“Highlights in Optometry: how optometrist change people’s lives”
The 2023 EastWest Eye Conference Poster Session
2023 Poster Abstracts
Chair: Dawn J. Goedde, O.D., F.A.A.O
OSU College of Optometry
1
Title: The Effect of Prolonged Gaming on The Development of Dry Eye Symptoms in College Age Students
Authors: Cecelia Koetting, O.D., FAAO, DipABO (Clinical Instructor, Department of Ophthalmology at the University of Colorado School of Medicine), Derrick Liu (MS2 at Frank H. Netter MD School of Medicine at Quinnipiac University), Edmund Farris, M.D., FAAO (Adjunct Associate Clinical Professor, Department of Medicine at Frank H. Netter MD School of Medicine at Quinnipiac University)
Abstract:
Background:
The aim of this study was to examine the effects that consistent gaming over a four-hour period with limited fluid intake has on the production of dry eye in college students.
A cohort of 41 college students were placed in a room (Quinnipiac University Gaming Lab) to play video games continuously over a four-hour period with a five-minute break every hour and a maximum fluid intake of 500 cc. Temperature and humidity were measured every hour. After informed consent, we obtained SPEED and OSDI questionnaires, Snellen visual acuity at distance and near, Tear osmolarity (Tear Lab, Escondito,CA), Schirmer test without anesthesia, and Matrix-Metalloproteinase-9 levels (Quidel, San Diego, CA). Immediately after conclusion of the study, the same tests were administered.
Case Presentation: The average SPEED score increased by 1.84 fold (baseline: 2.76 ± 3.43, final: 5.07 ± 4.97, p = 0.001). More specifically, the average frequency of soreness/irritation increased by more than threefold (baseline: 0.2 ± 0.46, final: 0.63 ± 0.86, p = 0.001), and the corresponding average severity increased by two and a half fold (baseline: 0.22 ± 0.47, final: 0.56 ± 0.84, p = 0.009). Similarly, the frequency of average eye fatigue nearly doubled (baseline: 0.56 ± 0.87, final: 1.02 ± 0.96, p = 0.007), and the average severity of eye fatigue increased by a factor of 2.4 (baseline: 0.46 ± 0.67, final: 1.1 ± 1.11, p = 0.0004). In addition, 36% of the participants who had normal levels of MMP-9 before gaming had elevated levels of MMP-9 after gaming. Temperature (22.92 ± 1.11 °C) and humidity (48.5 ± 3.19%) remained constant. Changes in all other parameters (OSDI, visual acuity, tear osmolarity, Schirmer’s test) from the beginning to the end of the study were not statistically significant.
Conclusions: After four hours of continuous gaming with limited fluid intake and in an environment with steady temperature and humidity, the average SPEED score for college students almost doubled and over a third of participants had elevated levels of MMP-9 compared to their normal levels at baseline. Our study suggests that prolonged periods of gaming in front of a digital screen can lead to the development of dry eye symptoms, specifically soreness/irritation and eye fatigue, as well as increased inflammatory mediators in certain individuals. To our knowledge, this is the first study to show the production of dry eye symptoms specifically focused on the gaming community.
Conflict of interest/Acknowledgement of grant support: Dr. Farris is a founder, investor, and Chief Medical Officer of Myze, LLC., and Dr. Koetting is a consultant to Myze, LLC. The study was funded by Myze, LLC., Harrison, NY.
2
Title: Aniseikonia Diagnosis and Management
Author: Curt Fritts-Davis, OD MS
Andrew Toole, OD, PhD
Abstract:
Background: The purpose of this case report is to describe a typical presentation of aniseikonia. This condition results when there is a mismatch in perceived image size for each eye. Aniseikonia is typically a result of significantly different refractive errors between eyes (i.e. cataract surgery in only one eye) or due to retinal distortions (i.e. macular pucker). Treatment options typically include contact lenses, eikonic lenses, refractive surgery, and monocular fogging.
Case Presentation: A 68-year-old retired engineer from California was referred to our clinic in Ohio for aniseikonia treatment. The patient had a history of retinal detachment repair in the right eye 20 years ago, a retinal detachment repair with a subsequent macular hole in the left eye 7 months ago, and bilateral cataract surgery 1 year ago. The patient reported horizontal diplopia with small distance targets. The patient had determined on his own that the image in his left eye was 10% smaller than the image in his right eye. This was confirmed with clinical testing using the New Aniseiknoia Test (Awaya). The patient had tried contact lenses without success and opted for eikonic glasses. After consulting with the patient, we prescribed separate pairs of distance and near glasses with magnification over the left eye.
Conclusion: Aniseikonia is a common but undertreated condition. Simple testing strategies paired with easily accessible treatment options can significantly improve patient quality of life
3
Title: Fovea Plana & Reduced Acuity in a Child with no Amblyogenic Risk Factors
Authors: Emily Weatherford, OD, MS & Catherine McDaniel, OD, MS, FAAO
Abstract:
Background: Fovea plana, also termed by some as foveal hypoplasia, is a flat or underdeveloped foveal pit. Fovea plana typically presents in patients with an associated congenital ocular condition, such as albinism, aniridia, or retinopathy of prematurity. Historically, retinal examination with biomicroscopy, fluorescein angiography, and histology were used to diagnose fovea plana. With the development of optical coherence tomography (OCT), clinicians are now able to not only diagnose fovea plana but are also able to differentiate it into stages. This case report is designed to demonstrate a case of fovea plana in a pediatric patient with bilateral reduced visual acuity.
Case Presentation: A 6-year-old white female presented to the clinic with reduced visual acuity, worse in the left eye than the right that was constant for two years. This was first discovered when the patient was advised to visit an optometrist by her occupational therapist for eye tracking concerns. Vision therapy was pursued for two years, with no improvement of the condition. The optometrist then referred the patient to our clinic with a tentative diagnosis of monofixation syndrome in the left eye and reduced acuity in the right eye with no known cause.
Entering visual acuities were 20/30 OD and 20/60-2 OS, following the Amblyopia Treatment Study protocol. A recheck with isolated Snellen lines revealed acuities of 20/25-2 OD and 20/40-2 OS.
Stereoacuity revealed few scattered correct answers on RANDOT and 400 seconds of arc on Lang II, though the ability to discern shapes was variable. Cover test was 6 prism diopters exophoria at both distance and near. Major Amblyoscope correspondence was tested, with no obvious deviation or suppression noted with second- and third-degree targets. Visuoscopy exposed fluctuating fixation, with up to 1.5 prism diopters temporal fixation OS.
Anterior health evaluation was unremarkable OU. Posterior health evaluation revealed a dim foveal light reflex OU and was otherwise unremarkable.
OCT of both optic nerve and macula were performed. OCT of optic nerve exhibited normal optic nerve head and retinal nerve fiber layer appearance OU. OCT of macula displayed a shallow foveal pit OU.
Conclusion: While fovea plana often presents with other ocular manifestations, some cases demonstrate fovea plana in isolation. In children with reduced visual acuity and the absence of amblyogenic risk factors, ocular health must be closely reviewed. Biomicroscopy may appear normal in affected individuals. Even so, OCT can be a useful tool in assessing and diagnosing fovea plana.
4
Title: Ocular Manifestations of Hematologic Disorders: Peripheral Retinal Hemorrhages in a Patient with Evans Syndrome and Myelodysplastic Syndrome
Author: Yaadam M. Jobe, OD
Cincinnati VA Medical Center
Abstract:
Background: Retinal hemorrhages have a wide array of etiologies, most commonly diabetic retinopathy, hypertensive retinopathy, and vascular occlusive disease. Hematologic disorders, however, represent a distinct and important cause of retinal hemorrhages that are often incidentally identified during ophthalmoscopic evaluation. Myelodysplastic syndrome (MDS) describes a group of blood cancers caused by abnormalities in the bone marrow. Evans syndrome is characterized by hemolytic anemia with severe thrombocytopenia. Ocular manifestations of these conditions may include sub-acute vision loss, iridocyclitis, vitreous hemorrhage, and cotton wool spots. The presence of ocular manifestations in hematologic disorders serve as an indicator of the severity of the disease. In MDS, for example, retinal hemorrhages are more common in patients with significantly reduced platelet counts. This poster aims to highlight the importance of a thorough case history and assessment of a patient’s medical history in cases of peripheral retinal hemorrhages.
Case Presentation: An 81-year-old Caucasian male presented for evaluation of subjective decline in vision OU. The patient’s medical history was positive for MDS and Evans Syndrome, which were closely monitored with weekly hematology visits and regular blood transfusions. The patient’s ocular history was positive for ocular hypertension and longstanding retinal hemorrhages OU. Entering visual acuities were 20/30 OD, 20/30 OS, which improved to 20/20 OD, OS with manifest refraction. Slit lamp examination showed centered PCIOL OU, with trace inferior PCO OD and an open capsule post YAG OS. Dilated fundus examination revealed midperipheral dot blot hemes OU, with clusters of dot blot hemes in the far periphery of each eye. The patient’s symmetrical bilateral retinal hemorrhages serve as a sign of his chronic hematologic conditions. In this case, blood work was not ordered due to the patient’s existing diagnoses and longstanding, symmetrical presentation.
Conclusion: Hematologic disorders serve as important differential diagnoses in cases of peripheral retinal hemorrhages and an important area of investigation in patients who present without prior systemic diagnoses. The presence of ocular manifestations in hematologic disorders serves as an important prognostic indicator of the severity of the disease course and risk of progression to acute leukemia.
5
Title: Ocular trauma complications from a Nerf gun injury in a pediatric patient
Author:
Angela M. Lin O.D.
Pediatric Optometry Resident
Akron Children’s Hospital, Ohio State University
Abstract:
Background: Ocular trauma is one of the most common injuries seen in children, primarily males. One of the most common causes is high velocity projectiles. Ocular trauma may lead to various complications including iritis, hyphema, angle recession, and IOP changes. These complications can be successfully managed in outpatient clinics with activity restrictions, topical steroids, and cycloplegics. While they can be self-limiting, careful monitoring and adjusting of treatment based on findings is critical to avoid long-term consequences.
Case Presentation: A 15-year-old Caucasian male was referred from the ED after being shot directly by a rubber Nerf dart in the right eye. The ED noted a hyphema and the patient was prescribed PredForte (PF) and Atropine. Medical history was unremarkable; ocular history included previous eye surgery for exotropia.
The patient presented to clinic with eye pain, photosensitivity, and blur OD. Entering DVA was 20/25 OD, 20/20 OS. The patient’s EOMs, CFVF, IOP (17/16mmHg; OD, OS) were normal. The right pupil was pharmacologically dilated with Atropine, but reverse SLT confirmed no APD.
External examination was unremarkable. Anterior segment showed corneal edema, a small epithelial defect, 4+ cells, 1+ flare and 0.25mm layered hyphema inferiorly. DFE was unremarkable. Due to the hyphema and significant iritis, PF was increased to q2h, atropine dose was unchanged. The patient was instructed to sleep elevated with a fox shield and avoid strenuous activities to prevent rebleeds.
The patient returned 4 days later: VA reduction, edema, epithelial defect, and hyphema were resolved. However, there were persistent 4+ cells and elevated IOP (38/19mmHg OD/OS). Cosopt BID was added.
The patient returned for a series of appointments throughout the following weeks. There was little improvement in cells and pressures remained elevated. Angle recession was suspected and gonioscopy was performed revealing a wider CB inferiorly. The patient was tapered off topical steroids and started on oral Prednisolone and Diamox due to suspicion of angle recession causing the increased IOP.
Conclusion: Ocular trauma requires close follow up and management until resolution. Traumatic iritis should be managed aggressively. Any complex cases of persistent uveitis with chronically increased IOP may be challenging to manage. Careful investigation of the etiology of increased IOP is required and the optometrist may need to balance treatment and management of iritis and elevated IOP. This case emphasizes the greater need for eye protection when using projectiles due to severe ocular injuries that can occur.
6
Title: Pseudo-Foster Kennedy Syndrome following Nonarteric Ischemic Optic Neuropathy and Intraoperative Posterior Ischemic Optic Neuropathy Induced Atrophy
Author: Rochelle Toulabi
Abstract:
Background: The purpose of this case report is to describe a presentation of bilateral sequential NAION. NAION is the most common type of optic neuropathy in patients over the age of 50. Systemic risk factors identified to be associated with the development of NAION include: hypertension, hypercholesterolemia, diabetes mellitus, cardio- and cerebrovascular disease, smoking, use of PDE5 inhibitors, and obstructive sleep apnea. Anatomical risk factors, coined a “disc at risk”, include a small cup-to-disc ratio, general crowding of the nerve, and optic nerve drusen. While the pathogenesis of NAION is not fully understood, the theory is that the optic nerve is not sufficiently perfused by the short posterior ciliary arteries as it passes through the scleral canal, leading to ischemia, edema, and subsequent apoptosis of the nerve fibers. Most commonly, the superior RNFL is impacted resulting in an inferior altitudinal defect. Patients will complain of sudden, painless, monocular vision loss and importantly do not exhibit any systemic symptoms consistent with arteritic ischemic optic neuropathy. In some cases, optic atrophy of the fellow eye may be present in absence of a space-occupying lesion. Bilateral sequential NAION is a clinical diagnosis that can be made in-office.
Case Presentation: A 57-year-old white female with diabetes and uncontrolled obstructive sleep apnea presented to Cincinnati Eye Institute in July of 2023. History includes complete loss of vision OS upon waking from cardiac surgery. One year later, the patient newly complained of a veil in the vision of her right eye gradually worsening over one week. Upon examination, the patient’s vision was 20/40 OD, with segmental disc edema, a corresponding inferior nasal defect on HVF 24-2, scattered dot hemes consistent with mild non-proliferative diabetic retinopathy, a bilateral “disc-at-risk” appearance, and retinal hemorrhage near the nerve in question. Exam of OS exhibited hand motion acuity, a pale, atrophic nerve appearance, and scattered dot blot hemes without macular edema.
Conclusion: NAION is the most common optic neuropathy in adults over the age of 50. Its pathophysiology is not fully understood. This unique case demonstrates an acute ischemic optic neuropathy of one eye with simultaneous optic atrophy of the fellow eye consistent with diagnosis of bilateral sequential NAION.
7
Title: Severe Glaucoma Secondary to Iridocorneal Endothelial Syndrome
Author: Erin E Seymour, OD; Cincinnati Eye Institute; The Ohio State University
Abstract:
Background: Iridocorneal endothelial (ICE) syndrome is a progressive disease process in which
corneal endothelial cells develop proliferative and migratory characteristics similar to epithelial
cells. The migration of these abnormal cells in the anterior chamber forms a membrane with
contractile properties affecting the cornea, iris, and iridocorneal angle. Corneal changes include
edema and a classic “hammered silver” appearance of the endothelium. Iris anomalies range
widely from correctopia to atrophy. Peripheral anterior synechiae (PAS) form in the iridocorneal
angle with risk for secondary glaucoma due to synechial angle closure. Clinical variations of ICE
syndrome are categorized mainly by the type of iris changes. Risks for vision loss related to ICE
syndrome are corneal decompensation and secondary glaucoma. Treatment for glaucoma due
to ICE sydrome can be challenging and nuanced, both clinically and surgically.
Case Presentation: A 64 year old East Asian woman presented to the Cincinnati Eye Institute in July 2023 for a self-referred glaucoma evaluation. The patient reported having undergone a
trabeculectomy OS in India in January 2023 for elevated pressure OS. The patient was not on
topical therapy at presentation. The patient complained of difficulty seeing faces OS.
At initial presentation, acuity was 20/20 OD, 20/40 OS. IOP was 22 mmHg OD and 42
mmHg OS. Entrance testing showed (+)APD OS, unable to perform CVF or motility testing OS.
Anterior exam showed corneal endothelial changes OS and abnormal iris appearance OS
including correctopia, inferior nodules and membrane, and patent superior PI. Gonioscopy
showed angle open to trabecular meshwork OS with sectoral PAS, moderate pigment, and fine
membrane spanning the angle. Fundus exam showed asymmetric optic nerve cupping: 0.4 CD
OD, 0.95 CD OS with complete loss of rim tissue. Both 24-2 and 10-2 visual field testing showed dense, diffuse depression OS with a small area of fixation spared. Optic nerve OCT showed diffuse RNFL thinning OS.
Over the course of three visits, the patient was started on topical hypotensive therapy including latanoprost OU, brimonidine-timolol OS, and dorzolamide OS. Despite failed trabeculectomy and membrane spanning the trabecular meshwork, the patient responded very well to medical treatment, with IOPs of 19 OD, 10 OS about one month from initial presentation.
Conclusion: ICE syndrome is a condition in which irregular, migratory corneal endothelial cells form a
membrane extending through the anterior chamber and iris. ICE syndrome manifests in a
spectrum of disease presentations including corneal decompensation, iris abnormailities, PAS,
and secondary glaucoma.
8
Title: Connecting the Dots: Diagnosing Multiple Evanescent White Dot Syndrome
Author: Phadra Lipsey. OD
Abstract:
Background: Multiple Evanescent White Dot Syndrome (MEWDS) is a self-limiting posterior uveitis from idiopathic inflammation of the outer retina, photoreceptors, and retinal pigment epithelium. The condition most commonly affects healthy, young women. In approximately half of cases, ocular symptoms are preceded by a viral prodrome. This condition typically presents as a unilateral episode; however, bilateral and recurrent cases have been documented. Upon retinal examination, multiple white dots can be observed scattered throughout the posterior pole and peripheral retina. Furthermore, the fovea may take on a granular appearance, and there may be a mild vitritis. Although MEWDS may cause patients to present with concerning new symptoms, such as blurry vision, photopsia, or scotoma, the condition typically resolves in two months without intervention.
Case Presentation: A twenty-six-year-old Caucasian woman presented to the urgent care clinic with complaints of mild blur and floaters in the left eye for two weeks. The patient’s entering visual acuity was 20/20 OD and 20/25+1 OS. The anterior segment examination was unremarkable with no marked injection or anterior chamber reaction. In the left eye, there was rare anterior vitreous cell and numerous small, white lesions outside the macula and throughout the peripheral retina. Optical coherence tomography showed disruption of the ellipsoid zone, or IS/OS junction, in the areas of the retinal lesions. Fundus autofluorescence showed hyperautofluorescence in the areas of the white dots, and fluorescein angiography showed early hyperfluorescence and late staining with a wreath-like pattern. All the data pointed to a diagnosis of MEWDS. The patient was educated that the condition could be monitored with resolution likely in six to nine weeks and advised to return if symptoms worsened.
Conclusion: Although there is no treatment necessary for MEWDS, diagnosing the condition and knowing its prognosis is important for patient management. Distinguishing between various white dot syndromes has become easier using technology such as optical coherence tomography, autofluorescence and fluorescein angiography.
9
Title: Acute Myeloid Leukemic-Associated Retinopathy
Author: Rachel Mathie, OD
Louis Stokes Cleveland VAMC
The Ohio State University College of Optometry
Abstract:
Background: Myelodysplastic Syndromes (MDS) define a large group of conditions characterized by abnormal bone marrow function, leading to subsequent cytopenias and blood dysplasias. It is estimated that about 30% of individuals with MDS will convert to malignancy in the form of Acute Myeloid Leukemia (AML). AML has the potential to affect many organs including the eye, and about a third of these patients develop ocular involvement. The purpose of this case report is to review various ocular manifestations of AML, including those most common and rare, as well as proper management of these patients.
Case Presentation: A 65-year-old white male was urgently referred to the clinic for new red floaters in his left eye. The patient was established in the clinic and had a fairly unremarkable ocular history. His medical history was remarkable for recent conversion from MDS to AML four months prior with subsequent chemotherapy treatment. Entrance testing was normal, and entering acuities were 20/20 in the right eye, 20/30- in the left without improvement on pinhole. Anterior segment was unremarkable. Dilated fundus exam revealed a small blot heme 1 disc diameter superior to the optic nerve in the right eye. Left eye revealed few blot hemes nasal to the nerve, a dense parafoveal Roth spot, and a posterior vitreous detachment with overlying vitreous hemorrhage extending inferior beyond the posterior pole. OCT of the macula proved no presence of intraretinal or subretinal fluid. Chair-side consultation from the retinal ophthalmologist confirmed no retinal breaks or tears. The patient was diagnosed with a hemorrhagic posterior vitreous detachment in the left eye with leukemic-associated retinopathy in both eyes. Per ophthalmology, there was no indication to treat from an ocular perspective, but to follow up with dilation in one week.
Conclusion: Leukemic-associated retinopathy is a very common complication of individuals diagnosed with AML, as 1 in 3 will have ocular complications, with up to 90% of individuals having ocular complications of the posterior segment on fundus exam at some point during their disease course. There is typically no direct treatment for leukemic-associated retinopathy, as the mainstay of treatment is ongoing oncological care to reduce disease burden.
10
Title: Clinical Evaluation of Vitreous Hemorrhage – A Field Guide for the O.D.
Author: Dr. Ashley Marshall Walker
Cincinnati VAMC
Abstract:
Background: Vitreous hemorrhage can be a causes for acute vision loss. While clinical signs are often conspicuous, the underlying etiology can remain more elusive. The purpose of this case report is to guide the clinician through the evaluation and differential diagnosis of vitreous hemorrhage.
Case Presentation: A 70-year-old White male, with a history of mild NPDR, reports with a sudden onset of shadows and foggy vision in the right eye. The patient states that five days ago he noted cloudy vision followed by a rush of floaters which he described as “spider webs”. The last A1C and fasting glucose were 8.1% and 187. The patient’s diabetes was controlled with insulin only. Entering acuity was 20/40 OD and 20/20 OS. Visual fields by confrontation showed constriction superior temporally OD and were full elsewhere. All other externals were unremarkable. Dilated peripheral fundus exam showed a 2DD vitreous heme inferiorly. Fundus photos were obscured by hemorrhage. Macular OCT showed a normal foveal contour OU. OCT of the right optic nerve showed a PVD and the B-scan shows no holes, tears or breaks.
The top four differential caused of a vitreous heme would be proliferative diabetic retinopathy, posterior vitreous detachment, retinal vein occlusion, and trauma. With proliferative diabetic retinopathy, the formation of new leaky blood vessel can lead to traction of the posterior hyaloid face or contraction of new fibrous material can lead to increased pulling on these areas of neovascularization which can eventually led to a vitreous hemorrhage. Laser photocoagulation would be the primary treatment for PDR once the view of the fundus is clear. With posterior vitreous detachments, a vitreous hemorrhage can form when the vitreous pulls away from the neurosensory retina and a blood vessel is nicked along the way. In most cases we would monitor the patient in four weeks for any RD, breaks or holes but if the vitreous heme doesn’t resolve on its own and the fundus view remains hazy, a pars plana vitrectomy may be performed.
Conclusion: Knowing the underlying cause of a vitreous heme can guide your treatment plan and patient education. Early conservative treatment with head elevation may aid in visual recovery and improved funduscopic evaluation.
11
Title: Corneal Abrasion in a Patient with Risk Factors for Neurotrophic Keratopathy
Author: Joshua Canavan, OD, MS
Affiliations: Cincinnati Eye Institute, The Ohio State University College of Optometry
Abstract:
Background: Neurotrophic keratopathy (NK) is characterized by corneal hypoesthesia due to loss of trigeminal nerve innervation, potentially resulting in complete corneal anesthesia. NK can be diagnosed with corneal sensitivity testing and it is indicated by corneal defects that do not seem to cause patients pain or heal well. Desensitized corneas experience poor re-epithelialization and can consequently develop perforating ulcers if left unmanaged. A leading cause of NK is Herpes Simplex Keratitis (HSK), and individuals with diabetes are at greater risk for impaired trigeminal innervation.
Case Presentation: A 77-year-old long-term diabetic female called the Cincinnati Eye Institute in August 2023 complaining of excessive tearing and light sensitivity in her left eye lasting two weeks. When asked, she denied any pain. She was seen urgently based on a history of severe glaucoma with a trabeculectomy and recurrent HSK in the left eye. Entering corrected visual acuity was 20/400 OS and there was no improvement in vision OS with a pinhole. She reported being unsure if there was any change in her vision over the last two weeks but had been correctable to 20/30 OS when last seen in May 2023. Examination of the cornea revealed a 4.5×2.5mm corneal abrasion with surrounding stromal edema and no underlying infiltrate. Several keratic precipitates were also noted on the endothelium. A bandage contact lens was placed on the eye, and silicone plugs were inserted into the upper and lower puncta. The patient was prescribed moxifloxacin every two hours and was advised to continue using her glaucoma medications as directed. Her long term once daily dose of 500 mg valacyclovir was increased to 1000 mg twice a day. Upon returning to clinic two days later, the patient reported less light sensitivity, but there was no measurable improvement in the vision of her left eye. Upon examination, the epithelial defect appeared to be mostly resolved, but the stromal haze and keratic precipitates persisted. The bandage contact lens and punctal plugs were kept in place, and dosing of moxifloxacin was decreased to four times a day. A once-daily drop of prednisolone acetate was also added to her regimen. The patient was advised to follow up in two weeks to check her ocular surface.
Conclusion: HSK and diabetes are both risk factors for loss of corneal sensitivity. Vague visual complaints should be taken seriously in patients with this comorbidity since a neurotrophic cornea can experience irreparable harm if not managed in a timely manner.
12
Title: tPA Saves the Day – a Panuveitis Case
Author: Shail Gajjar, OD, MS
Abstract:
Background: Ocular inflammation anteriorly and posteriorly with no site of primary involvement may be labeled as panuveitis.1 Conditions which can cause this include: Vogt-Koyangi-Harada Syndrome, sarcoidosis, tuberculosis, Behcet’s Disease, or syphilis. Careful slit lamp and fundus examination, appropriate ancillary testing (optical coherence tomography, indocyanine green angiography, fluorescein angiography, etc.), and oftentimes lab testing are necessary to determine the cause. Both topical and oral steroids are mainstay treatments, though, definitive treatment requires management of the underlying systemic condition. This poster discusses a case of recurrent panuveitis wherein intracameral injection of tissue plasminogen activator was used to permit fundoscopy, and other ancillary testing was crucial to steer management.
Case Presentation: A 30 year old Asian female was referred to the Ohio State University (OSU) Wexner Medical Center for a case of bilateral panuveitis. Indocyanine green angiography was hazy OD, and hypolucent spots implicative of sarcoidosis were noted in the left eye (OS). Corticosteroids were started, and the patient was referred for bloodwork to screen for tuberculosis, syphilis, and measure levels of angiotensin-converting enzyme. All three tests were unremarkable. 4 months later, the patient presented to Columbus Ophthalmology Associates with best-corrected visual acuity of 20/400 OD, 20/25+ OS. Slit lamp examination showed stromal haze, 4+ cell with dense flare in the anterior chamber, and dense fibrin on the anterior capsule OD, and normal findings OS. Prednisolone acetate was prescribed, to be instilled hourly, and 1 drop of 1% atropine was instilled in office OD. The patient was urgently referred to OSU Wexner Medical Center. Here, best corrected acuity was hand motion OD. Tissue plasminogen activator was injected intracamerally, after which, acuity improved from hand motion to 20/80 OD. Corneal edema, a dense 4+ posterior subcapsular cataract, and 1+ vitreous cells were noted OD, and normal findings OS. The patient was prescribed 60 mg oral prednisone once daily, and a chest x-ray was ordered. About 2 weeks later, acuity improved further to 20/70-1 OD, cornea was clear, the cataract was stable OD, and the OS remained normal. A steroid taper was initiated and the chest x-ray was reordered.
Conclusion: A thorough review of systems, observant slit lamp and dilated fundus examination, pertinent ancillary testing (indocyanine green angiography, optical coherence tomography, etc.), and pointed blood work can help determine the etiology.2 Prompt treatment with topical and oral corticosteroids is important to control inflammation. If the inflammatory process is non-infectious, immunosuppressants or intraocular agents may be considered.2,3
13
Title: Unilateral Central Serous Chorioretinopathy Secondary to Obstructive Sleep Apnea
Author: Connor Monaghan
Cleveland VAMC
Abstract:
Background: Central serous chorioretinopathy (CSCR) is a branch of pachychoroid conditions characterized by subretinal fluid accumulation, usually in the presence of an otherwise unremarkable fundus. Resolution of fluid occurs generally within the first six months of onset without treatment. If fluid persists, anti-vascular endothelial growth factor (VEGF) injections, photodynamic therapy (PDT), or oral eplerenone may be indicated. Typically, young adult males with certain risk factors are affected — stress, type A personality, and corticosteroid use. But other systemic conditions like obstructive sleep apnea (OSA) could also increase risk, specifically through vascular endothelial dysfunction from transient asphyxia, which can lead to choroidal hyperpermeability. This case investigates a unilateral presentation of CSCR with a possible correlation to preexisting untreated OSA.
Case Presentation: A 38-year-old Caucasian male presented to the clinic in July 2023 complaining of central blur of both eyes. Onset was a few weeks prior when he started using his continuous positive airway pressure (CPAP) machine for treatment of OSA. Medical history was positive for OSA, environmental allergies, and chronic post-traumatic stress disorder (PTSD). The patient had also been using an intranasal form of budesonide, a corticosteroid targeting allergic and sinus inflammation.
Best corrected visual acuity was 20/20-1 in the right eye, 20/20-2 in the left eye with refraction exhibiting a small hyperopic shift in both eyes. Anterior segment health was unremarkable. Posterior segment evaluation showed a small, foveal pigment epithelial detachment (PED) in the left eye, while the right eye showed no visible maculopathy. Macular optical coherence tomography (OCT) revealed a small, subfoveal serous PED in the left eye with adjacent retinal pigmented epithelium (RPE) disruption. The choroidal depth of the left eye was measured at 422 um, which is thicker than average. The right eye showed no maculopathy on OCT.
It was recommended the patient discontinue budesonide in order to evaluate for resolution of CSCR of the left eye. He was advised to continue using his CPAP nightly. The patient was referred to the retina clinic for a follow-up appointment to re-evaluate the condition and assess the need for treatment versus monitoring.
Conclusion: Most CSCR cases should resolve with time or through elimination of the aggravating factors. Obstructive sleep apnea, while understated in literature, could demonstrate the ability to be just as causative as more known factors. Though more research is needed, initiating treatment of OSA via CPAP could be effective in resolving subretinal fluid without resorting to more invasive treatments.
14
Title: Visual Outcomes and Management of Chronic Central Serous Chorioretinopathy
Author: Karissa Newsom, OD
Cincinnati Veterans Affairs Eye Clinic/The Ohio State University
Abstract:
Background: Central serous chorioretinopathy (CSCR) is characterized by serous neurosensory retinal detachment, usually accompanied by retinal pigment epithelial detachment (PED). Acute CSCR usually resolves within the first 3 months with good visual prognosis. However, about 5% of cases can become chronic, leading to photoreceptor and RPE damage and a higher burden of vision loss.
Case Presentation: A 61-year-old male patient presents for dilated fundus exam and OCT to monitor chronic central serous chorioretinopathy in both eyes.
The patient was diagnosed incidentally with bilateral CSCR when presenting for routine care in March 2017. At this visit, the patient’s best corrected visual acuities were 20/20 OU. Dilated fundus exam showed multiple PEDs in both eyes with the left eye also showing associated subretinal fluid. The patient was referred to retina clinic.
The patient received a series of three intravitreal injections of aflibercept OS between April and August 2017. Due to the good response after the initial series of anti-VEGF, retina continued with observation every three months. It was documented that the patient had been receiving concurrent steroid injections for his back, and once these were discontinued, the retina findings stabilized to multiple PEDs without subretinal fluid. He was subsequently observed quarterly.
The patient was lost to follow up but returned to optometry in December 2022. The patient had remained asymptomatic with BCVA of 20/20 OU. The macula OCT revealed stable serous PEDs with a small area of schitic retinal edema nasally OD and stable large serous PEDs with improved intraretinal fluid and an ERM OS. The patient was to be monitored in 6 months for a repeat macula OCT with dilation.
At the 6 month follow up in July 2023, the patient reported stable vision. Entering uncorrected acuities were 20/20-3 OD and 20/25+2 OS. The macula OCT was stable to previous with large juxtafoveal serous PED and scattered PEDs, with stable schisis nasally OD, and stable large serous PEDs OS. Fundus photos revealed scattered RPE changes OD and a large area of RPE disruption/whitening superior temporal OS. Observation at 6-month interval was continued.
Conclusion: Several treatment options exist for the treatment of chronic CSCR including photodynamic therapy, oral aldosterone antagonism, subthreshold multifocal laser, and anti-VEGF injection. Chronic CSCR accounts for a much larger share of long-term visual impairment than acute CSCR, and there are several opportunities to optimize management strategies for these patients.
15
Title: Calcific Retinal Emboli
Author: Elizabeth Stern-Green, OD, MS
Louis Stokes Cleveland VAMC
The Ohio State University College of Optometry
Abstract:
Background: Retinal emboli are organic objects of varying origin that can get lodged in retinal arteries, causing partial or full blockages. This can lead to central or branched retinal artery occlusions, which in turn cuts blood supply off to the downstream retina and subsequent vision loss. If the embolus had gone to the brain and not the eye, this could result in a cerebrovascular incident (CVA), or more commonly known as a stroke. Calcific emboli are dull, white, chalky emboli that typically emanate from calcification of heart valves. The purpose of this case report is to describe a patient with multiple calcific retinal emboli and discuss how the different types of retinal emboli that can affect the eye.
Case Presentation: A 87-year-old black male presents to our clinic with complaints fluctuating vision when he rubs and blinks his eyes. The patient was not new to the eye clinic and had history of amaurosis fugax, hollenhorst plaques OD/OS, pseudophakia, dry eye, floppy lid syndrome, and allergic conjunctivitis. Both eyes were correctable to 20/20 and all entrance tests including pupils and confrontation visual fields were normal. An anterior segment exam revealed MGD, reduced TBUT, and floppy eyelids. A dilated fundus exam revealed a normal posterior pole of the right eye with only mild A/V crossing changes. Evaluation of the left eye revealed two white, square, chalky retinal emboli in the inferior arcades. The patient symptoms of amaurosis fugax, TIA, or stroke. The patient had a recent echocardiogram and was being monitored by a cardiologist at the VA. Once educated on the signs and symptoms of a stroke and sudden vision changes, he was put on a 6-month recall to optometry to monitor with DFE or sooner with new vision changes.
Conclusion: Calcific emboli are blockages that can occur in the eye. They usually come from the valves of the heart and should therefore be followed up with an echocardiogram and a referred to a cardiologist. As with any retinal emboli, calcific emboli can put the patient at risk for vision loss or a stroke and should be monitored with DFE to make sure the emboli do not fully block an artery leading to vision loss.
16
Title: Management of ocular manifestations of empty sella syndrome
Author: Caroline Obermeier, OD
Cleveland VAMC
Abstract:
Background: The purpose of this case report is to describe the management of ocular complications secondary to Empty Sella Syndrome (ESS). This rare condition is pathognomonic
for pituitary gland flattening or shrinking within the Sella turcica, resulting in hormonal imbalances, headaches, and changes in vision. ESS is not life threatening and is treated primarily by symptom management. It is four times more common in females than in males, and commonly occurs between age 30 and 40. The primary role of the optometrist in managing ESS is ruling out papilledema and the presence of a pituitary lesion. Fundoscopic examination of the optic nerve, multimodal imaging (MMI) via en face imaging (EFI) and enhanced-depth imaging ocular coherence tomography (EDI-OCT), automated visual field (VF) testing, and neuroimaging of the head are crucial in these cases.
Case Presentation: A 53-year-old Caucasian female presented to the eye clinic with a complaint of longstanding intermittent peripheral visual disturbances, common intractable migraine headache without status migrainosus and a history of a recent incidental finding of empty Sella on Computerized Tomography (CT). Examination revealed 20/20 best-spectacle corrected visual acuity (VA) in each eye, scattered Humphrey visual field defects OS>OD without enlarged blind spot or bitemporal appearance, healthy appearing optic nerves with congenital nasal heaping of the optic nerve heads (ONH), and normal RNFL and absence of M sign, lazy V sign, and optic disc drusen on MMI. Magnetic resonance imaging (MRI) of the orbit with and without contrast confirmed ESS with a cerebrospinal fluid (CSF) leak and absence of pituitary adenoma. Laboratory hormonal imbalance workup via follicle stimulating hormone (FSH) and luteinizing hormone (LH) labs was subnormal, supporting ESS, and negating an abnormal hypersecreting pituitary adenoma. No surgical intervention was indicated for the empty Sella, and Topamax and Sumatriptan were initiated by the consulted Neurology section resulting in successful migraine headache symptomatic management.
Conclusion: Empty Sella Syndrome is a rare condition that can result in unspecified vision changes and papilledema, warranting dilating fundus examination, visual field testing, MMI, neuroimaging, and coordination of care with neurology.
17
Title: In the Blink of an Eye: Understanding and Overcoming Benign Essential Blepharospasm
Author: Matthew McGee, OD and Chantelle Mundy, OD FAAO FSLS
The Ohio State University Havener Eye Institute Department of Ophthalmology and Visual Sciences
Abstract:
Background: Benign essential blepharospasm is a bilateral episodic, involuntary contraction of the orbicularis oculi that is not associated with facial weakness. The onset of the condition occurs in the 6th or 7th decade of life and has a predilection for females. This condition is idiopathic. Patients present with a history of increased blink rate and forced eyelid closure causing ocular irritation. This poster aims to explore the identification and management of benign essential blepharospasm.
Case Presentation: A 79-year-old White Female presented to the Havener Eye Institute with symptoms of severe dry eye. Her dry eye therapies include scleral lenses, nighttime ointment, and punctal plugs, as well as copious preservative-free artificial tears. She also uses a warm compress and lid wipes four times a day. She has tried and failed to find relief with autologous serum tears, LipiFlow, Restasis, Xiidra, Tyrvaya, fluorometholone suspension drops, and Maxitrol ointment. Additionally, she underwent lab testing which revealed that she was rheumatoid factor negative, cyclic citrullinated peptide negative, and Sjogren’s negative. She was then evaluated for a lacrimal gland transplant and presented seeking alternate therapeutic options.
Entering visual acuity was 20/40-2 OD and 20/25+2 OS with scleral lenses. Pupils, visual fields, and extraocular muscle movements were within normal limits. Slit lamp examination revealed 1+ conjunctival injection and 2-3+ diffuse punctate epithelial erosions OD and OS. All other anterior segment findings were within normal limits. However, sporadic, and excessive blinking noted on exam warranted a referral to the oculoplastic service. She was then diagnosed with benign essential blepharospasm and elected to receive botulinum toxin A, 2.5u/0.1cc, injections into her orbicularis oculi.
The patient self-reported an immediate improvement in her blink and ocular comfort after botulinum toxin injections. However, she has persistent dry eye symptoms. She has started Intense Pulse Light (IPL) therapy and was re-fit into an 18.0 diameter scleral lenses that yielded a BCVA of 20/25-2 OD and 20/20 OS. She has currently undergone 5 IPL treatments and has yet to undergo repeat botulinum toxin A injections.
Conclusion: Patients with benign essential blepharospasm may present with ocular irritation and concomitant dry eye symptoms. High dose botulinum toxin A is the primary treatment for benign essential blepharospasm while dry eye disease has a wide range of potential therapies, including scleral lenses. Therefore, it is imperative to have a multidisciplinary approach for patients suffering from this condition to provide optimal treatment success.
18
Title: Carotid Artery Disease in the Retina – Early Detection, Prevention, & Management
Author: Keerthana Kumar, O.D.
Cincinnati Veterans Affairs Eye Center / The Ohio State University
Abstract:
Background: Hollenhorst plaques are cholesterol emboli that originate from within ipsilateral carotid arteries and become lodged along arteriole bifurcations. The refractile nature of these plaques give them a unique appearance upon fundus examination, although patients are usually asymptomatic due to adequate vascular perfusion throughout the vessels around the emboli. The symptomatic presence of these emboli warrants a full work-up for carotid artery disease including a carotid doppler, cholesterol panels, and coordination of care with the patient’s primary care provider to provide early surgical intervention when needed to prevent more serious complications such as cerebrovascular accidents (CVA) or transient ischemic attacks (TIA)s.
Case Presentation: A 75-year-old white male presents for a refraction after cataract extraction 1 month prior. Medical history includes hyperlipidemia, GERD, varicose veins, gout, acute bronchitis, calculus of kidney, obesity, partial retinal arterial occlusion, cerebral infarction, history of transient ischemic attack due to embolism, peripheral arterial occlusive disease, COPD, and heart failure.
Patient reports cholesterol is currently under control and previously has a history of 4 long-standing hollenhorst plaques in the left eye since 2015 with 2 new emergent plaques noted in 2020. Initial carotid duplex testing in 2015 revealed 16-49% stenosis of the left internal carotid artery (ICA) and 1-15% stenosis of the right ICA. Subsequent carotid duplex testing revealed further stenosis of the right ICA (16-49% in 2018) and left ICA (50-79% in 2018, 50-69% 2020, and < 50% in 2022) with stable atherosclerotic plaques. Cholesterol work-up revealed elevated triglyceride levels of 309 mg/dL (2015), 583 mg/dL (2017), 718 mg/dL (2018), and back to 127 mg/dL (2023). Patient reports regularly seeing nephrologist and primary care doctors to keep cholesterol under control.
Conclusion: Coordination of care with primary care providers is essential in preventing new developments in patients with comorbidities. In the event of discovering plaques and emboli upon fundus examination, optometrists must spring into action by educating their patients on vascular changes noted during exams, alert them to the signs and symptoms of strokes, promptly order additional lab work and testing such as carotid duplexes and lipid panels, and touch base with other healthcare providers so surgical interventions such as carotid endarterectomies can be provided in a timely fashion. Monitoring patients with carotid artery disease at regular intervals is imperative for comprehensive care, as evidenced by the increasing amount of stenosis observed in this patient and the bilateral nature of worsening vascular conditions.
19
Title: Diagnosis and Management of Branch Retinal Artery Occlusions: A Case Discussion
Author: Cole W. Jordan, O.D.
Michigan College of Optometry
John D. Dingell VAMC
Abstract:
Background: Branch Retinal Artery Occlusion (BRAO) is an urgent finding that involves an arterial blockage of a central retinal artery tributary, resulting in retinal ischemia to the corresponding area of retina. The most common source of occlusion is a thromboembolism, usually associated with cardiovascular disease. Emboli are composed of cholesterol, calcium, and platelet-fibrin. A BRAO needs urgent attention for the patient could experience permanent vision loss if the ischemia lasts longer than 100 minutes. If untreated, patients will experience permanent visual field defects. Treatment for BRAO has a relatively low efficacy. The current treatment involves lowering the eye pressure via drops or paracentesis, ocular massage, and hyperbaric oxygen therapy. However, a new treatment method is being tested in small patient populations involving intravenous prostaglandin analogs which has shown early signs of success.
Case Presentation: A 75 year old patient presented to a retina specialist with complaints of vision changes in the right eye that began 1-2 weeks ago. He noticed a “shade” coming down over his right eye and noticed a dot in his vision. A hollenhorst plaque was found on DFE with corresponding ischemia of the retina. The retina specialist sent him to the ER for a full stroke workup. Testing was significant for two recent strokes likely secondary to uncontrolled blood pressure and elevated cholesterol. Carotid dopplers showed significant stenosis. Medication dosing was increased and blood thinners were added to the treatment regimen.
Conclusion: Patient presented to the optometry clinic 5 months later for his first comprehensive exam since the stroke. Patient’s medical history is significant for hypertension, hypothyroidism, and hypercholesterolism. The patient had a BCVA of 20/25 OD/OS, severely reduced confrontation visual fields superiorly OD and a small hollenhorst plaque within the inferior artery leaving the optic nerve head; the rest of the artery was sclerosed. HVF 30-2 results show an absolute loss of the superior half of the patient’s field OD. Treatment was not indicated at this time due to the longevity of the plaque and the sclerosed vessels. At this point, the patient still believed his vision would recover, which made patient education crucial. Although the patient did not leave the office with improved vision or widened peripheral vision, he was now able to fully understand what happened to his eyes and is now making the proper adjustments in his daily life to better cope with his visual loss.
20
Title: Retinal Arterial Macroaneurysms
Author: Aishu Pillai
Abstract:
Background: Retinal artery macroaneurysm (RAM) is an acquired, focal dilation of retinal arterial branches. The disease process initiates with weakness of the arteriolar wall leading to dilation. This can rupture causing hemorrhage and exudation of protein- and lipid-rich exudates in the sub-, intra-, pre-retinal, or vitreal spaces. RAM has three classifications. Quiescent RAMs are asymptomatic and the hemorrhage or exudate measures less than one disc diameter (DD). Hemorrhagic RAMs are characterized by acute vision loss caused by a hemorrhage greater than one DD. Exudative RAMs present as gradually worsening acuity with exudation greater than one DD. RAMs are commonly singular and unilateral. They are often seen in elderly females and associated with hypertension, arteriosclerosis, and abnormal lipid levels. Diagnosis is made via internal exam, Fluorescein Angiography (FA), and/or Optical Coherence Tomography (OCT). Treatment can be observation, laser photocoagulation, vitrectomy, or anti-VEGF depending on the individual case.
Case Presentation: A 59-year-old African American male presents with “wavy” vision in his left eye that began four days prior. He has long standing floaters. He reports tingling of extremities and headaches that started concurrently with his visual symptoms. He denies flashes, eye pain, and diplopia. Medical history includes hypertension and hyperlipidemia. Entering acuities were 20/40 PH 20/20-2 OD and 20/60+2 PH NI OS. EOMs and confrontations were WNL OU. He had a 1+ APD OS. Anterior segment evaluation was unremarkable. IOPs were 22 OU. Posterior segment evaluation revealed a macroaneurysm within the inferior temporal arcade with hard exudates surrounding OS. Hard exudates were found superior to the optic nerve OS. C/D ratios were 0.50H/0.55V OD, 0.45 OS. There were dot-blot hemes within the inferior arcade, superior to the optic nerve, and superior temporal midperiphery OD. The vitreous was clear and quiet OD, and a past vitreous heme in the inferior temporal periphery OS. Vessels had arteriolar attenuation, arteriovenous crossing changes, and tortuosity OU. OCT-Mac depicted intraretinal fluid (IRF) nasal to the fovea OD and IRF inferior nasal to the fovea with surrounding and interspersed hard exudates OS. OCT-RNFL revealed no thinning OD and superior temporal thinning and inferior thickening OS. The patient was referred to urgent care following this appointment due to elevated blood pressure readings in-office, retinal findings, and stroke-like symptoms. He was scheduled with Retina Clinic within a week for further evaluation.
Conclusion: Identifying retinal artery macroaneurysm is crucial, both from an ocular and systemic standpoint, to save a patient’s vision and potentially their life.
21
Title: Orbital Myositis Diagnosis and Management in a Pediatric Patient
Authors: Emily Hackbarth, OD, Veeral S. Shah, MD, Melissa Rice OD, FAAO
Abstract:
Background: The purpose of this case report is to describe diagnosis and management of orbital myositis (OM) in a pediatric patient. OM is most commonly acute and idiopathic in origin. Signs and symptoms may include acute onset of orbital pain with exacerbation on eye movement, conjunctival chemosis or injection, diplopia, or restriction/paresis of the affected muscle on EOMs. Females are affected more than men in a 2:1 ratio. OM can occur at any age; however, it is most often seen in young adults mean age 37 years. Systemic corticosteroids are first line treatment for orbital inflammatory disorders. Dosing of the steroid is usually 1mg/kg/day with slow taper.
Case Presentation: A 2-year-old Caucasian male presented to CCHMC emergency department (ED) with unilateral periorbital ecchymosis, edema, subconjunctival hemorrhage, and exotropia of the right eye (OD) without history of trauma. Initial onset began three days prior with subconjunctival hemorrhage OD. The patient presented without pain. Consultation with ophthalmology occurred in the ED on the day of admission. Imaging and full lab workup was ordered to rule out malignancies such as rhabdomyosarcoma and neuroblastoma as well as any acute leukemias.
Slit lamp exam revealed medial subconjunctival hemorrhage and chemosis, dark periorbital ecchymosis of upper lid with diffuse yellow ecchymosis of upper and lower lid. CT of head/face showed enlargement of right medial rectus (RMR) with inflammatory stranding within the infraorbital fat as well as soft tissue thickening of right medial orbit. MRI of brain and orbit showed irregular enlargement of RMR extending posteriorly to the orbital apex, sparing tendinous insertion to the globe.
CT scan of chest/abdomen/pelvis were normal. Biopsy of RMR was ordered and performed given CT/MRI findings and revealed presence of eosinophils in Tenon’s capsule as well as non-specific mixed inflammatory infiltrate and edema of RMR muscle. Testing ruled out all diagnosis except orbital myositis and the patient was treated with oral prednisolone 15mg/5mL solution once daily with slow taper.
Conclusion: Orbital myositis in children is a rare and difficult diagnosis of exclusion. It is imperative to rule out malignancy in a presentation of sudden onset unilateral orbital edema or proptosis. Rhabdomyosarcoma is the most common malignant childhood orbital tumor and must be considered. Orbital myositis can be managed with oral corticosteroids, the course of treatment may be long with slow taper of the steroid. Patients should be monitored closely during steroid taper to ensure steady improvement in condition.
22
Title: Non-arteritic Anterior Ischemic Optic Neuropathy (NAION): A Case Report
Author: Pangeni, Gobinda1,2; Lemos, Elizabeth1; Staats, Julie M1
1VA Medical Center, Dayton, Ohio
2 The Ohio State University, Columbus, Ohio
Abstract:
Background: Non-arteritic Anterior Ischemic Optic Neuropathy (NAION) leads to acute, painless loss of vision in patients over the age of 50 years with no sex predilection. The pathophysiology of NAION remains uncertain but literatures suggest to vascular insufficiency in the optic nerve head supplied by the short posterior ciliary artery. Risk factors include medical conditions like diabetes, hypertension, hyperlipidemia, crowded optic disc, COVID-19, obstructive sleep apnea, glaucoma, and use of certain medications like amiodarone, phosphodiesterase-5 inhibitors and interferons. Swelling of optic nerve head (ONH) leading to acute decrease in vision acuity (VA) and visual field (VF) defects are the initial findings in NAION. There is no proven treatment for NAION. VA and VF defects may improve but with guarded prognosis.
Case Presentation: A 69-year-old Caucasian male presented for an eye consult from the emergency department one day after he woke up with “black shadow, scintillating and blue arc” in his right inferior field of vision. Patient denied eye pain, jaw claudication, scalp tenderness, fever, chills, weight loss, cat/dog scratch. Patient is treated for hyperlipidemia, hypertension, atrial fibrillation, cardiac arrythmia, erectile dysfunction. Patient is waiting on consult for sleep study. Current medications include alprostadil for erectile dysfunction and amiodarone for the atrial fibrillation. On examination, VA was 20/25 in the right eye (RE) and 20/25 in the left eye (LE), no relative afferent pupillary defect, and normal color vision. Dilated fundus exam revealed edematous superior-nasal ONH in the RE with no peripapillary hemorrhages and unremarkable LE. Optical Coherence Tomography of ONH showed retinal nerve fiber layer thickening in the RE. VF test with screening field showed inferior-temporal defect. Given the onset of symptoms, clinical findings, and negative review of system for Giant Cell Arteritis (GCA), the most likely diagnosis was NAION in the RE. Patient was advised to continue care with the cardiologist, primary care, participate in the sleep study and sent for a retinal consult.
Conclusion: Review of systems (ROS) of our patient correlate with various risk factors to develop NAION described in the literature. Even though there are no proven treatment methods for NAION, a thorough work up including ROS and possible laboratory tests are important to rule out conditions such as GCA. Vascular risk factors should be identified and controlled with the coordination of the patient’s primary care provider.
23
Title: When he stops being the Fun-gi
Author: Olivia Ruiz, OD
Abstract:
Background: Presumed ocular histoplasmosis syndrome (POHS) can cause ocular and systemic signs in the human body. In regards to ocular findings, it can present unilaterally or bilaterally. It’s an inflammation that is typically characterized as including choroidal neovascularization, mid-peripheral scars, peri-papillary atrophy, and chorioretinal scars. This condition is clinically found in patients that frequently work with birds or chicken droppings, or that live along the Mississippi and Ohio River Valleys. The fungus responsible for the ocular signs is called Histoplasma capsulatum which can be transmitted through inhaling particles of it in the air. There are multiple chorioretinal scars and no vitritis involved which can help differentiate from other inflammations found posteriorly.
Case Presentation: A 54-year-old white male initially presents to the Veteran Health Administration eye clinic in Chillicothe, OH on July 25, 2022. The patient’s best corrected acuities were 20/20 in the right eye and 20/60-2 in the left eye without any improvement with pinhole. With the use of amsler grid, the patient subjectively reported central blur and distortion of the left eye. During examination of the posterior pole and periphery, it was discovered that the patient had central elevation, macular fibrosis, and scarring from an inactive choroidal neovascular membrane in the left eye which the patient was unaware of. At the following visit on January 1st, 2023 all findings were stable, except for visual acuities of the left eye were 20/200-2 due to the patient having a difficult time using eccentric fixation. At the most recent visit on July 25, 2023, findings were stable and hadn’t progressed. The patient was scheduled to return to the clinic in 6 months for another dilation examination, OCT scans of the macula, and fundus photos to monitor further.
Conclusion: POHS typically doesn’t affect visual acuities unless there is macular involvement, so in some instances the patient isn’t aware they have inflammation happening. With this patient- that is the case. Routine examination is vital to monitor for re-occurring choroidal neovascular membranes from forming and preventing severe vision loss.
24
Title: A Case of a Rhegmatogenous Retinal Detachment and Treatment with Pneumatic Retinopexy
Authors: Daniele Ewert, OD1, 2
Julie Staats, OD1
Rebecca Diller OD, FAAO1
Veterans Affairs Medical Center, Dayton, Ohio1
The Ohio State University, Columbus, Ohio2
Abstract:
Background: A rhegmatogenous retinal detachment starts with a retinal break that allows fluid to enter the sub-retinal space resulting in the separation of the sensory retina from the retinal pigment epithelium. Visual symptoms can include flashes of light, floaters, a curtain over vision, and vision loss. Risk factors include, but are not limited to, age, male gender, myopia, cataract surgery, and ocular trauma. There are many treatment options for retinal detachments, but pneumatic retinopexy is the least invasive and has the fastest recovery. It involves injecting a gas bubble into the eye and positioning the patient, so it pushes the detached retina back into place. Then cryoretinopexy or laser retinopexy is used to seal the hole. This poster reviews the characteristics of a rhegmatogenous retinal detachment and the pneumatic retinopexy used to repair it.
Case Presentation: A 71-year-old white male complained of acute onset one day prior of a curtain appearance over half of his vision in the left eye. He denied any trauma. His ocular history included a repaired stage 3 macular hole and cataract surgery, both in the left eye and a pseudo-hole in the right eye. His medical history included type 2 diabetes, hypertension, and hyperlipidemia. Best corrected visual acuity was 20/30 OD and 20/400 OS. Confrontation visual fields were restricted nasally OS. Pupil testing revealed an afferent pupillary defect OS. Anterior segment evaluation revealed a temporal cataract incision scar and a nasal pterygium OS. Goldman applanation was performed with pressures of 15 mm Hg OD and 24 mm Hg OS. Posterior segment evaluation revealed a round retinal break in the temporal periphery associated with a retinal detachment from 2:00 to 6:30 that extending into the posterior pole and ended at the temporal fovea. OCT confirmed that the macula was still partially attached and revealed retinal elevation due to sub-retinal fluid. The patient was scheduled for a retinal detachment repair the next day with a retinal specialist. A pneumatic retinopexy was performed at this visit.
Conclusion: Proper patient selection is important for a successful pneumatic retinopexy. Patients should avoid this treatment if they have any of the following: inferior breaks, advanced glaucoma, proliferative vitreoretinopathy, aphakia, and lattice degeneration. Visual prognosis depends on the involvement of the macula. A macula-on retinal detachment requires an urgent referral for surgery whereas a macula-off retinal detachment can be repaired within a week for the best visual outcome in each case.
25
Title: Corneal Hydrops without a Decrease in Visual Acuity
Author: Megan Ingalls, O.D.
Abstract:
Background:
- 43-year-old, Black male
- CC: Acute onset, red and irritated OD
- POH: History of keratoconus OU; blunt force trauma OS in 1998; Glaucoma suspect OS
- PMH: Asthma, Seasonal Allergies
- History of scleral lens wear OU; presented with scleral lens in OS only
Case Presentation:
Pertinent Findings - Entering VA: SC HM, Pinhole 20/100 OD, CC 20/30 OS
- SLE: 3+ conjunctival injection, 4+ inferior corneal stromal edema, scattered epithelial microcysts, areas of negative staining, and diffuse corneal staining OD
- Anterior segment photodocumentation OD
Differential Diagnosis
Corneal hydrops, bullous keratopathy, keratoconjunctivitis, herpes simplex keratitis
Treatment/Management Discussion
This patient was prescribed Muro 128 ung TID and tobramycin 0.3% / dexamethasone 0.1% TID OD. During patient education, emphasis was placed on the importance of avoiding eye rubbing. At the initial follow up exam, three days later, prominent central epithelial bullae were noted OD and both the Muro 128 and the tobramycin 0.3% / dexamethasone 0.1% were increased to QID OD. Additionally, erythromycin ointment was added QHS OD. At subsequent follow up exams, every four days initially and then weekly over a six-week period, improvement in corneal edema and re-epithelialization were noted and the patient was switched from tobramycin 0.3% / dexamethasone 0.1% to prednisolone acetate 1% to begin a brief taper. Prednisolone acetate 1% was to be used QD OD for the next four days and then discontinued. At that point scleral lens wear could be resumed. Six months after, the patient returned to the clinic with a BCVA, in scleral lenses, of 20/20 OD.
Conclusion: Acute, painful, red eyes have a multitude of etiologies. In addition to a detailed slit lamp examination, a careful case history always narrows down the differential list. In this case with a history of keratoconus, a sudden reduction in vision, and the presence of significant corneal edema the diagnosis was made with relative ease. Prompt treatment can improve patient comfort and, in some cases, resolve the edema more expediently than simply monitoring the condition. Unfortunately, in many cases not only does the corneal scarring further decrease vision but necessitates surgical intervention.
26
Title: Management of Keratoconus Utilizing a Toric Central Clearance Zone in a Scleral Lens
Author: Madison Roth O.D.
Abstract:
Background: Keratoconus is a corneal ectasia defined as non-inflammatory thinning of the corneal stroma that progresses over time. This degeneration leads to an irregular corneal shape commonly characterized by protrusion of the inferior cornea which causes impairments to vision. These corneal changes result in blurry and distorted vision that is not fully correctable with traditional spectacle correction. Previously, patients with keratoconus were often treated with traditional gas permeable (GP) lenses. GP lenses are still used to mask irregular astigmatism caused by this condition. However, in the last two decades, specialty scleral lenses have become the first line of therapy for optimal visual correction in keratoconic patients. Advancements to scleral lenses, such as the ability to make quadrant specific adjustments, has allowed specialty lens practitioners to successfully fit and manage more complicated corneal degeneration cases. In this case, a toric central clearance zone (CCZ) was used to successfully fit an advanced keratoconus patient into scleral lenses.
Case Presentation: A 32-year-old Caucasian male was referred to the OSU Optometry Clinic in June 2023 for a scleral lens fitting. The patient was first diagnosed with keratoconus in 2009 at the age of eighteen with moderate progression overtime greater OD than OS. The patient was previously given spectacles and fit in soft toric and gas permeable contact lenses with mild improvement to vision with any correction modality. He has also been seen by OSU Havener Ophthalmology for corneal crosslinking assessment but did not receive treatment due to central corneal scarring OD and minimal progression OS. Entering uncorrected visual acuity was 20/200-2 (PH 20/50-2) OD and 20/25+2 OS. The patient was diagnostically fit in Custom Stable Elite 15.8 mm scleral lenses with toric landing zones OU. After multiple lens parameter variations and unsuccessful attempts to stabilize the right lens, a toric CCZ was used to help reduce excessive lens movement. The addition of a toric CCZ allowed for better lens stabilization and a more accurate assessment of the final lens prescription. Ultimately, this change provided the best vision this patient has experienced since progression of his condition.
Conclusion: In cases of corneal degeneration, it is important to utilize and understand all variations that can be made to improve the fit of a scleral lens. When patients have a greater difference in curvature along the cornea, a toric CCZ technique should be considered.
27
Title:
Author: Dominic Lombardi
Abstract:
Background: Anterior uveitis is inflammation of the anterior chamber. Intermediate uveitis is inflammation of the vitreous. Posterior uveitis is inflammation of retina and choroid. Panuveitis is a combination of all 3 as well as the iris, ciliary body, and optic nerve being affected. Often, the specific cause is unknown but there are several systemic conditions that have been linked to panuveitic episodes. The affected population varies greatly depending on the underlying cause. Lab testing and imaging is necessary for diagnosis of a definitive cause in all cases of panuveitis. Treatment also largely depends on the underlying cause but corticosteroids and cycloplegics are almost always part of the treatment plan.
Case Presentation: A 75-year-old white male presents with a decrease in vision in his left eye, weblike floater, photophobia, watering intermitently for the past 10 months. Entering acuities were 20/40+1 OS. Left cornea presented with diffuse keratic precipitates and edema. Left anterior chamber contained mild cells. Posterior vitreous detachment with large strands and possible haze OS captured with Optos. Pachymetry measures were taken OS: 616um. OCTm revealed cystoid macular edema ODOS , KPs OD<OS, small flame heme OD. OCTm reveals mild improvement in CME. Added cyclo BID again, repeat lab work, and see pulmonary specialist as past imaging revealed 3 lung nodules. Patient will follow-up again in 2 months following eighth follow-up and another retina visit is scheduled.
Conclusion: Identifying the cause of panuvieitis and the subsequent management can be exceedingly difficult.