Admissions conference
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Admissions Conference. Karen Faye M. Serrano July 30, 2011. Patient Data. E. D. Female 55 yo Tandang Sora , QC. Chief Complaint . “ Mahapdi ang kaliwang mata na parang may nakaharang .”. History of Present Illness. 4 months PTA March 24, 2011  Cataract surgery OS

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Admissions Conference

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Admissions conference

Admissions Conference

Karen Faye M. Serrano

July 30, 2011


Patient data

Patient Data

  • E. D.

  • Female

  • 55 yo

  • TandangSora, QC


Chief complaint

Chief Complaint

  • “Mahapdiangkaliwangmatanaparang may nakaharang.”


History of present illness

History of Present Illness

  • 4 months PTA

    • March 24, 2011 Cataract surgery OS

    • March 25, 2011  IOL displacement

    • March 26, 2011  swelling of the lens

      • Something is blocking her center vision

      • Painful (‘mahapdi’), redness, and tearing

      • No itchiness and discharge

      • Prescribed with 4 eyedrops

      • Minimal improvement


History of present illness1

History of Present Illness

  • 3 months PTA

    • Weekly check-up

  • 2 months PTA

    • May 28, 2011  scheduled for operation  was postponed due to persistence of swelling

  • 1 month PTA

    • June 22, 2011  scheduled for operation  was postponed due to persistence of swelling and schedule did not coincide with the doctors


History of present illness2

History of Present Illness

  • 5 days PTA

    • scheduled for operation  was postponed due to persistence of swelling and schedule did not coincide with the doctors

  • Day of admission (July 27, 2011)

    • Went to OPD

    • Got CP clearance

    • Scheduled for surgery the next day


Past medical history

Past Medical History

  • Diabetic

    • 24 years ago

    • Metformin 500 mg; 3x a day

    • Glicazide (Diamicron) 80 mg; 4x a day


Past medical history1

Past Medical History

  • Hospitalizations/Surgeries

    • 2009 Nov

      • Felt cold during the night

      • Fever

      • Admitted for 2 weeks

      • Wound in the L foot was already gangrenous and was excavated

    • 2010 Jan

      • Operation was done

      • Autograft from abdomen to L foot

      • Admitted for a week


Family history

Family History

  • Father

    • Hypertension

    • Died of cancer


Personal and social history

Personal and Social History

  • Housewife

  • Never smoked

  • Never drank or tried drinking alcohol

  • Never used illegal drugs

  • Maintained on a healthy diet


Physical examination

Physical Examination

  • ROS unremarkable

  • Highest BP: 150/100

  • Normal BP: 130/70

  • Current BP: 140/80

  • RR: 16

  • HR: 82

  • Glucose 9.75 (NV: 4.1-5.9)


Physical examination1

Physical Examination

  • DVA

  • NVA


Physical examination2

Physical Examination

  • Full and equal EOMs


Physical examination3

Physical Examination

  • Gross

    • OD

      • Arcussenilis

      • Anictericsclerae

      • Pinkish conjunctiva

      • PRL, 2-3 mm pupil


Physical examination4

Physical Examination

  • Gross

    • OS

      • Arcussenilis

      • Hyperemic limbal area

      • Swelling of cornea

      • Clouding on the cornea

      • Bullae on cornea

      • Hypermicsclerae

      • Indentations on the pupil border


Physical examination5

Physical Examination

  • Gross

    • OS

      • Arcussenilis

      • Hyperemic limbal area

      • Swelling of cornea

      • Clouding on the cornea

      • Bullae on cornea

      • Hypermicsclerae

      • Indentations on the pupil border


Physical examination6

Physical Examination

  • Tonometry

    • OD: 10 mmHg

    • OS: 10 mmHg


Physical examination7

Physical Examination

  • Slit Lamp

    • OD

      • Grade 4


Physical examination8

Physical Examination

  • Slit lamp

    • OS

      • Grade 4


Admitting diagnosis

Admitting Diagnosis

  • Dropped IOL, OS

  • BullousKeratopathy


Iol dislocation

IOL Dislocation

  • Early = before 3 months after surgery

  • Late = 3 months after surgery

  • Posterior dislocation

    • Posterior capsular rupture or zonular dialysis

    • Improper fixation within the capsular bag and instability of the IOL (capsular bag complex)

    • Solution: Continuous Curvilinear Capsulorrhexis


Differentials

Differentials


Pseudophakic bullous keratopathy

PseudophakicBullousKeratopathy

  • Corneal edema from cataract extraction

  • Corneal endothelium is damaged  corneal swelling

  • Damaged endothelium  irregularly shaped and enlarged cells  pump function fail

  • Unable to pump to deturgesence the cornea  stroma swell (central)  folding of Descernet’s membrane  fluid accumulation  blisters and bullae  fluid to anterior chamber


Pseudophakic bullous keratopathy1

PseudophakicBullousKeratopathy

  • Pain

  • Degree of pleomorphism and polymegathism increases


Surgical procedure

Surgical Procedure

  • Penetrating Keratoplasty OS and Vitrectomy with IOL retrieval


Specular microscopy

Specular Microscopy

  • Number of endothelial corneal cells per square millimeter inch

  • Percentage of hexagonal cells

  • Polymegathism

  • Polymorphism


Specular microscopy1

Specular Microscopy

  • Endothelial cell count is normal if 2600-2800 cells per square millimeter

  • If below this level  greater likelihood of complications

    • Corneal edema

    • Loss of visual acuity


Specular microscopy2

Specular Microscopy

799

001

599

002

799

001

785

001

785

001


Penetrating keratoplasty

Penetrating Keratoplasty

  • Complete corneal transplant

  • Entire cornea is removed  replaced by a complete donor cornea

  • With decreased visual acuity due to corneal opacity

  • Pseudophakic corneal edema


Penetrating keratoplasty1

Penetrating Keratoplasty


Penetrating keratoplasty2

Penetrating Keratoplasty

  • Possible Complications

    • Wound leak

    • Glaucoma

    • Primary endothelial failure

    • Persistent epithelial defect

    • Microbial keratitis

    • Late failure

    • Recurrence of primary disease


Penetrating keratoplasty3

Penetrating Keratoplasty

  • Corneal graft rejection

    • Symptoms

      • Decreased vision, pain, redness, photophobia

    • Signs

      • Keratic precipitates, stromal edema, subepithelial edema, conjunctival injection, cells and flare, neovascularization

    • Treatment

      • Topical steroid (Prednisolone 1%)

      • Cycloplegics


Vitrectomy

Vitrectomy

  • Surgical removal of the vitreous humor


Pre op

Pre-op

  • BP 140-150/70-80

  • Moxifloxacin q4

  • At the OR:

    • BP 200-240/130-140

    • Nicardipine 10mg 10gtts

    • Uncontrolled BP

    • Deferred


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