A Grand Rounds Web site by an OD for OD and students!

[Richard_Hom]

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

Dear yOyOYoo,

I'm designed these cases or questions not for didactic enjoyment but as an exercise in analysis and investigative prowess. I like discussion. Offer your thoughts and I will respond. As a beginning third year, you should have sufficient background to begin thinking how you would go about investigating something.

 

[Richard_Hom]

Do you think this presentation is relevant to the chief complaint?

Richard Hom OD FAAO
Society of Optometrists in Hospitals

 

[cpw]

I wish i'd had a slit lamp camera to take photos today of the welder patient of mine who REFUSES to wear safety goggles. I removed yet another foreign body today and checked out the tons of scars from all the other times he's gotten hit in the eye with other pieces of flying metal.

Sometimes what I say and what people want to hear are two different things.

 

[Richard_Hom]

I wish i'd had a slit lamp camera to take photos today of the welder patient of mine who REFUSES to wear safety goggles. I removed yet another foreign body today and checked out the tons of scars from all the other times he's gotten hit in the eye with other pieces of flying metal.

Sometimes what I say and what people want to hear are two different things.

Dear cpw,

Please read my article in CL Spectrum. Click here to jump to that article.

Richard Hom OD FAAO
Society of Optometrists in Hospitals
www.geocities.com/rchom

 

[Frumps]

Nice website. How do I get any of the answers to the cases? I don't see any discussion of the cases. Thanks!

 

[Richard_Hom]

Nice website. How do I get any of the answers to the cases? I don't see any discussion of the cases. Thanks!

Frumps,
There is a small hyperlink in one of the corners that jumps to my discussion of the case.

 

[Richard_Hom]

Sometimes (1:5000) LASIK complications do occur.

Richard Hom OD FAAO

 

[Frumps]

Hi Richard,

Some cases have links and others do not. For example, the Lasik case only has a link for an online submission form. I have tried Safari and Firefox webbrowser.

Thanks again

 

[Richard_Hom]

You're correct about the last case. I am discussiong this case privately and in this and other forums. I usually post the "answer" a week later.

Do you have any input on this case?

 

[Richard_Hom]

Dear student or new graduate. You've probably had some form of introduction to glaucoma and its relatives. See the clinical data here and tell me what would you do?

Chief Complaint - (1) Dry Eyes (2) Red conjunctiva - chronic

HPI This is a pleasant ambulatory 72-year old African American Male who presents to my care in April 2007 to establish primary eye care. He has been characterized as a "glaucoma suspect" since 2005 by another eyecare provider (ECP) with no medications at this time. He was lost to follow up from that visit until today.

He is in no acute distress and has no vision complaints, and no eye pain or diplopia.

Current Medical Problems

1. Hypertension
2. History of tophaceous gout, currently asymptomatic.
3. Osteoarthritis of his knees.
4. Neurosensory hearing loss
5. Hypothyroidism, on replacement with good level TSH.
6. Possible history of alcohol abuse which patient is currently denying.

Current Medications

1. Lisinopril 20 mg daily.
2. Allopurinol 300 mg daily.
3. Levoxyl 0.05 mg daily.
4. Enteric-coated aspirin 81 mg daily.

Relevant physical Examination

1. Current glasses OD 20/25 each eye
2. Tapp 14:00 20 each eye
3. Pachymetry OD 508 and OS 490
4. Gonioscopy open 360 degrees, Grade 4
5. Cortical cataracts in both eyes
6. Cup-to-disk ratios are OD 0.75 vertically and OS 0.65 vertically (sorry no fundus description or disk photos)
7. Optic nerve head diameter optically measured as 2.0mm

On 08/27/2007, his entrance acuities were measured as 20/20 in each eye and his IOPs were 16 each eye at 10:30am
See attached GDX and visual fields by clicking here http://www.geocities.com/rchom/FilePages/GrandRoundsPhotoIndex_007.html


Question:

1. What is your diagnosis?
2. If you do diagnose glaucoma, what is your rationale and your medical or surgical regimen/ plan?
3. If you do not treat, what do you say to the patient.

Richard Hom OD FAAO

 

[cunikki]

Hi; I am new to this so be nice just my comments.....

I would still diagnose as glaucoma due to damage to RNFL and VF loss consistent with glaucoma? Although the pressures are measured as 16, the pachymetry is low so the pressures may be read as false low. Maybe do a diurnal curve to see what other pressures you might see?? Since he seems likely to not return for follow up I would probably try to treat... travatan .005% qhs??

 

[hello07]

My opinion, "glaucoma suspect" but no glaucoma; no reason to treat. Monitor every 6 months with VF's, GDx. Tell him you have large optic nerves; most likely physiological- born with him or normal for people of different ethnic background.
Give him some systane 1-2 gtt OU q hr or q2h and refresh pm ointment at bedtime. Actual IOP's may be 5-6 mm Hg higher than what Applann Ton reads. 21-25 might be his true IOP's based on pach readings. I wouldn't treat. Those optic nerves from what I see on GDx are not that suspicious.

My 2 cents.

 

[Richard_Hom]

Hi; I am new to this so be nice just my comments.....

I would still diagnose as glaucoma due to damage to RNFL and VF loss consistent with glaucoma? Although the pressures are measured as 16, the pachymetry is low so the pressures may be read as false low. Maybe do a diurnal curve to see what other pressures you might see?? Since he seems likely to not return for follow up I would probably try to treat... travatan .005% qhs??

cunikki,

Thank you for your post and reply. What is your threshold for characterizing "damage to the RNFL and VF loss"? Could you please elaborate on why "he seems likely to not return for followup?"

Remember, this is Grand Rounds and there are no bad questions nor are there any bad answers.

Thanks
Richard Hom OD FAAO

 

[Richard_Hom]

My opinion, "glaucoma suspect" but no glaucoma; no reason to treat. Monitor every 6 months with VF's, GDx..."

Hell07

Why q6mos for vF and GDX? Remember, this is Grand Rounds and there are no bad questions nor are there any bad answers.

Richard Hom OD FAAO

 

[cunikki]

I based that on the fields... looked like superior RNFL loss and arcuate defect to match it?? Also if he was told he was a glaucoma suspect 2 years ago but then did not go back to that dr it seems like he would be less likely to come back more often? i am assuming that the dr who called him a suspect would have told the patient he needs to be seen back at least in 1 year or 6 months?? the GDx seemed to show on the low end of normal for RNFL thickness??
I would probably treat based on the fields showing loss, plus risk factors- age, hypothyroid, race, unequal c/d ratios, and pachymetry
I was wondering if any of the drugs he is on would have any effect on his eyes.... ?? or where you were going with the alcohol abuse????

hello7- why wouldnt you treat???

 

[hello07]

Hello Dr. Hom,

I would repeat VF's and GDx in 6 months to see if there are any significant changes from the fields and GDx obtained in 7-07. I would like to see the optic nerve photos. In my opinion, he might be considered a "low probability glaucoma suspect" but not glaucoma yet. Is his blood pressure ubder control?

Hello cunikki, does the GDx analysis of each eye (RNFL loss obtained) correspond with the visual field of each eye? I wouldn't treat based on the GDx alone and those visual field losses are questionable.

Not an easy case.
Thanks.

 

[Richard_Hom]

Hell07 and cunikki,

This is actually more common than not. There will be few cases where the findings are so unequivocal that treatment is inevitable.

Other than the patient's lack of followup, what else about the history might indicate a compliance problem?

 

[hello07]

Dr. Hom, possibility of dementia at 72 years old with history of hypothyroid and alcohol abuse. Treat b/c noncompliance issue with Alzheimers perhaps? Do you suggest ALT or SLT and see what happens? No doubt that this "early glaucoma suspect" will most likely develop glaucoma. Unless I am out in left field or misinterpreting those fields with the GDx findings, I don't see a correlation among the two. Please help me.

 

[Richard_Hom]

Dr. Hom, possibility of dementia at 72 years old with history of hypothyroid and alcohol abuse..

How would you assess cognitive state?

 

[cunikki]

i would say that even though you cannot base field loss off one field it looked like one to me...
assess congnitive state with mmse and just in general from speaking to the patient during the exam??
helloo7... i guess i dont understand the difference between you saying you wouldnt treat based on suspicious gdx and fields that dont necessarily match ( i think they do if it is an arcuate field loss and low RNFL in inferior and superior) but then say its a glaucoma suspect that probably will be glaucoma anyways ???
where do you go to school? i think its because my school stresses treating based on any field loss consistent with glaucoma and/or pressures and/or RNFL/ONH damage and/or high risk alone (especially if you dont think they will come back)

 

[Richard_Hom]

"...assess congnitive state with mmse and just in general from speaking to the patient during the exam??"...

Does your school or training expose you to the MMSE?

 

[cunikki]

yes there is a dr on the clinical staff who has mentioned it several times in different lectures... also a lot of the chronic care forms in our clinic have check off forms (one is for mmse and one main one has about 100 different questions so they can bill with a 99 code...)

 

[hello07]

I would assess cognitive state based on conversation with a patient anywhere from 30 minutes to seeing him/her in a few month period. Although HBP can present at any age at any time; his gout and thyroid problem most likely didn't begin at age 72. He had those problems throughout his life; therefore not being on any meds 2 years early is very questionable in terms of his memory state.
I wish I had a view of the optic nerves it would tell me alot (retinal rim tissue 360 and cupping) but I am not trying to make any excuses.
cunikki, i believe every school stresses the importance of treating glaucoma patients based on field loss, IOP's, optic nerve damage and high risk. that is the hallmark. GDx's are secondary in my opinion.
Say for argument sake, you and Dr. Hom believe it is glaucoma at the present moment; what treatment would you offer? If Topical meds what would be your target pressure to sustain any further damage ? Do you believe that would be sufficient enough?
Again, based on what I see from fields, I wouldn't initiate any treatment YET.

 

[Richard_Hom]

Dear hello07,

I think you have to believe that glaucoma isn't quite as bimodal, or yes or no, as you might think. I tend to think of what the average doctor would do. If 50% of the doctors think it's glaucoma, that is one thing. I might still observe. However, if 90% of the doctors think it is glaucoma, I would initiate treatment.

But I'd rather concentrate more on the thought proces rather whether there is a right or wrong answer.

But to the both of you, how do you assess compliance or the capability of compliance?

Richard Hom OD FAAO

 

[hello07]

Dr. Hom, I know very well many glaucoma cases are not black or white but indeed fall into a rather large grey area. I agree with your previous statement. No one doubts the fact that if 90% of our colleagues or MD's think it's glaucoma you would initiate treatment. Who wouldn't? I would too. I voiced my impression of your presenting case. How do you assess compliance? Express to him or her their current situation(whatever it might or might not be), see if they understood what you told them and have them express back to you in their own language. Give them the treatment and hope to see them back on F/U whether it's been working or not.
Am I missing something obvious here?

 

[Richard_Hom]

'.... How do you assess compliance? Express to him or her their current situation(whatever it might or might not be), see if they understood what you told them and have them express back to you in their own language. Give them the treatment and hope to see them back on F/U whether it's been working or not.
Am I missing something obvious here?

hell07,

My response was meant to expand thinking not to be dogmatic. Part of the wisdom of elders is the possibility of what is and less on thinking there is a right answer. My answer isn't the only right answer and there may be more.

Compliance is a mixture of things. It could be responsiveness. Did the patient answer the questions in the form you asked every time? Was the patient aware of time, place and person? Was the patient able to calculate? How is the memory. MMSE is great but in a clinical situation, you might not have 30minutes to run a good MMSE. Some clinical version might be what you need.

Is the history suggestive of any kind of memory lapse. Well, if someone is a substance abuser, there is likelihood of forgetfulness.

Just a thought or two.

 

[Olddog1]

Dear hello07,

I think you have to believe that glaucoma isn't quite as bimodal, or yes or no, as you might think. I tend to think of what the average doctor would do. If 50% of the doctors think it's glaucoma, that is one thing. I might still observe. However, if 90% of the doctors think it is glaucoma, I would initiate treatment.

Richard Hom OD FAAO

Just my two cents. The above is probably a good rule of thumb. However, I believe many busy docs find it easier to throw some drops on a patient (even worse SLTs that are not needed, so many patients with "I was "cured" by SLT" when they really didn't have any dz in the first place - another story) and send them out the door, it takes less time and you need to think less. If you have open angles with normal fields and are 72 years old will you progress fast enough to give you any visual disablily before you die with normal IOP? Probably not. One of my multiple pet peeves is treating people who really don't have glaucoma or significant ocular HTN. Alot of people are treated for thin corneas with normal IOPs, family history, big symmetric cups with big nerves, it is a huge waste of money, but everybody is practicing defensively for a very slow moving disease (usually). For the record I would likely start tx on this patient because of the possible worsening fields, tell them I may be wrong, and repeat the field in 4 months. If it is normal you could consider Dx tx.

 

[hello07]

Greetings Dr. Hom,

Can you please tell me when will the answers to your case be posted?
I'm interested to read what treatment modality was given or not.


Thanks.

 

[Richard_Hom]

Greetings Dr. Hom,

Can you please tell me when will the answers to your case be posted?
I'm interested to read what treatment modality was given or not.


Thanks.

Too many things happening at once, I'll post to this thread my action in the cases that are requested by the audience here. Please reply to this thread the response you are most interested in.

Regards,
Richard Hom OD FAAO

 

[Richard_Hom]

Chief Complaint - (1) Dry Eyes (2) Red conjunctiva - chronic

HPI This is a pleasant ambulatory 72-year old African American Male who presents to my care in April 2007 to establish primary eye care. He has been characterized as a "glaucoma suspect" since 2005 by another eyecare provider (ECP) with no medications at this time. He was lost to follow up from that visit until today.

He is in no acute distress and has no vision complaints, and no eye pain or diplopia.'...

1. What is your diagnosis?
2. If you do diagnose glaucoma, what is your rationale and your medical or surgical regimen/ plan?
3. If you do not treat, what do you say to the patient.

Hi, forum,

In this case, I treated the patient with the a PGA nightly. Some things to note are the lack of compliance.

I prefer to treat someone who is likely to be compliant and return than to defer treatment and not have that person follow through. If there were "missed" appointments for a year for any doctor, I would consider that non-compliance. In addition, a patient who at this age and who is still abusing alcohol might lapse more often into forgetfulness and might thereby also contribute to non-compliance.

How does one assess mental status. I have used the Short Portable Mental Status Questionnaire and the Minimum Mental Status Examination and prefer the former for its speed.

Faced with non-compliance as a major issue, is this patient ready for selective laser trabeculectomy? In my opinion, it is still too early to definitively say that this is glaucoma.

Each practitioner must decide for themselves what their risk provider. When I say that there are few "pat" answers or few "single" answers, I mean that most clinical problems can be approached in different ways. After some experience, it is possible to create one's own risk management profile.

Richard Hom OD FAAO
Society of Optometrists in Hospitals

 

[Richard_Hom]

et's talk about corneal staining. If you saw this pattern (click here to jump to the image) of staining in a...



1. Pseudophakic...

2. A 25 year old Soft contact lens wearer...

3. 70 year old phakic and diabetic...



...what would be your first differential diagnosis? The history is as above and you know that each is seeing between 20/100 to 20/200 in this eye. The slit lamp was the first test that you have done.

 

[vsarge0708]

et's talk about corneal staining. If you saw this pattern (click here to jump to the image) of staining in a...



1. Pseudophakic...

2. A 25 year old Soft contact lens wearer...

3. 70 year old phakic and diabetic...



...what would be your first differential diagnosis? The history is as above and you know that each is seeing between 20/100 to 20/200 in this eye. The slit lamp was the first test that you have done.

Hey Dr. Hom,

I'm only a first year, so I don't know anything about anything but I'll give it a shot. 25 year contact lens wearer, so initially I would think DES or k.c. sicca--maybe sjogren's syndrome due to staining, did cc or hpi mention foreign body sensation, dryness, severe pain, etc?

 

[IndianaOD]

Richard, its difficult to tell what's going on in your photo. It is just the diffuse punctate staining?

List might include:

Dry eyes
Exposure keratopathy (neurologic)
toxic keratopathy
CLARE
Corneal decompensation

 

[ODduck]

et's talk about corneal staining. If you saw this pattern (click here to jump to the image) of staining in a...



1. Pseudophakic...

2. A 25 year old Soft contact lens wearer...

3. 70 year old phakic and diabetic...



...what would be your first differential diagnosis? The history is as above and you know that each is seeing between 20/100 to 20/200 in this eye. The slit lamp was the first test that you have done.

SPK for the 25yo SCL wearer

 

[Richard_Hom]

The gist of this post is that SPK, puncate staining, keratitis, etc, isn't so distinguishable from one another just by the presenting physical sign. Often the history is as important as well.

I think everyone would easily take care of case 2 and 3. But in case 1, the IOP was 24 and 48. The vision was 20/200. Was the staining a function of the corneal compensation or aggravated by the increase in IOP? Kind of a chicken and egg thing. In this case (3), the patient also had iridocyclitis with Grade 4 flare (headlights in the fog) and Grade #2 Cells.

 

[IndianaOD]

The gist of this post is that SPK, puncate staining, keratitis, etc, isn't so distinguishable from one another just by the presenting physical sign. Often the history is as important as well.

I think everyone would easily take care of case 2 and 3. But in case 1, the IOP was 24 and 48. The vision was 20/200. Was the staining a function of the corneal compensation or aggravated by the increase in IOP? Kind of a chicken and egg thing. In this case (3), the patient also had iridocyclitis with Grade 4 flare (headlights in the fog) and Grade #2 Cells.

I had a feeling you might have a pressure spike in there!

 

[ODduck]

The gist of this post is that SPK, puncate staining, keratitis, etc, isn't so distinguishable from one another just by the presenting physical sign. Often the history is as important as well.

I think everyone would easily take care of case 2 and 3. But in case 1, the IOP was 24 and 48. The vision was 20/200. Was the staining a function of the corneal compensation or aggravated by the increase in IOP? Kind of a chicken and egg thing. In this case (3), the patient also had iridocyclitis with Grade 4 flare (headlights in the fog) and Grade #2 Cells.

48?!!

I may only be a first year, but I know that that is WAY too high!

Isn't 24 pretty stinking high? Let alone double that!!

 

[Richard_Hom]

48?!!

I may only be a first year, but I know that that is WAY too high!

Isn't 24 pretty stinking high? Let alone double that!!

48 is high, but I'm not sure about "stinking high". If IOP gradually increases over two or four weeks, it may be uncomfortable but the it isn't acute. An IOP spike to 48 over 2 days will be noticeable.

By the way, I often get IOP's from the ER in the 60 range.

 

[IndianaOD]

48 is high, but I'm not sure about "stinking high". If IOP gradually increases over two or four weeks, it may be uncomfortable but the it isn't acute. An IOP spike to 48 over 2 days will be noticeable.

By the way, I often get IOP's from the ER in the 60 range.

Agreed, I've had several in the 50's

 

[PreOptMegs]

Do you think this presentation is relevant to the chief complaint?

Richard Hom OD FAAO
Society of Optometrists in Hospitals

is that a episcleritis nodule? eye is not too terribly red though

 

[362.04]

is that a episcleritis nodule? eye is not too terribly red though

No it is irritation secondary to an embedded lash.

 

[PreOptMegs]

No it is irritation secondary to an embedded lash.[/QUOTE]

oh wow, i didn't see that

 

[362.04]

No it is irritation secondary to an embedded lash.

oh wow, i didn't see that[/quote]

Eye lashes are notorious for being "Dirty" with all kinds of bugs.

 

[Richard_Hom]

This 62 year old woman presented in NAD and without any loss of vision (BVA 20/25+ ea eye). What is the provisional diagnosis for this kind of facial rash? See image at http://www.geocities.com/rchom/FilePages/GrandRoundsPhotoIndex_007.html. Please be aware that the page loads slowly and Brain Teaser 24 is in the last row at the bottom of the page.

 

[PreOptMegs]

Herpes Zoster is what I am thinking

 

[362.04]

Herpes Zoster is what I am thinking

On both sides of the face?

 

[WoodyJI]

On both sides of the face?

Looks like rosacea or Kaposi sarcoma to me...i should probably read the rest of this thread since i had no idea we were playing a quiz game!

 

[Richard_Hom]

Between onset and this 1st visit with me were one visit to a friendly pharmacist where Visine was given, two Emergency Department visits (Ciprofloxacin Q2hrs) before coming to the Eye Department. Records show that VA in this eye started out at 20/40 and is now Counting Fingers at 3 feet.

What would you do?

 

[IndianaOD]

Between onset and this 1st visit with me were one visit to a friendly pharmacist where Visine was given, two Emergency Department visits (Ciprofloxacin Q2hrs) before coming to the Eye Department. Records show that VA in this eye started out at 20/40 and is now Counting Fingers at 3 feet.

What would you do?

I don't refer much, but this would be on the way to a corneal subspecialist stat. I don't think a general OMD has any business with this either.

 

[Richard_Hom]

I don't refer much, but this would be on the way to a corneal subspecialist stat. I don't think a general OMD has any business with this either.

IndianaOD,

By the way it looks or by the vision? I actually took this case for the first week, had the corneal guru look at it. The Guru didn't change the plan of action at all, and asked me to monitor for two more weeks to see what the final outcome would be before the next step.

My question, when you see this come in, what are the top three things that go through your head?