension or diabetes mellitus. Upon further investigation of the patient’s prior medical history, it was revealed that the patient had a record of cocaine abuse. His most recent bloodwork on June 16, 2024 had a positive indicator for cocaine.
Conclusion: While cocaine can cause a plethora of systemic manifestations, its vasospastic and toxic properties cannot be overlooked in ocular disease properties.
#13
TITLE: Management of Thygeson Superficial Punctate Keratitis with Perfluorohexyloctane
Ophthalmic Solution
AUTHOR: Tiffany C. Lu, OD (The Ohio State University College of Optometry)
CATEGORY: Ocular Disease
ABSTRACT:
BACKGROUND: This case report explores the use of perfluorohexyloctane ophthalmic
solution for management of Thygeson Superficial Punctate Keratitis (TPSK). TPSK is a
chronic, recurrent condition that presents as bilateral, elevated gray-white opacities
scattered throughout the anterior cornea. Incidence is highest in females between the
second and third decades of life. Typical symptoms include foreign body sensation,
tearing, burning, irritation, and blurry vision without conjunctivitis. Episodes may last from
1-2 months, with average remission lasting 4-6 weeks. Differential diagnoses include
staphylococcal keratitis, keratoconjunctivitis sicca, neurotrophic keratitis, exposure
keratitis, recurrent corneal erosion, and anterior basement membrane dystrophy.
Standard first-line treatment for TPSK consists of topical corticosteroids, topical
cyclosporine, and topical lubricants. TPSK tends to wax and wane over the course of
many years, and eventually disappears without serious ocular sequelae.
CASE DISCUSSION: A 49-year-old white female presented for a cornea consult with
complaints of dryness, foreign body sensation, and itching. She had previously been
treated for Thygeson Superficial Punctate Keratitis (TPSK) from the ages of 14-30 years,
and had not had a flareup since that time. Her most recent episode began 4 days prior to
the visit. There was no history of contact lens wear, injury, or foreign body. The patient
reported an improvement in symptoms following treatment with topical fluorometholone
(FML), cyclosporine, and lubricating drops. However, over the course of 9 months, the
patient was not able to completely discontinue the use of FML without triggering a
recurrence. After adding perfluorohexyloctane ophthalmic solution as a supplemental
treatment, the patient was able to discontinue cyclosporine after 4 months and FML after
9 months without any symptom recurrence.
CONCLUSION: TPSK is a chronic condition of the anterior cornea with variable
remission and recurrence over years. Perfluorohexyloctane should be considered as a
supplemental management option for patients with TPSK, particularly those at risk of a
steroid response.
#14
Title: Irvine-Gass Syndrome
Author: Caroline Pasi, OD
Chillicothe VA Medical Center
Category: Ocular Disease
Abstract
Background:
Irvine-Gass syndrome, also known as pseudophakic cystoid macular edema, is one of the most common findings following an uneventful cataract surgery. Diagnostic findings include intraretinal cystic spaces within the inner and outer nuclear layers on OCT and early leakage in a petaloid pattern on FA. Patients are at a higher risk of postoperative macular edema if they are diabetic, use topical glaucoma medications, have a history of uveitis, or have an epiretinal membrane. Although this condition typically is self-limiting, first line treatment generally involves the use of a topical NSAID or steroid.
Case Presentation:
A 76 year old white diabetic male presented to the Chillicothe VA in July 2024 for a one month cataract post op for the right eye. The patient felt the surgery went well but reported mild blur and an increase in floaters without flashes. Visual acuity OD was 20/60-, no improvement with pinhole and diffuse distortion on Amsler grid. The right eye showed trace anterior chamber cells and flare. Fundus exam of the right eye showed elevation of the macula without blood or exudate and nasal ERM. OCT testing revealed an elevated foveal contour with moderate intraretinal fluid characteristic of cystoid macular edema and trace subretinal fluid. The diagnosis of pseudophakic cystoid macular edema was made and the patient was prescribed 0.5% ketorolac QID and 1% Pred Forte QID x 1 week, then TID x 1 week, BID x 1 week, QD x 1 week, then discontinue, both right eye only. The patient returned one month later, and despite his admittedly poor drop compliance, his visual acuity improved to 20/30- with a nearly complete resolution of intraretinal fluid with a small subfoveal elevated lesion remaining. He was instructed to continue ketorolac QID and to return to clinic in 3 weeks for refraction and macular scans.
Conclusion:
Pseudophakic cystoid macular edema should be a top differential in the presence of visual decline following cataract surgery. Understanding the expected recovery rate and treatment options are crucial for proper patient care.
#15
Title: An Atypical Presentation of Typical Optic Neuritis
Author: Kelly Klimo, OD, MS
Cincinnati Eye Institute
Poster Category: Neuro/Optic Nerve
Background: The purpose of this case report is to describe an atypical presentation of typical optic neuritis. Optic neuritis is an umbrella term meaning inflammation of the optic nerve and does not specify the etiology of the inflammation. Typical optic neuritis usually presents in middle-aged adults. For a diagnosis of typical optic neuritis, there typically is acute vision loss in one eye that rapidly worsens over hours to days, and orbital or eye pain must be present in the absence of other neurological symptoms. On examination, there will be a RAPD, color vision and visual field abnormalities, and the optic nerve head may be normal or mildly edematous. Patients who meet all these diagnostic criteria for typical optic neuritis do not require further evaluation to confirm the ocular diagnosis, although the diagnosis increases the risk of developing multiple sclerosis. Patients who do not meet all the requirements for diagnosis require urgent blood work and imaging.
Case Presentation: A 44-year-old African American female presented in the clinic with no known ocular conditions and a complaint of blurred vision in her right eye. The patient went to the emergency department four days prior for a complaint of a right-sided headache. The patient only noticed a subjective decrease in the right eye’s vision for the first time when her vision was tested in the emergency department. The patient denied eye or orbital pain. On examination of the right eye, the patient’s vision was count-fingers, she was unable to perform color vision, and there was a subjective APD, as she had already been dilated prior to the doctor’s exam. The dilated fundus exam revealed the patient’s right nerve was hyperemic with superior nasal elevation and questionable edema in said area. A macular OCT was unremarkable, and a visual field revealed central loss. The left eye was 20/20 with normal findings. Due to the inconclusive duration of vision loss, the absence of pain, and the right nerve presentation, an atypical optic neuritis was suspected. The patient went to the emergency department where imaging and blood work were performed. Normal blood values and and white matter lesions on MRI were discovered. The diagnoses of typical optic neuritis and multiple sclerosis were made, steroid treatment was initiated, and the patient fully recovered.
Conclusion: Although typical optic neuritis can be a straight-forward in-office diagnosis, it is possible for this disease entity to present atypically, indicating urgent further evaluation.
#16
Title: Progressive Schsis-Related Retinal Detachment
Author: Akhila Manu, OD
Cincinnati VA
Category: Posterior Segment
- Background: Degenerative Retinoschisis is often a benign ocular finding, usually involving splitting at the outer plexiform layer in the peripheral retina. However, ocular complications such as retinoschisis detachment or progressive symptomatic schisis-related retinal detachment can lead to vision loss. Retinoschisis Detachment, secondary to outer retinal holes allowing fluid to enter subretinal space, is less likely to progress beyond the schisis cavity and be vision threatening . Whereas the very rare condition of Progressive Symptomatic Schisis-Related Retinal Detachment is more likely to be sight threatening, due to the combination of outer and inner layer holes allowing liquified vitreous to directly enter the subretinal space.
- Case Presentation: 62-year-old White male presents to clinic with a history of Bullous Retinoschisis in the left eye. Patient is complaining of blurry vision and hundreds of new floaters in the left eye that began 3 days ago, denies any pain or flashes in either eye. Vision in left eye was reduced to 20/200 from being 20/20 in prior exams. Dilated fundus examination of the left eye revealed retinoschisis retinal detachment with two large outer retinal holes extending from 9-3 o’clock, with macula off. Patient was sent for immediate vitreoretinal surgery involving the following procedures for the left eye: Scleral Buckle, Pars Plana Vitrectomy, Fluid-Air Exchange, Endolaser, Air-Silicone Oil Exchange, and
Methotrexate Infusion.
- Conclusion: Although retinoschisis is often an uncomplicated ocular finding. The presence of outer and inner layer holes can change the management course of these patients. Without proper diagnosis can lead to severe vision loss.
Title: Beyond a Bandage Lens: Using Scleral Lenses to Treat Persistent Epithelial Defects in Neurotrophic Keratitis
Authors: Shihij Takoo, OD, MS; Chantelle Mundy, OD, FAAO, FSLS
Havener Eye Institute
Poster category: Contact lenses
Background information
Neurotrophic keratitis (NK) is a corneal disease characterized by decreased corneal sensitivity secondary to an impaired trigeminal nerve pathway. Damage to this pathway can lead to corneal degeneration over time that may present as a persistent epithelial defect (PED), recurrent corneal erosions, corneal ulceration, or corneal perforation. There are multiple medical therapies on the market or undergoing investigation to treat NK. Additionally, increasing research points to the therapeutic use of scleral lenses to manage patients with NK. This poster will focus on the imperative role of scleral lenses to treat a PED in a patient with NK.
Case discussion
A 37-year-old Caucasian woman was referred for a scleral lens fit due to a non-healing epithelial defect secondary to NK caused by HSV. Prior to the referral, she was treated for 6 weeks with multiple bandage contact lenses (BCL), oral Valtrex, and topical Ofloxacin BID OD without improvement. She presented to our clinic without pain and with minimal light sensitivity. Her entering VAs with habitual glasses were 20/200 OD, 20/20 OS. Slit lamp examination revealed a 2.5mm central epithelial defect OD with central corneal haze and peripheral corneal neovascularization. Her OS examination was unremarkable. Her right eye was diagnostically fit with a 17.0mm diameter BostonSight SCLERAL lens. BCVA OD with over-refraction was 20/70. The lens was ordered with 3 venting channels. At the dispense visit, the patient was instructed to wear the scleral lens for 7-8 hours daily and use Moxifloxacin QID: before lens wear, in the lens bowl prior to insertion, after lens removal, and before bed. Additionally, the patient was to wear a BCL during waking hours without scleral lens wear. After 1 week, her defect improved but epithelial haze remained, limiting BCVA OD to 20/80. The lens was redesigned with 4 venting channels and increased central and limbal vault. After 2 weeks of wearing the second lens and continuing Moxifloxacin, the patient had minor epithelial irregularities; however, her defect and haze had resolved completely. Her BCVA OD at this visit was 20/40. She was instructed to continue scleral lens wear OD, decrease Moxifloxacin use to BID OD (discontinue drop in lens bowl), and to return in one month.
Conclusion
Scleral lenses are a viable, long-term therapeutic option for patients with NK to improve and maintain corneal epithelial health, improve visual function, and resolve a PED not responding to conventional treatment.
#18
Title: Unexplained, Sudden Vision Loss due to Late Intraocular Lens Dislocation
Authors: Emily Magas, OD
Ohio State University College of Optometry
Poster category: Low Vision Rehabilitation
Background information
- A rare cause of sudden, painless, and profound vision loss in older adults can be dislocated intraocular lens (IOL), also known as “late in-the-bag dislocation.”1 Estimates of the incidence of various types of late IOL displacement (defined as occurring more than 3 months after surgery) range from 0.05 to 3%, with occurrences averaging 86 months after surgery.1,2 In the absence of trauma, IOL dislocation is often attributed to age related zonular instability and dehiscence. Population aging and high rates of cataract surgery suggest the dislocation incidence may rise.2 Eye care providers need to be sensitive to the possibility of IOL dislocation and assess appropriately when exploring unexplained, sudden vision loss. Important assessment components include testing for large refractive changes, examination of the posterior chamber, dilated fundus examination, and possible further imaging. Surgical referral is critical to restore vision and avoid serious ocular complications.3
Case Summary
- An 87-year-old female with recent better eye vision loss was referred by an ophthalmologist for low vision evaluation. Extensive workup, including blood work, MRI of the brain and orbits, CTA of the head and neck, visual evoked response, and electroretinogram, had been inconclusive, with some remaining concern for central retinal artery occlusion. Ocular history was notable for three retinal detachments in the right eye and pseudophakia and Descemet stripping endothelial keratoplasty (DSEK) in both eyes. Her chief complaint was sudden, painless, and non-progressing vision loss about five months prior. She reported extreme frustration with pervasive visual difficulties and parenthetically mentioned clearer distance vision through a magnifier (+6.00) held about one and a half feet from her eye. We noted light perception only for the right eye and an entering visual acuity of 20/320 for the left eye. Trial frame refraction showed a twelve-diopter hyperopic shift for the left eye, yielding a visual acuity of 20/25. Un-dilated slit lamp exam revealed no apparent intra-ocular lens in the posterior chamber of the left eye. Patient management included extensive education, provision of temporary high plus glasses and a clip-on add, and a referral for surgical consultation.
Conclusion
- With population aging, IOL dislocation is an important differential when exploring unilateral, sudden, painless vision loss. Detection of large refractive changes can point to the possibility of late in-the-bag dislocation. Subsequent thorough examination of anterior and posterior segments can solidify the diagnosis. Extensive patient education and appropriate surgical referral are likely key to good outcomes.
#19
Title: Conjunctival papilloma in a soft contact lens wearer
Authors: Emily Deng OD, Sarah Guillette OD
Akron Children’s Hospital
Poster category: Primary Care
Background: The purpose of this case report is to describe a soft contact lens fit in a patient with multiple squamous cell conjunctival papillomas. Squamous cell papillomas are benign tumors that appear as lobulated lesions with a central vascular core, typically localized to the inferior fornix, caruncle, or palpebral regions. Most lesions are slow-growing, asymptomatic, and do not present with any folliculitis or conjunctivitis. Squamous cell papillomas are most commonly found in patients under twenty years of age and are associated with Human Papilloma Virus (HPV) types 6 and 11, typically transferred to the child during parturition or direct contact. As the majority of papillomas are benign, the mainstay of treatment is observation. In symptomatic cases, cryotherapy or excision may be recommended. Recurrence of viral and completely excised squamous cell papillomas is rare but may require more aggressive treatment.
Presentation: A 19-year-old Asian male presented with two marginal multilobulated papillomas with prominent vasculature at the left upper eyelid margin, without extension onto the palpebral conjunctiva. Previously, treatment with Prednisolone acetate 1% ophthalmic suspension every 8 hours and surgical excision were recommended, however the patient did not follow through with the procedure. As the patient was a habitual contact lens wearer, he reported mild dryness and lens discomfort at the end of the day. The patient was advised to decrease lens wear time and use contact lens rewetting drops at the end of the day if experiencing discomfort. As there were no further complications or issues with lens wear, an updated contact lens prescription was released with an annual follow up scheduled.
Conclusion: While squamous cell papillomas typically present asymptomatically, discomfort may arise when considering contact lens wear. Longer adaptation periods, in addition to rewetting drops and decreased wear time, may be necessary to warrant successful contact lens wear in patients with squamous cell papillomas.
#20
Title: Contact Lens Related Bacterial Corneal Ulcer
Authors: Teresa Pockl, OD* & Elizabeth Perch, OD
Category: Ocular Disease
Background: The purpose of this case report is to describe the presentation and treatment of a bacterial corneal ulcer secondary to contact lens (CL) overwear. Development of a corneal ulcer begins with a break in the epithelium allowing microbes to invade the stroma. This results in an inflammatory response and release of polymorphonuclear neutrophils. Interleukins, cytokines, and proteolytic enzymes are sent to the damaged cornea leading to an increase in the stromal infiltrate and overlying epithelial defect. CL wear is one of the biggest risk factors for developing infectious corneal ulcers with overnight wear increasing the risk by 5.4 times. Pain, blurriness, and photophobia are symptoms patients may experience. A well-defined corneal ulcer with surrounding edema will be seen on slit lamp examination. Prompt treatment is important since this can lead to permanent scarring, vision loss, corneal perforation, or endophthalmitis if untreated.
Case Discussion: A 37-year-old African American male presented with left eye pain, a swollen left eyelid, photophobia, and blurriness. He was a monthly CL wearer that typically slept in his lenses nightly and replaced them every 1-2 months.
Entering visual acuities were 20/20 OD and 20/30+1 OS with no improvement on pinhole. On slit lamp examination, there were peripheral corneal stromal scars OU. There was a 1mm corneal ulcer superior to visual axis with staining equal in size to the infiltrate, stromal streaming, and surrounding edema OS. There were grade 2+ cells in the anterior chamber OS. IOPs were 21mmHg OU. Due to the size and proximity of the ulcer to the visual axis, a loading dose was given in office of 1 drop of moxifloxacin 0.5% every five minutes for five doses OS. The patient was prescribed moxifloxacin 0.5% and Polytrim to alternate one drop every one hour and cyclopentolate 1% twice a day. The next day, there were G1+ cells in the anterior chamber, trace staining over the infiltrate, and mild surrounding edema. The patient was to alternate one drop of moxifloxacin 0.5% and Polytrim every two hours. At the 2 week follow up, the anterior chamber was quiet, the epithelium was healed with a remaining stromal scar, and final visual acuity was 20/20-2 OS.
Conclusion: Overnight CL wear puts patients at high risk for developing bacterial corneal ulcers which can be vision threatening. It is important to promptly treat these with broad spectrum antibiotics and follow up with patients to preserve vision.
#21
Title: Scleral lenses and their role in pathological myopia with maculopathy
Author: Olivia Jilek, OD
Columbus Ophthalmology Associates
Category: Retina/ Contact Lens
Background: Pathological Myopia is a serious condition, recognized as the second most
common cause of choroidal neovascularization (CNV) in the world. While pathological myopia
may be a less frequently discussed disease, it is still important for practitioners to recognize key
features that separate it from other diseases like Age-Related Macular Degeneration (AMD).
These distinctions are integral in proper treatment and management of the condition, as well as
determining a visual prognosis. This case highlights a patient that displays several key clinical
features of pathological myopia that practitioners can look towards when diagnosing.
Case Presentation: A 40 year old Hispanic female presented in August 2024 with a referral from an outside provider for a contact lens exam. The patient reported having a history of RGP wear, high myopia, and astigmatism. Upon further questioning, the patient revealed that they have had reduced vision since birth in both eyes and have been wearing hard contact lenses since their early teens to help correct vision. Manifest refraction revealed a prescription of -16.50 SPH OD (BCVA 20/80-2) and -17.00 SPH OS (BCVA (20/300). Upon slit lamp examination, posterior segment evaluation showed myopic macular atrophy OU, tilted discs OU, and peripapillary atrophy (PPA) OU. Pentacam scan also revealed mild keratoconus in the right eye. A scleral lens fit was performed with an over refraction of -17.00 -2.50 x 025 OD (BCVA 20/50) and -18.75 SPH (BCVA 20/40). The clinical findings indicated pathological myopia to be the cause of the reduced vision in the patient.
Conclusion: Myopia is known to most as simple refractive error, easily treatable with corrective
lenses like glasses and contacts. However, there can be far more serious complications if the
disease state causes degenerative changes to the eye and vision can be much more difficult to
correct. Practitioners should be aware of the distinguishing factors of pathological myopia, as
well as the different ways to help manage the condition.
#22
Title: Conjunctival Erosion and Exposure of XEN Gel Stent
Authors: Celestine Miller O.D. ; Scott Young O.D. ; Richard Lehrer M.D.
Ohio Eye Alliance
Poster Category: Ocular Disease
Background: XEN gel stent implantation is a minimally invasive glaucoma surgery (MIGS) that allows for subconjunctival drainage of aqueous humor through a scleral channel and formation of a filtering bleb. Conjunctival erosion and exposure of the XEN gel stent is a rare mechanical complication that may occur in the early postoperative period or months later. Potential mechanisms of this complication include administration of mitomycin C (MMC), ab interno approach, subconjunctival placement, long term use of topical drugs, and mechanical stress/friction. Resultant bleb leakage may be managed conservatively with pressure patching or contact lens wear and vitamin A ointment or repaired surgically.
Case Presentation: This 63-year-old Caucasian male is an established patient of Dr. Lehrer M.D. at Ohio Eye Alliance (OEA) with a complicated history of Severe Primary Open Angle Glaucoma OU and XEN gel stent OS. His drop regimen consists of Latanoprost 0.005% QHS OD, Brimonidine 0.2% BID OD, Dorzolamide/Timolol 2%-0.5% BID OD, and Prednisolone Acetate 1% BID OS. Patient’s VAs are 20/70 OD and CF OS. His initial XEN implantation via ab externo approach was performed without complications in October 2023 with a revision in December of 2023. His other ocular history includes SLT OD, repair of iris coloboma OD, DMEK corneal transplant with subsequent graft failure OS, scleral refixation of displaced IOL OS, and severe chronic blepharitis OU. The patient presented to OEA on July 24th 2024 for a regularly scheduled 24-2 HVF and IOP check. Anterior segment exam showed 4-5mm conjunctival retraction of the bleb and exposure of the XEN OS. Seidel test was positive, showing slight leakage at the distal end of the XEN. Intraocular pressure measured 16 OD and 11 OS (target IOP 14 OU). The recommendation for repair with scleral patch graft was made and patient agreed to proceed. A close watch for signs or symptoms of infection due to the patient’s chronic blepharitis and nighttime protection of the eye was emphasized during patient education.
Conclusion: Conjunctival erosion and exposure of the XEN gel stent is a rare mechanical complication of implantation. While the efficacy and safety profile of XEN gel stent is well proven, the importance of thorough slit
#23
Title: River water is not the cure for EKC
Author: David Verastegui-Olvera
Dayton VA
Category: Ocular Disease
Background
– The purpose of this case is to describe the presentation of epidemic
keratoconjunctivitis (EKC). This condition is a highly contagious form of viral
conjunctivitis with no current effective treatment available. It initially presents
unilaterally before infecting the contralateral eye. Slit lamp examination reveals
conjunctival hyperemia, follicular reaction, epithelial keratitis, subepithelial
infiltrates, and pseudomembranes. EKC has a wide range of symptoms that can
be separated by periods of about 8 days from the initial infection. During the
latency period the patient is asymptomatic. The next 8 days are the onset of viral
conjunctivitis, followed by 8 days of keratitis. While EKC can be clinically
diagnosed based on signs/symptoms, definite diagnosis can be done in-office
with antigen-based immunoassay with a swab of the conjunctiva. EKC gradually
resolves on its own, so the management is focused on reducing symptoms with
cold compresses, artificial tears, topical cycloplegics, and, in severe cases,
topical steroids. Care should be taken to educate patients on the highly
contagious nature of the condition.
– Case Summary
– A 44 year-old Caucasian man presented from the Dayton VA emergency
department (ED) on 8/14/24 for non-improving unspecified bilateral conjunctivitis.
The patient had rinsed their eyes out with river water on 8/3/24 after thinking they
had gotten something in their eye. They were initially seen by an outside ED on
8/7/24 for a watery, irritated left eye that presented with similar symptoms in the
contralateral eye 5 days later. They were prescribed an unspecified antibiotic
drop. They reported to the Dayton VA ED on 8/12/24 due to no improvement in
symptoms and was prescribed Ciprofloxacin every 2 hours in both eyes. On
examination, severe diffuse conjunctival injection, follicular palpebral reaction,
pseudomembrane, corneal microcystic edema w/ Descemet striae, and
preauricular lymphadenopathy were noted which are highly indicative of EKC.
The patient was prescribed PredForte QID OU, erythromycin ointment BID OU,
and continuation of ciprofloxacin prophylactically. At the first follow up on 8/16/24,
the patient showed mild improvement. Further improvement was noted on
second follow up (8/21/24) with new signs of SEIs, and therefore was instructed
to taper steroids. This case remains ongoing.
– Conclusion
– While EKC is highly contagious and one of the more common causes of acute
conjunctivitis, it is not uncommon for keratitis signs to present for weeks after
conjunctivitis resolution.
#24
Title: Macular Telangiectasia Type 1
Authors: Darren Vong, OD; David Roncone, OD; Rachael Canania, OD
Cleveland VA
Category: Ocular Disease
Background:
This case report presents a case of macular telangiectasia (mac tel), an often
misdiagnosed condition characterized by abnormalities in the capillaries of the fovea or
perifoveal region. These abnormalities can lead to the loss of outer nuclear layers and
the ellipsoid zone, which may progress to cystic changes throughout all retinal layers,
the development of a full-thickness macular hole, or subretinal neovascularization
(SRN) in advanced stages. Visual impairments associated with mac tel may include
metamorphopsia, scotoma, or reduced visual acuity. Anti-VEGF therapy is the primary
treatment for cases with SRN. This poster highlights a case of mac tel without
neovascularization, the importance of accurate diagnosis, and the optometrist’s role in
management.
Case presentation:
A 61-year-old African American female presented to the clinic with a history of
intermediate age related macular degeneration (AMD) OD and diabetes without
retinopathy. She reported a general decline in vision in each eye and difficulty reading
with glasses due to eyestrain. Her best corrected visual acuity was 20/20 in each eye.
Slit biomicroscopy was unremarkable in each eye. Dilated fundus examination showed
mild macular mottling, hard drusen, and adjacent temporal hemorrhages. OCT imaging
revealed cystoid edema temporal to the fovea, with thickening of retinal layers and
vitreomacular adhesion (VMA). OCT-A revealed anomalous parafoveal blood vessels in
the absence of SRN. Differential diagnoses included diabetic macular edema, in
addition to VMA, juxtafoveal telangiectasia, and progression of the previously diagnosed
intermediate AMD to exudative status. The patient was referred to a retinal specialist for
further evaluation and management.
Conclusion:
Mac tel is a relatively rare condition that frequently remains undiagnosed or is
misdiagnosed. However, with advancements in understanding the disease and
improvements in retinal imaging technology, accurate diagnosis and management and
treatment is feasible.
#25
Title: Nonarteritic Ischemic Optic Neuropathy: Clinical Manifestations and Workup
Authors: Nicole Haessly, O.D.
Cleveland VAMC
Category: Neuro-ophthalmology
ABSTRACT
Background: The purpose of this case report is to describe a presentation of non-arteritic ischemic optic neuropathy (NAION) in a patient unilateral optic nerve head edema. This condition is characterized by a unilateral disc edema that typically presents in middle aged to elderly individuals with no predilection for males or females. Often, this condition is accompanied by sudden, painless, unilateral vision loss that presents upon waking, a relative afferent pupillary defect (RAPD), decreased color vision, and corresponding visual field loss. NAION can mimic a more sight threatening condition, arteritic ischemic optic neuropathy (AION). AION presents similarly to NAION, however it is systemically associated with giant cell arteritis (GCA) which, if left untreated, can cause bilateral vision loss in 65% of cases. Laboratory testing including ESR and CRP are required to rule out GCA in cases of unilateral disc edema.
Case Presentation: A 66 year-old male presented to the Cleveland Veterans Affairs Medical Center with complaints of blurred/grey vision OS that began 3-4 days ago upon waking. The patient did not endorse any jaw or temple pain at the time of examination. Clinical examination revealed an inferior nasal constriction on confrontational visual fields of the left eye which was confirmed with a Humphery visual field. Fundus examination revealed grade two edema superior greater than inferior of the left optic nerve. All other anterior and posterior findings were within normal limits for the left eye. All exam findings for the right eye were within normal limits. Laboratory testing revealed elevated ESR and CRP. The patient will need a temporal artery biopsy to properly rule out giant cell arteritis (GCA), but in the setting of no GCA symptoms and today’s presentation, the elevated ESR and CRP readings are more likely due to the patients acute and chronic medical conditions. An MRI would also be recommended to rule out the unlikely cause of a compressive lesion, as well as blood work to rule out other infectious or inflammatory causes. However, the patient denies any additional testing at this time and was lost to follow up.
Conclusion: NAION is typically associated with systemic vascular diseases. However, due to its similarities to AION and the sight threatening nature of the disease, giant cell arteritis must be ruled out immediately in these cases. Urgent laboratory testing including ESR and CRP must be performed on all patients to rule out GCA.
#26
Title: Don’t Mess with the Pituitary Gland
Authors: Gabriella Thomsen, OD; Cari Nealon, OD
Cleveland VA
Poster Category: Ocular Disease
Background: The purpose of this case report is to describe a presentation of bitemporal visual field loss in a patient with a pituitary macroadenoma. A pituitary macroadenoma is a benign tumor that is classified as greater than 10mm in size. Given its location, it can compress the pituitary gland as well as the surrounding structures. If the nearby optic chiasm is involved, it can lead to bitemporal visual field loss due to compression of the nasal optic fibers. However, nearly 50% of patients will not notice visual field loss as a presenting symptom. Treatment is dependent on the patient and their specific adenoma location. A good visual prognosis is possible with a tumor resection procedure.
Case Presentation: A 75 year-old black male was referred to the eye clinic by endocrinology for a formal visual field due to a known pituitary tumor extending from the sella turcica into the supracellar cistern with compression on the optic chiasm. His medical history also included hypertension, hyperlipidemia, and congestive heart failure (CHF). He reported no subjective peripheral vision loss. Humphrey Visual Field (HVF) testing revealed bitemporal field loss that was greater superiorly versus inferiorly and respected the vertical midline. This field loss correlated to binasal ganglion cell thinning on Optical Coherence Tomography (OCT). The patient’s endocrinology team was notified of findings and decision was made to monitor condition with a repeat HVF in 6 months. The patient is scheduled for repeat Magnetic Resonance Imaging (MRI) in December 2024 to assess for progression of the macroadenoma.
Conclusion: Patients will often not perceive peripheral field loss when they present with pituitary adenomas or other space-occupying lesions. Therefore, it is important to perform visual field testing to quantify and assess the extent of underlying field loss. This information will be necessary to inform the appropriate treatment plan and is often taken into consideration when determining if surgical intervention is appropriate.
#27
Title: Under Pressure: A Case Reports about Elevated Intraocular Pressure after Cataract Surgery
Author: Danielle Torre, OD
Category: Primary Care
Background: The purpose of this case report is to discuss possible causes of postoperative IOP spikes in cataract surgery along with the role of optometry in treatment and management.
Case Discussion: A 62 year-old black male presented for a one day postoperative exam after cataract extraction in the right eye. At the exam, the patient reported improvement in overall vision and denied any ocular discomfort since the surgery. He confirmed using his postoperative combination ophthalmic eye drop (prednisolone/moxifloxacin/bromfenac) as directed. His vision was 20/70-2 (20/50-2 pinhole) OD. The patient’s preop vision was 20/50 OD with a 2+ nuclear sclerotic with 1+ cortical spoking graded cataract. Slit lamp examination showed a large positive Seidel sign at the temporal surgical incision with an IOP of 71. The anterior chamber had 2+ cells. Paracentesis was performed in office by an ophthalmologist, resulting in immediate wound closure and an IOP of 23. Patient was started on Alphagan-P BID OD at a follow-up visit due to elevated IOP in the high 20s. He remained on the same combination eye drop with the appropriate taper.
One month later, the patient presented for a one day postop after cataract extraction OS. The patient reported improvement in vision and denied any ocular or systemic discomfort. He confirmed using his combination drop as directed. His vision at the exam was 20/150- (20/60 pinhole) OS. The patient’s preop vision was limited to hand motion due to the presence of a white cataract OS. Slit lamp examination revealed a closed surgical incision, negative Seidel sign, and a large corneal abrasion. The anterior chamber had 1+ cells. IOP OS was 65. Again, parecentesis was performed in office by an ophthalmologist, lowering the IOP to 16. Patient was started on Alphagan-P BID OS to manage the IOP and to continue tapering his drop.
Conclusion: IOP spikes following cataract surgery can be treated in different ways depending on the severity. The role of optometric co-management will only grow as the number of cataract surgeries is expected to increase in the future due to the aging population. It will be crucial to identify certain clinical features in postop exams and have correspondence with the surgeon. Even if postop care is not in your practice, there are a number of proposed risk factors for IOP elevation during the early cataract postoperative period that can be identified during routine exams before referring for surgery.
#28
Title: Intermediate Uveitis After Traumatic Cataract Extraction with Intra-Ocular Lens Implantation
Author: Nicholas J Bernhardt, OD, Susan Zacatelco, OD, FAAO
Columbus VA
Background
The purpose of this case report is to describe the presentation and treatment of posterior chamber uveitis in an otherwise health individual. Intermediate uveitis is defined as inflammation of the anterior vitreous, ciliary body, and peripheral retina. There are several etiologies that can cause intermediate uveitis: idiopathic, infectious etiologies such as lyme disease, tuberculosis, syphilis, cat-scratch disease, inflammatory diseases stemming from autoimmune conditions, and non-infectious or masquerade etiologies like multiple sclerosis, sarcoidosis, or primary ocular lymphoma. Clinical diagnosis is made based on patient complaints of decreased vision and or floaters in the absence of pain, redness, and photophobia with ocular findings of vitreous cells greater in quantity than anterior chamber involvement, cellular aggregation, and or snow banking along the ora-serrata.
Case Presentation
A 38-year-old African American male presented to the Columbus VA in July 2024 for his one-month post-operative exam. The patient complained of his left eye having new floaters since the surgery, being red, painful, and swollen since his one week post-operative follow up. The patient had a deep and quiet anterior chamber with no cells or flare, but had 2+ cells and pigment in the posterior vitreous with a posterior vitreous detachment. Patient denied any underlying autoimmune conditions, but was symptomatic for lower back pain. The patient was sent for blood work to rule out infectious and inflammatory conditions. Fundus photography and optical coherence tomography were obtained and later intra-veinous fluorescein angiography is scheduled to be completed with the retinal specialist. Studies have shown it is best to initiate topical corticosteroid therapy every one to two hours. This patient was initially started on topical corticosteroid therapy four times a day in the left eye, which was increased to every two hours after there was no improvement of clinical findings despite no patient symptoms at the one week follow up. If inflammation does not improve on topical treatment, the retinal specialist may proceed with periocular corticosteroid injections, oral corticosteroids, systemic immunomodulators, or pars plana vitrectomy.
Conclusion
Intermediate uveitis can be caused by many different etiologies: idiopathic, infectious, inflammatory, or masquerade syndromes. A systemic work up should be completed for all cases of an intermediate uveitis involving blood work and additional retinal imaging. Observation or topical corticosteroids are generally the first line of treatment for mild, non-visually threatening cases. Depending on patient response, symptoms, and severity, referral to uveitis/retinal specialists for next line interventions may be warranted.