1. New SDN Article! The Residency Interview Trail
    Dismiss Notice

Case #9 (03-26-2004)

Discussion in 'Ophthalmology: Eye Physicians & Surgeons' started by Andrew_Doan, Mar 26, 2004.

Previous Thread Next Thread
Loading...
  1. Andrew_Doan

    Andrew_Doan Doc, Author, Entrepreneur
    Physician Moderator Emeritus Lifetime Donor Verified Account 15+ Year Member

    Joined:
    Oct 1, 2002
    Messages:
    5,633
    Likes Received:
    17
    Status:
    Attending Physician
    CC: 60 y.o. man who was evaluated 1 wk ago for ?conjunctivitis? OS by internal medicine.

    HPI: Patient complained of a painless, gradual redness of his left eye over the last several months. He does not report any pain, discharge, discomfort, or itching. He presented to the on-call ophthalmologist for evaluation. He pointed to some fullness of the superior aspect of the medial canthus OS with mild conjunctival injection. Pt also complained that things were "blurry" with a slight double image, which resolved when one eye was closed separately.

    PMH: h/o non-Hodkin's lymphoma and in remission for numerous years. No other ocular history or medical problems. No h/o of ocular traumas or sugeries.

    EXAM
    Best corrected visual acuities: 20/20 OU.
    Pupils: 4.5->3.5, no RAPD
    EOM: elevation deficit OS with left hypotropia in primary gaze; VF Full to FC OU
    IOP: 18 mmHg OD, 19 mmHg OS
    DFE: retina exam notable for normal macula, vessels, and periphery OU. Optic nerves, normal.
    SLE: OD normal, OS see photos below.

    Hertel (base 113): 13 mm OD and 17 mm OS

    EOM: Note the left hypotropia in primary gaze and elevation deficit OS with upgaze.
    [​IMG]

    Left eye with superior conjunctival injection.
    [​IMG]

    Left medial canthus with fullness. Note the asymmetric ptosis OS (more ptosis medially).
    [​IMG]


    Feel free to discuss the following:

    What tests should you order (I'll post labs when asked for them)?

    What's the differential diagnosis?

    What's the diagnosis?

    What is the treatment of choice, surgically and/or medically?
     
    Stop hovering to collapse... Click to collapse... Hover to expand... Click to expand...
    #1 Andrew_Doan, Mar 26, 2004
  2. Redhawk

    Redhawk Fellow
    7+ Year Member

    Joined:
    Jul 2, 2003
    Messages:
    186
    Likes Received:
    0
    He appears to have orbital involvement causing left proptosis and diplopia. Do you have an MRI?

    Lymphoma can mimic conjuctivitis. I would think that the lack of itiching or burning would raise suspicions even higher.
     
    #2 Redhawk, Mar 26, 2004
  3. Kalel

    Kalel Membership Revoked
    Removed

    Joined:
    Feb 1, 2004
    Messages:
    792
    Likes Received:
    3
    Yup, I agree. Lymphoma causing a mass effect in the orbit is the most probable diagnosis. The only other dx's in the differential that I could think about was cavernous venous thrombosis or some weird case of neurosarcoidosis? Anyways, w/u would begin with an MRI. If a tumor is seen, a CT of the whole body should be ordered to stage, and optho might be able to do a biopsy or needle aspiration to confirm the dx. CBC, CMP, HIV test, beta 2 microglobulin, LDH, HTLV should also be ordered.
     
    Stop hovering to collapse... Click to collapse... Hover to expand... Click to expand...
    #3 Kalel, Mar 26, 2004
  4. Andrew_Doan

    Andrew_Doan Doc, Author, Entrepreneur
    Physician Moderator Emeritus Lifetime Donor Verified Account 15+ Year Member

    Joined:
    Oct 1, 2002
    Messages:
    5,633
    Likes Received:
    17
    Status:
    Attending Physician
    I got a CT because it's faster, and I wanted to see the boney architecture.

    Coronal without contrast
    [​IMG]


    Axial without contrast
    [​IMG]
     
    Stop hovering to collapse... Click to collapse... Hover to expand... Click to expand...
    #4 Andrew_Doan, Mar 29, 2004
  5. Redhawk

    Redhawk Fellow
    7+ Year Member

    Joined:
    Jul 2, 2003
    Messages:
    186
    Likes Received:
    0
    #5 Redhawk, Mar 29, 2004
  6. Kalel

    Kalel Membership Revoked
    Removed

    Joined:
    Feb 1, 2004
    Messages:
    792
    Likes Received:
    3
    I was just thinking that an invasive biopsy may not be indicated in this case since the patient has already earned a previous dx of lymphoma. Given that the patient has compressive sx, he is probably indicated for a surgical intervention anyways. A full physical exam and a full body ct should still be done with my previously reccomended labs; the exam and scan may turn up some easier sources for histology.
     
    Stop hovering to collapse... Click to collapse... Hover to expand... Click to expand...
    #6 Kalel, Mar 29, 2004
  7. Andrew_Doan

    Andrew_Doan Doc, Author, Entrepreneur
    Physician Moderator Emeritus Lifetime Donor Verified Account 15+ Year Member

    Joined:
    Oct 1, 2002
    Messages:
    5,633
    Likes Received:
    17
    Status:
    Attending Physician
    I don't think we can get enough tissue for diagnosis with a FNAB. Path diagnosis of lymphoma requires multiple stains and to look at the organization of the lymphocytes, e.g. are they forming germinal centers. FNAB would make it very difficult to analyze.

    Excisional biopsy is the most appropriate method to confirm the diagnosis. It's important to make a definitive diagnosis before treatment. The patient did have a full body CT scan which was negative.

    The diagnosis and discussion are posted on the Iowa site:
    http://webeye.ophth.uiowa.edu/eyeforum/case9.htm
     
    Stop hovering to collapse... Click to collapse... Hover to expand... Click to expand...
    #7 Andrew_Doan, Mar 30, 2004
Previous Thread Next Thread
Loading...
(You must log in or sign up to post here.)

Share This Page