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cpw

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Sometimes, you get a pterygium and you shake your head.

what kind of vision did this patient have ? (just curious)
 

Richard_Hom

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For those who are cramming for exams or just want some intellectual fun, this is 36 year old woman was referred for a glaucoma workup. Just by physical gross examination, what would your differential diagnoses and working strategy be? The entrance acuities without lenses are OD 20/50 and OS 20/40.

Richard Hom OD FAAO
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Richard_Hom

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Thanks to those who private messaged or emailed me.

The first thing is the relative anisocoria. What kind of history can you begin to expect? Good for 1st and 2d years also.

Richard Hom OD FAA
 

POJO

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This is a 47 year old Hispanic male with no apparent acute eye problems who presents for his first ever eye examination after having been diagnosed a few months prior with Type 2 Diabetes on both oral and insulin therapy. The IOPs are 18/17 whether in the late morning or late afternoon, the CD's by indirect examination are about 0.70 in each eye. There are no signs of any retinopathy.

What do you think you'd do?
 

Richard_Hom

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A 63 year old woman presents to your office for a routine examination. She is new to your office and you don't have any prior medical history on her. Or you cannot get her medical information. As she gets up off of her chair, she appears to be unsteady and is looking for assistance. Her companion provides an arm. As she slowly crosses the threshold of the interior office she is more unsteady. As a matter of fact, on the next step, she starts to sit down on the floor and then proceeds to lay down flat. She is incoherent, and conscious, but is unable to lift herself off of the floor.

What would you do?

Richard Hom OD FAAO
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luckyfool

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not much branching. i'm honestly not sure, you asked what else so i took a guess. :)

+ retinal scar by any chance?
 

POJO

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Anyone think they see neovascularization ("NVD") at the disc? Usually this sign is sign that retinal laser treatment is near rather than far term.
 

luckyfool

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microaneurysms all around the macula. not impressive in the disc besides some vessel abnormality.
 

Richard_Hom

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microaneurysms all around the macula. not impressive in the disc besides some vessel abnormality.

I think the most notworthyhing you should see is the NVD (neovascularization at the disk). NVD is often missed but is prominent as this signifies pre-proliferative diabetic retinopathy. The other notweorthy sign is the large hemorrhage inferior to the disc.

Of course, looking at a photograph and see the patient in person are two completely different things. I think the live observation might impress you more than the photos will.

Yours truly,
Richard Hom
 

luckyfool

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you mean noteworthy?

thanks for sharing with us dr hom. it's an interesting case.
 
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Ben Chudner

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I think the most notworthyhing you should see is the NVD (neovascularization at the disk). NVD is often missed but is prominent as this signifies pre-proliferative diabetic retinopathy.
Actually, it would signify early (or low risk) proliferative diabetic retinopathy. Background and pre-proliferative diabetic retinopathy were eliminated as classifications with the release of the ETDRS. I am sure there are retina docs that still use those classifications, but they are considered obsolete.
 

Richard_Hom

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Actually, it would signify early (or low risk) proliferative diabetic retinopathy. Background and pre-proliferative diabetic retinopathy were eliminated as classifications with the release of the ETDRS. I am sure there are retina docs that still use those classifications, but they are considered obsolete.

Ben,

Thanks.

I agree that this might the first stage for the risk of proliferative retinopathy. Because treatment is imminent, I believe that referral to for further evaluation is warranted, though at this stage it might me near term rather than in the distant future.

Richard
 

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If I recall the ETDRS study correctly, high risk characteristics include NVD of any amount if associated with VH. If that hemorrhage below the disc is in the vitreous then this patient needs to be referred for PRP.
 

Ben Chudner

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If I recall the ETDRS study correctly, high risk characteristics include NVD of any amount if associated with VH. If that hemorrhage below the disc is in the vitreous then this patient needs to be referred for PRP.
You are absolutely correct. NVD less than 1/3 disc area with VH would be classified as High Risk PDR. I was only referring to the comment "NVD is often missed but is prominent as this signifies pre-proliferative diabetic retinopathy". Any neovascularization, whether it be NVD or NVE signifies proliferative diabetic retinopathy, not pre-proliferative. Low, moderate, or high risk is determined by the amount of neo in relation to location as well as other findings such as vitreous hemorrhages. Pre-proliferative diabetic retinopathy is a classification that no longer applies based on the ETDRS. Furthermore, there are some retinal specialists that seriously consider treatment at the severe NPDR stage. Regardless, this patient needs to be referred for a retinal consult fairly quickly.
 

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If I recall the ETDRS study correctly, high risk characteristics include NVD of any amount if associated with VH. If that hemorrhage below the disc is in the vitreous then this patient needs to be referred for PRP.

In the insignificant point department: The Early Treatment Diabetic Retinopathy Study (ETDRS) defined CSME and NPDR, set guidelines for treatment of CSME, and investigated the role of PRP in the treatment of NPDR. However, it was the Diabetic Retinopathy Study (DRS) which defined the high risk characteristics listed above and the role of PRP in the treatment of certain types of high risk characteristics.
 

Richard_Hom

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The reason for this post is to examine the disc properly and to avoid missing NVD in the first place which may precede a VH (vitreous hemorrhage). I have to say that I have read retinal consultant reports that often gently remind the referring doctor of the presence of NVD or NVE that was not mentioned in their original consultation request or in the clinic notes. This is probably more relevant for optometrists than ophthalmologists.

Richard Hom OD FAAO
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luckyfool

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I've been inundated recently with a lot of new projects but I saw this interesting chap a couple of weeks ago. For all of the hot shots, what do you see, what history would you take, what is your working diagnosis, how woud you manage it?

Richard Hom OD FAAO
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Looks like a pterygium - ask the patient if he's been exposed to too much sunglight recently. the growth can be surgically excised.
The ring around the iris looks like a case of senilis - ask the man about his eating habits, and cholesterol level. Can be treated with medication (lipitor).
 
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Richard_Hom

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Looks like a pterygium - ask the patient if he's been exposed to too much sunglight recently. the growth can be surgically excised.
The ring around the iris looks like a case of senilis - ask the man about his eating habits, and cholesterol level. Can be treated with medication (lipitor).


Describe the anatomical structures first. What is unusual about these structures. I think I would try that approach first before diagnosing this so quickly.
 

itek2OD

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Already one post operative procedure done already. Successful?

Richard Hom OD FAAO
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Whoa. Doesn't look successful, though impossible to tell how many months post- op pterygium excision. Was it the the temporal one that was done - recently?

That's a really nice pic. Thanks
 

Richard_Hom

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Low technology approach - Your equipment is a slit lamp, 90D/78D lens, direct and indirect ophthalmoscope and a threshold field system (either a Matrix FDT or a Humphrey SITA Fast/SAP-capable machine)

High technology approach - All of the above and OCT/HRT/GDX

For those with the low appraoch, can you be comfortable with managing it? Do you feel that the high technology approach is the only way to go with this kind of patient?

Richard Hom OD FAAO
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cpw

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Quite often, contact lens wearers experience misfortune when they panic about their lenses. This is a 24 year old woman who thought her lens was still in her eye and proceeded to attempt removal repeatedly.

How would you manage this?


Richard Hom OD FAAO
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This makes me cringe just looking at it. Poor thing -- she must have been in lots of pain ! The one I saw this week was only half that size.
 

IndianaOD

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This makes me cringe just looking at it. Poor thing -- she must have been in lots of pain ! The one I saw this week was only half that size.

I'm sorry, I just have to say it. The ophthalmolgy lobby that just attacked our ability to Rx narcotics said: "there aren't any times when its neccessary."
Uhmm, cough. I had a patient that had a similar appearance bilaterally. She was in so much pain she could not walk without help. She had to suffer because of some egos.
 

yOyOYoo

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First, what is your background? pre-optometry or in a program?

Richard Hom OD FAAO
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late reply.... I am a third year optometry student at SCCO about to go on rotations, I can't wait! Anyways, I was hoping that you would put your assessment and management of these patients on your website, maybe "after the jump" so that we could learn from your experiences.

Your questions are thought provoking, and your images are excellent! We would all just like to see how you approached and handled these cases.
 

Richard_Hom

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Sometimes a well intended gesture can cause complications to the resolution of a corneal abrasion. A patient presented the Emergency Department of a local hospital and was inadvertently given. allowed to take, or purloined a bottle of topical anesthetic. The eye failed to resolve after three days with photophobia, pain and lacrimation. What should have resolved in 1 day has now ballooned to a potentially damaging situation for this patient's vision. NEVER give a patient a topical anesthetic for a corneal abrasion.
 

yOyOYoo

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late reply.... I am a third year optometry student at SCCO about to go on rotations, I can't wait! Anyways, I was hoping that you would put your assessment and management of these patients on your website, maybe "after the jump" so that we could learn from your experiences.

Your questions are thought provoking, and your images are excellent! We would all just like to see how you approached and handled these cases.

Anyone else feel this way too?!? Or is it just me? :confused:
 
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