Grand rounds in eye care
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Grand Rounds in Eye Care. FROM THE LIDS TO THE MESHWORK Lee W. Carr, O.D. Jeff D. Miller, O.D. 28 y.o. White female. C/O: “I had a big stye on my lid, and now it’s really swollen up, and it hurts really bad.” No known health problems No medications, currently Allergic to penicillin

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Grand Rounds in Eye Care


Lee W. Carr, O.D.

Jeff D. Miller, O.D.

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28 y.o. White female

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

  • No known health problems

  • No medications, currently

  • Allergic to penicillin

  • No other known allergies

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Relevant History

  • First noted “sty” one week ago

  • Initially: small, non-tender “lump”

  • “Looked ugly. Made me look ugly.”

  • Patient squeezed it, “Like a zit.”

  • Patient tried to “pop it” using a sewing needle.

  • DID sterilize the needle in a flame

  • Did not disinfect skin first

  • Did manage to draw blood from the site

  • Worked on lesion “…for about 20 minutes.”

  • Worked on lesion “…till it started to swell pretty good and it really started to hurt.”

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  • “Swelling is spreading”

  • Lesion is becoming increasingly painful

  • “It really hurts now.”

  • “I’m afraid I’ve got an infection in my eye.”

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The Exam

  • VA’s (sc): OD: 20/20 OS: 20/20

  • Pupils: PERRLA, brisk OU

  • Motilities: full, unrestricted OD + OS

  • Conf Fields: full, OD + OS

  • SLE: quiet and clear cornea and anterior chamber

  • EXTERNAL: OD: quiet, WNL OS: extensive lid swelling

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Assessment: Preseptal vs Postseptal Cellulitis

  • Re-checked EOM’s. Full, unrestricted

  • Took patient’s temperature: 97.5 degrees

  • Pulse & BP: 74 bpm; 122/78

  • Questioned patient regarding current or recent sinusitis

  • Evaluated nasal passages with transilluminator light

  • Attempted sinus transillumination

  • Attempted combined scan ultrasound

  • Discussed monitor/empiric therapy or CT evaluation options with patient

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  • Rx: azithromycin (z-pack x 2)Take 2 (250mg) tablets twice per day for two days;Then reduce to 1 tablet per day until all tablets are gone

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

  • Requested tetanus booster via Adult Med

  • RTC: 24 hours to re evaluate motilities,other findings

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  • All findings considered benign and WNLfor OD and for OS

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54 year old male

  • Yearly eye exam

  • C/O OD blurry for the last 3-4 weeks

  • Has happened before but intermittent

  • Refr. Hx: hyperopic/astigmat/presbyope

  • Medical Hx: Type II DM, HTN, elevated cholesterol

  • Meds:Metformin,HCTZ,Toprol-XL, Zetia,Vitamins

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The Exam

  • VA’s sc OD 20/40 OS 20/30

  • Pupils, motility, CVF all normal

  • BVA OD:+1.25-0.25x100 20/30

  • OS:+1.25-1.00x097 20/20

  • Ant Seg: trace SPK OD > OS

  • Quick TBUT OU

  • NS 1+ OU

  • IOP: 21/23 @3:25pm

  • Retina and ONH appear normal OU

  • .3 c/d OU

  • No BDR noted

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Additional Testing

  • Lissamine Green

  • Cirrus OCT of Macula OU

  • Topography

  • Pachymetry OD 530 OS 509

  • Additional History: always sleeps with ceiling fan on high

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Cirrus SD OCT

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Working Diagnosis

  • Irregular topography OD secondary

    to Dry Eye

  • Suspect corneal thickness OS > OD

    (Ocular HTN/Glaucoma suspect?)

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

  • RTC 3-4 weeks progress evaluation

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F/U Exam

  • Patient states mild improvement some days better than others

  • Using Soothe XP with some success

  • C/O of Mild itching

  • VA cc OD 20/25- OS 20/20

  • Cornea eval trace SPK OD, clear OS

  • Everted Lids: clear however, lids very “flaccid”

  • Lids everted w/o any particular effort or technique

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Additional History

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

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

  • Working Diagnosis Changed

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FES, Sleep Apnea, and Glaucoma

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

  • 5-15% of OSA pts. have FES

  • 96% of FES pts. have OSA (collagen in esophagus / pharynx similar to tarsal plate – results in esophageal collapse)

  • 57% of NTG pts. Have sleep apnea symptoms

  • Glaucoma – 2% of general population, 7+% of OSA patients

  • Multiple studies have shown over 70% of NAION pts. have OSA

    Trigger: failure of AUTOREGULATION

    (all NAION pts. Should be advised to be evaluated for OSA)


  • Rick Trevino, O.D.

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Evidence of Ischemia’s Role in Glaucoma

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

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

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


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  • Continue to treat Ocular surface disease

  • Continue to monitor for Glaucoma

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

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66 y.o. White female

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

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

  • Hx: Type 2 diabetes, on insulin Hypertension

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Ocular History

  • General Ophthalmologist

    • Pan retinal photocoagulation OU (2002)

  • Retinal Specialist

    • PRP and grid (2002)

    • Vitrectomy, OD, (2003)

  • Low Vision Service (2003)

    • VA: OD: 10/400 OS: 20/150

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Hx (continued):

  • Corneal Specialist

    • Exposure keratitis management (2005)

    • Cataract surgery, OD, (2005)

    • Lateral tarsorrhaphy, OD, (2005)

    • Recommendation: Cataract surgery OS

  • Retinal Specialist

    • More PRP (2006)

    • Cataract surgery, OS, (2006)

  • Low Vision Service

    • VA: OD: 10/100 OS: 10/350

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Hx (continued):

  • Retinal Specialist

    • PRP, OU, (2007)

    • Anti-VEGF, OU (2007)

    • Vitrectomy and Retinal Detachment Repair, OS, (2007)

  • Low Vision Service

    • VA: OD: 6/80 OS: HM at 2 feet

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Specialty Care Exam (4/22/08)

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

  • “No pain; I’ve gotten used to it.”

  • “Sometimes I forget to use my artificial tears, but not often.”

  • Mx: insulin, Fosthopace, Systane, Thera-tears, Erythromycin ophthalmic ointment (prn use)

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  • VA: OD: 20/400 at 4 feet OS: Light Projection

  • Ext: Severe right face droop—full facial palsySignificant edema below right lower lid.Mild ectropion, right lower lidGrossly incomplete lid closure, OD.Mild red eye reaction OD—wateryBlue tinge to right lower lidSolid nodule palpable within edematous right lower lid

  • Assessment: Atypical for ectropion

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Consult with our clinical ophthalmologist

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

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

  • Pathology report identified basal cell carcinoma.

  • At March, 2008 exam, PCP expressed concern to patient that residual tumor may exist, and again recommended eye lid surgery.

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Lesson Learned


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

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

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

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22 y/o male college student

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

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

  • OD red, questions allergy to drops?

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The Exam

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

  • VA sc OD 20/30 OS 20/20

  • All entrance visual skills normal

  • SLE:

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Assessment / Treatment

  • Herpetic lid lesion and HSK

  • D/C Tobradex

  • Begin Viroptic q1h OD

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

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Herpes Simplex Keratitis

The Leading Cause of Corneal

Blindness in the US

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Ocular Herpes Simplex

  • Each year in the U.S. 25 million people have flare-ups

    of facial Herpes (95% of population exposed by age 6yrs)

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

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

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

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

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

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

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Ocular Herpes Simplex

  • After the second infection odds of further recurrences

    greatly increases

  • 40% of these patients have more than one recurrence

    Infectious Epithelial keratitis

    Neurotrophic Keratopathy

    Necrotizing Stromal Keratitis

    Immune Stromal Keratitis (ISK)


    (Keratouveitis or trabeculitis)

  • One of the leading indications for PK in the US

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Diagnostic Pearls

  • Evaluate lid margin and lash follicles closely

  • Look for a follicular vs. papillary response

  • Look for more of a serous vs. mucous discharge

  • Don’t forget decreased corneal sensitivity

  • Cotton wisp test (check before staining!)

  • Multiple raised epithelial defects vs. medium

    to large classic dendrites

  • Be careful with steroids on garden variety eye inflammation

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Oasis Medical Inc.


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Treatment - Oral Antivirals

  • Valacyclovir hydrochloride

  • Trade name – Valtrex

  • Acyclovir

  • Trade name – Zovirax

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

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Acute PhaseDosages and Precautions

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

  • Zovirax 400mg 1 p.o. 5 x a day

    for 10-14 days (14 days $20)

  • Contraindicated in patients with

    kidney disease, liver disease, and

    immunosuppressed patients (HIV)

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Acute PhaseTreatment - Topical Antivirals

  • Trifluridine ophthalmic drops

  • Trade name – Viroptic ($125, generic $95)

  • 1 drop q1h (8 times a day)

  • Vidarabine ophthalmic ointment (UNAVAILABLE EXCEPT BY SPECIALORDER)

  • Trade name – Vira-A ung (5 times a day)

  • Effective against strains unresponsive to

    Viroptic and Acyclovir

    What about steroids to decrease scarring?

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Treatment of Ocular Herpes Simplex

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

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

  • 400mg daily, compliance is mandatory

  • Patients who stopped early – re-infected

  • 12 months vs. 18 months vs. Indefinitely

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We’ve all heard “Herpes Zoster the Great Imposter” however, Ocular Herpes Simplex can be cunning as well

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

  • Remember subsequent epithelial infections are not as irritating or painful

  • Family and friends watch for “red eye”

  • Do not miss multiple doses of oral Acyclovir can lead to reactivation

  • Think of it as BC or a daily Vitamin

  • If nonresponsive try Vira-A ung

  • – 800-292-6773

  • Be cautious with steroids!!

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60 y.o. white male

  • POAG diagnosed 3 years previously

    • IOP

    • Disks

    • 24-2’s

    • GDX

  • (+) Family History

    • Mother

      • Significant field loss

      • Managed with Timoptic .5%

  • Baseline IOP consistently around 21mmHg

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C.E.O. of major academic institution

  • Engaged in major capital fundraising campaign

  • Anticipating program’s 100 year anniversary celebration week

  • Prominent lecturer on CME circuit

  • Professionally, very active

  • Personally, Physically, very active

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Initial Treatment

  • Timoptic .25%

    • Rx: 1gt OD + OS, once per day, a.m.

  • IOP OD: 20 and OS: 19

    • Rx: 1gt OD + OS, twice daily, a.m. + p.m.

  • IOP OD: 19 and OS: 19

  • Patient complains of difficulty with daily early-morning jogging

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Timoptic discontinued

  • Xalatan treatment initiated

    • Rx 1 gt OD + OS at night, prior to sleep

  • IOP OD: 16 OS: 15

  • Complaint of “red eye reaction”

  • Daily dosing schedule altered

    • Rx 1 gt OD + OS at dinner time

  • “Red eye reaction” complaint persists

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Xalatan discontinued

  • Travatan initiated

  • “Red eye reaction” complaint intensifies

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Argon Laser Trabeculoplasty discussed with patient

  • Selective Wavelength Laser Trabeculoplasty mentioned to patient

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S.L.T. performed OD + OS

  • Inferior 180-degrees

  • IOP at 2 months: OD 21 OS 21

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Second S.L.T. performed

  • Superior 180-degrees

  • IOP at 1 month: OD: 16 OS: 15

  • IOP stable at 15 – 18 at this time

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52 y/o Female

  • “I want to have LASIK”

  • Previous CL wearer (monovision) started to have comfort issues and previous doc told her to go to glasses – “hates them!”

  • Med Hx: menapausal, mild controlled HTN

  • C/O VA is blurry with glasses in distance OD > OS

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The Exam

  • VA cc OD 20/40 OS 20/25

  • Pupils, EOM’s, CVF normal OU

  • BVA OD -3.00-75 x 040, 20/30-

    OS -4.00-1.00 x 025, 20/25-

  • SLE: Lids and lashes clear, A/C deep and quiet, 1+NS OU,

  • See corneal photos

  • Internal: .25 C/D OU, Macula and periphery clear OU

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?? LASIK Candidate ??

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

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

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Fuch’s Endothelial Dystrophy

  • Females 3:1

  • Autosomal Dominant

  • Slowly progressive formation of guttate lesions between the corneal endothelium and Descemet’s membrane

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

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

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Refractive Surgery and Fuch’s

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

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

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

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  • Descemet’s Stripping Endothelial Keratoplasty

  • Descemet’s Stripping Automated Endothelial Keratoplasty

  • Impressively mild post-op

  • Minimal corneal edema or anterior

    corneal compromise

  • Rapid rehab with minimal to no astig.

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Cogan’s Dystrophy

  • MDF, ABMD, EBMD, Microcystic Epithelial Dystrophy

  • Nonprogressive but fluctuating in course

  • F > M

  • 1/3 of patients have RCE

  • Irregular Astigmatism common cause of VA loss

  • VA loss does not match clinical picture via slit lamp exam

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Cogan’s Dystrophy

  • Pathophysiology: Corneal epi adheres to underlying BM

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

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

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

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Cogan’s Dystrophy

  • Treatments: AT’s, Muro 128 gtts and ung

  • 2005 only prospective study to date no difference between AT”s and NaCl

  • Irregular Astig. CL fix? RGP vs. Soft

  • Superficial Keratectomy

  • Polish BM w/ diamond burr or alger brush

  • ASP for erosions or post Keratectomy, consider donut approach and spare visual axis

  • PTK or PRK if going for refractive correction

  • Not great LASIK candidates

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Cogans Dystrophy

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

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

  • Daily vs. EW? Poor dexterity in elderly