Clinical Medicine Problem ....

[UWSO2003]

Hi all,

I'm posing an open question that hopefully some of your more experienced students/doctors can help me with.

The case is very open ended and was intended to be approached via. PBL (problem based) or EBM (evidence based) mindsets.

A 45 y/o african american male presents for his first eye exam in quite some time. He complains of difficulty reading the telephone book. His uncorrected VAs were 20/20 (-1) dist, and 0.4M at near.

Refraction showed a slight hyperopic correction for distance, and with cross-cyl a +1.00 add proved to make reading less strainful.

Anterior Seg exam showed discrete subepithelial infiltrates bilaterally, and IOPs of 8mmHg.

Posterior Seg exam showed 1 cotton wool spot 1DD nasal to the ONH on the OD. Examination of the posterior poles showed diffuse refractile deposits OU.

General health history was unremarkable. He is taking Tylenol for "pain" he associated with his job and his frequent headaches.


SOooooo ..... since this is a systemically oriented course this is where my group was thinking:

* Sarcoidosis: More prevalent in this racial group. Has been known to cause Ocular Hypotony via. a granulomatous anterior uveitis and/or iridocyclitis. Also shows corneal infiltrates. Also assoc. with retinochoroiditis and choriodal nodules. The posterior uveitis can also lead to pain (what the pt. may mistaken for headaches) and rhematoid like arthritis.

Problem is that we are missing several key signs such as AC rxns like cells+flare. The KP on the corneal endo was not noted. No other granulomatous response has been noted ... no skin lesions/marks.

*Whipple's Disease (Posterior Uveitis caused by a bacterial infection). This encompasses all the key S&S's ... but the problem is that this presentation is relatively rare. Zebras from the horses in this case ....

*Sickle cell diease (not necessarily anemia). Also more prevalent in this racial group. Now this hasn't been my area of focus, but from what I gather there are 4 main types. There are 2 which are "carrier" presentations. No family Hx was given. However, none of the tell-tale signs of sickel cell disease is presented. However, could this be a mild presentation?

Two more that were thrown out were:
*Lupus
*Multiple Myeloma

As you can see .... the case is quite vague. I'm not looking for a direct answer (as I'm sure it is quite possible this patient may be presenting with multiple problems) but perhaps some direction. What would you consider as a clinician? What are you hunches? What would you like to rule out? What would you like to consider that I haven't?

Thanks for reading ... hope to get some replies ... even if it's an "I don't know"!!

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[cpw]

I'm just a first year, so I'm not big on clinical presentation yet. That being said.. aren't those IOP's REALLY low?? I don't know if that indicates anything I'm just curious more than anything. I'd like to see what Tom might have to say about this one. Good luck on your assignment Freddie. I can't wait until I get to do stuff that's actually *gasp* relevent to optometry.

 

[UWSO2003]

Hi CPW (again),

The condition of Ocular Hypotony/ocular hypotension is technically classified as under 5mmHg. But out group was thinking the same thing ... seeing as 8mmHg is still quite boarderline.

I personally am leaning towards Sarcoidosis because of the fact that it can cause lowered IOPs via. an anterior uveitis/iridocyclitis. But still we're missing sooo many of the "typical" presentations assoc. with sarcoidosis. But, I've been told that not everything is text book obvious.

Argh ... well we have out first objectives tutorial where hopefully some things will be straightened out .... I'll keep you updated if you want!

 

[cpw]

yeah, that would be cool. keep me posted. More for curiosity's sake than anything else.

 

[TomOD]

Hey Freddie,

This guy sounds like just about every VA patient I have these days.

First off, it looks like his acuity is good with a small presbyopic add....thats a generally good sign, of course.

As far as the discrete subepithelial infiltrates bilaterally......hmmmm......could be from past trauma or infection or corneal dystrophy/degeneration.

IOP's of 8mmHg......a little low but not dangerous. Possibly due to previous surgery (had an 86 yo guy today who swore he never had eye surgery but had two patent Peripheral iridectomys and bilateral IOL's??....go figure). If no surgery...possible an inflamatory condition essentially "shutting off" the ciliary body"...ie. Uveitis???

Is that 1 cotton wool spot (infarct) that is 1 DD in size or 1 DD from the nerve? Could be DM or HTN but only 1 CWS may just be nothing. Usually DM will show much more retinal signs and HTN retinopathy doesn't occur until the pressure is greatly elevated. Did you have a BP reading?
Refractile deposits??...this is a good one. Could be cocaine retinopathy? Could be a hereditary retinopathy such as Dominant drusen??

Anyway with such vague findings, I really don't have a clue. Don't you just love school?

What I would do--- To keep from guessing all day, I would do a FA and send this guy to his Family doc (if he has one) to get a CBC and chest X-ray to begin.

Unless his insurance doesn't cover it. Then you have to beg him to get the test done which he won't because he just needs some glasses and doesn't know why you are doing all these tests.....OH I forgot, your in Canada...Never mind!

Good luck. Let us know what you find out.


Tom

 

[medstud721]

Forget the family doc--he will just refer this patient to an ophthalmologist.

If you want the answer, refer him to the EyeMD to help you out--this will be a piece of cake for him/her.

It's funny to hear optoms talk about disease!

 

[abs1]

Hahhaha, you have to admit this medstud dude is funny. He's tryng soooooo hard to piss us all off. That last post was so transparent that it really is making me lol! Good stuff. <img src="graemlins/laughy.gif" border="0" alt="[Laughy]" /> <img src="graemlins/laughy.gif" border="0" alt="[Laughy]" /> <img src="graemlins/laughy.gif" border="0" alt="[Laughy]" />

 

[cpw]

so, come on Freddie, what was the answer?? Enquiring minds want to know. (and anything's better than going back to studying ocular anatomy lab)

 

[UWSO2003]

Hey C,

Well it's still a work in progress. My profs and I are having a little dispute on how Problem Based Learning should be implemented

Well it's been probably narrowed down to two main problems .... one which no one thought of!

1) Sarcoidosis
2) HIV

Again, sarcoidosis can manifest itself initially with ocular signs and sympotms. However, a definitive diagnosis would require either lung or conjunctival biopsy and a Gallium Scan. However, our patient again has not presented with any sort of systemic manifestations of a typical sarcoid patient. This is where my profs and I disagree on how PBL should work. So far they have "sat back" in our tutorials ... where as I feel their expertise would be better served in a guiding/probing type role. We haven't been given access to any other information ... ie. futher case history, futher testing results etc.
One quick little peice of info that was brough up was the prevalance of sarcoidosis in different racial groups. In North America, Sarcoidosis has a higher indicence in african americans ... however in Europe Sarcoidosis is seen more in those from Northern regions of Europe .. such as Ireland and Scotland.

Now HIV. It's funny because you're always told to consider the "horses" and not the "zebras" ..... but we were told to still consider HIV. I realise that it is important to consider all options ... there was not sign pointing specifically towards HIV. Case history was normal, the patient is "happily married" and has an unremarkable medical history. However ... all the "eye" signs can manifest from opportunistic infections ... The IOPs can be a result of iridocyclitis. The corneal infiltrates can be from IK, HSK, VSK ... and the retinal signs and symptoms can be from a multitude problems such as PORN, HIV retinopathy (via. microvasulopathy).

The case is definitely interesting ... however I think that it's very unrealistic that we could come to this kind of a clinical conclusion from what we were given. In most cases, you'd probably think along the lines of TomOD. You'd want to gather a more detailed history, preform tests to rule out certain conditions and others to confirm your tentative diagnosis. It's nearly impossible with any certainty to say that Patient X has this problem ..... I'll keep you updated ....

 

[acurarte]

How about syphilis?

 

[Whisker Barrel Cortex]

Wow, I didn't know PORN could cause retinal signs and symptoms Although I agree that with the history you were given, HIV wouldn't be high on your list, it is definitely NOT a zebra. There are many more people with opportunistic infections due to HIV than due to sarcoidosis.