Case Summary:
A 74-year-old African American female presented for an annual exam and follow-up care for Grave's Ophthalmopathy. She reported chronic symptomology that included tearing, photophobia, swollen lids, pain behind the eyes, and intermittent diplopia. Her previous care had been somewhat fragmented due to a complex medical and psychosocial history. Objective testing corroborated the likelihood of her primary diagnosis as the cause of the reported symptomology. Over the following year, there was evidence of mild progression of the Grave's Ophthalmopathy. Both social service and neuro-ophthalmologic consultations have been initiated to better manage this patient's condition and to coordinate multi-disciplinary healthcare efforts. Palliative treatment of the reported symptoms and detailed patient education/counseling were also undertaken.
Case Report:
M.C. is a 74-year-old African American female who presented as an established patient to the Illinois Eye Institute (IEI) on July 28, 1997 for a general eye examination. She was not presently employed outside of the home M.C. reported chief complaints that included intermittent diplopia, dizziness, tearing, foreign body sensation, photophobia, lid swelling, and pressure behind the eyes chronically for several years with frequent, spontaneous exacerbation's and remissions for the last several years. She further reported a gradual increase in both frequency and severity of the above symptoms.
M.C. has been followed as a patient at IEI sporadically since 1990. She has voluntarily re-entered and discontinued treatment in accordance with her financial situation and frustrations about the chronic nature of her condition. Her last ocular examination at IEI was on 11/27/95, as she has not been compliant with the recommended follow-up regimen. She has sought no other vision care. Her primary ocular diagnoses included Grave's ophthalrnopathy, compound hyperopic astigmatism, presbyopia, early nuclear sclerotic cataracts, and borderline intraocular pressures, and left hypotropia. She has previously been prescribed separate distance and near spectacle prescriptions (the former containing vertical prism), and has been placed on a daily regimen of ocular lubrication. Compliance with these treatment modalities was also sporadic. Her family ocular history was unremarkable.
M.C. 's last general medical examination was approximately one month ago where she reported that her care has been equally sporadic due to the same psychosocial factors discussed above and because of frequent disagreements with her health care plan. Her primary medical diagnoses included Grave's disease, cardiomegaly, hypertension, status post CVA, and questionable SLE. Her current daily medications include Synthroid, Lanoxin, Cordarone, Lasix, Vasotec, and Hydralazine. She reported allergies to certain radiographic contrast media and had a family medical history that was remarkable for thyroid disease and various forms of cancer.
Ocular Evaluation:
Uncorrected visual acuities at distance were 20/40 OD, 20/40 0S, and 20/30 OU. Corrected visual acuity's at through habitual of +4.25 -0.75 x 030 OD and +4.25-0.75 x 150 OS were 20/40 OD and 20/50 OS at 14 inches. Manifest refraction in the distance yielded -0.50 DS OD (20/30+) and p1-0.50 x 150 OS (20/30+) with a +2.50 add required at near to achieve 20/25 0U at 16 inches. 5 prism diopters base down OD and 5 prism diopters base up OS were required to provide fusion in primary gaze of the distance for a majority of viewing time. This represents a significant myopic shift and a slight increase in vertical prism from the last recorded spectacle prescription. Cover test showed an 8 prism diopter left hypotropia at distance uncorrected and a 4 diopter left hypotropia at near through habitual reading prescription. Extra-ocular motility testing showed a grade 2 bilateral restriction in up gaze with some discomfort and a slight increase m symptomology in upgaze in horizontal extremes of gaze. Pupils were round, regular, and equally reactive to light with no afferent pupillary defects. Confrontation fields in each eye were full to finger counting. Color vision, tested via Ishihara plates, showed no defects in either eye. Keratometry readings were 43.75/45.50 OD and 44.00/45.12 OS with grade 1 distortion and fluctuation upon blinking. Forced duction testing revealed an equivocal positive result in attempted up gaze. Blood pressure was 135 I 85 RAS. Biomicroscopy was remarkable for a significant lagophthalmus OD>0S, trace left lid retraction, bilateral incomplete blink, grade 1+ lid swelling OU, grade 1+ inferior comeal SPK OU, tear break-up time of 2 seconds OU, and Grade 1 cortical/nuclear sclerotic lenticular changes OU. Palpebral apertures were measured atI 1lmm OD and 12.5mm OS. Exophthalmometry, as measured by Hertel, was l8mm OD and 18.5mm OS with a 96mm base. Tonometry, as measured by applanation technique, was 18 mmHg OD and 19 mmHg OS. A dilated flindus evaluation was performed using 1% Tropicamide and 2.5% Phenylephiiine in each eye. The fundus evaluation was essentially unremarkable, with no retinal folds or optic disc swelling indicative of compressive optic neuropathy. Cup to disc ratios of 0.55 x 0.55 OU with normal neuro-retinal rims and distinct margins, and an artery to vein ratio of 0.6 were found OU. Each macula was clear with a dim, but distinguishable foveal reflex. The right eye showed a longstanding area of myelination approximately 1 disc diameter superior to the optic disc. The vitreous and peripheral retinas of both eyes were unremarkable. An automated, threshold visual field and orbital ultrasound were strongly recommended to the patient at this visit, but both were declined due to the time and effort required.
The patient's primary ocular assessments for this visit included Grave's ophthalmopathy -atypical stage 5, longstanding vertical tropia, simple myopia, myopic astigmatism, early cortical/NS cataracts with presumed myopic shift, and dizziness of unknown etiology. The patient was placed on a regular regimen of ocular lubrication (6X/day) and cold compresses, separate distance and near prescriptions were written with appropriate prism corrections, and telephone/written correspondences were both initiated the patient's internist. A full neurologic evaluation with appropriate imaging studies of the head/orbits, and a screening test for diabetes mellitus were requested. The patient was educated about the chronic yet manageable nature of her ocular diagnoses, and admonished about the importance of compliance with both treatment and follow-up regimens. She was also urged to reconsider undergoing both the visual field and orbital ultrasound testing. A follow-up date for 4 months was established.
Follow-up # 1:
M.C. returned on August 9, 1997 for an emergency follow-up visit,
complaining of blur and
diplopia with her new spectacle prescriptions and confusion over the
use of the ocular lubricants. Visual acuity's, as measured through
her new distance prescription, were 20130+ OD and 20/30+ OS.
Single vision was found to be present in primary distance gaze for
the vast majority of the time. Near vision, as measured through the
patient's new reading only prescription, was found to be 20/25 OU
with no diplopia reported. The prescriptions were verified and found
to be as written. Entrance tests and biomicroscopy showed no
significant changes from her previous exam one month earlier. Upon
further questioning, it became apparent that the patient had confused
the use of the two prescriptions.
M.C. was re-educated about the correct use of her spectacle prescriptions, as well as the most efficacious use of ocular lubrication for her condition. She discussed, at length, being both emotionally and financially overwhelmed by her healthcare issues and personal circumstances, but declined a social service referral. She also declined further ophthalmic testing at this time, but agreed to keep her follow-up appointment in 3 months and to call me if she again begins to feel overwhelmed by her ocular treatment regimen or diagnoses.
Follow-up #2:
M.C. failed to show for her scheduled appointment. Both written and telephone contact were attempted to no avail.
Follow-up #3:
M.C. returned to clinic for her next appointment on June 3, 1998. She complained of more frequent diplopia with distance viewing, dryness and mucoid discharge gradually increasing upon awakening in the AM, more pronounced tearing and photophobia than previously, and an increase in the pressure sensation behind her eyes. In short, all of M.C.'s previous subjective complaints seemed to be gradually worsening. The patient was extremely fatigued and overwrought, declining a complete examination, but agreeing to a limited, problem-oriented exam, today. The patient's medical history was unchanged except that Hydalazine had been eliminated from her medication regimen.
Visual acuity's, as measured through the patient's present spectacle prescriptions, were unchanged from the previous exam, however, 2 more vertical prism diopters were required to allow single vision in the distance for a majority of viewing time in primary gaze. Extraocular motility testing showed a grade 2+ restriction bilaterally in up gaze with slightly earlier pain and diplopia than had been previously noted. Biomicroscopy showed grade 2 diffuse conjunctival injection with some concentration near the recti muscles, grade 2 bilateral lid edema, and grade 2+ inferior corneal SPK. Exophthalmometry, as measured by Hertel, was 19mm OU with a 96 mm base. The patient declined further testing today.
The decision was made to defer any changes in the patient's spectacle prescriptions until she was better rested and less distraught. The frequency of ocular lubrication was increased during the day to 1 gtt every 1-2 hours. A bland ointment was still to be used at bedtime with the addition of lid taping as needed to improve comfort in the AM. The patient was also instructed to use extra pillows at night to maintain a more upright posture and, thereby, help alleviate some of the lid swelling. M.C. agreed to compliance with these measures and also expressed willingness to accept a social service referral. A consultation request was filled out and sent to the IEI Social Work department. She also agreed to return in 4 weeks for further ophthalmic testing.
Follow-up #4:
M.C. returned to clinic for her next visit on July 23, 1998. She reported significant improvement in all of her ocular symptoms except the diplopia at distance, which she felt was essentially stable. She also reported contact with the IEI Social Work department, which she felt was having a very constructive effect on her stress level. The patient also reported that, after consultation with her primary care physician, Prozac had been added to her daily medications, and she was feeling optimistic about the effects of these interventions.
Manifest refraction revealed a slight change in her distance prescription: OD was found to be -0.25-1.00 x 035 (20/30) and OS was found to be p1 -0.50 x 150 (20/40+). Additionally, a total of 12 vertical prism diopters was split between the two eyes to maintain single vision in primary distance gaze. This represents a net increase of 2 prism diopters. Entrance tests, such as EOM's , pupils, color vision, confrontation fields, and cover test appeared unchanged from previous exams. Biomicroscopy showed significant improvement of conjunctival injection, corneal SPK, and lid swelling. Lagophthalmus, slight bilateral lid retraction, and incomplete blink appeared unchanged from previous exams. The nuclear sclerotic changes of the left lens appeared slightly more advanced. Forced duction testing also showed no clinically significant change from one year prior. Tonometry, as measured by applanation technique, showed pressures of 19 mm Hg OD and 20 mm Hg OS. Attempted up gaze showed an increase in lOP of approximately 3 mm Hg in each eye. A dilated fundus exam that was completed today also failed to show clinically significant changes from prior exams. A Humphrey Th24-2 automated threshold visual field was performed and showed no clinically significant changes OU. Orbital ultrasonography was also performed, today, and showed mild thickening of both inferior recti muscles and questionable thickening of the left medial rectus muscle. The orbital apex did not appear significantly attenuated.
M.C.'s primary ocular diagnoses remained Grave's ophthalmopathy, longstanding left vertical tropia, compound myopic astigmatism, myopic astigmatism, and early cataracts. Over the past year, there was slight progression of the sign and symptoms related to the Grave's ophthalmopathy, but improved compliance and more aggressive palliative treatment with ocular lubrication has caused significant recent improvement. A new spectacle prescription with slightly increased vertical prism has been recommended to meet the patient's distance viewing needs. Social service intervention and counseling have clearly been helpful in alleviating much of the patient's chronic frustration and anxiety. A follow-up visit to check on performance with the new distance spectacles has been scheduled for one month. Once again, both telephone and written correspondence were attempted with the patient's PCP to advise of her ophthalmic status and to request neuro-ophthalmologic consultation with appropriate imaging studies. This would rule
out the presence of certain serious systemic disease entities and, hopefully, better monitor the patient's clinical presentation.
Discussion:
Until recently, Grave's disease was very poorly understood. Even now, we don't completely understand its etiology or pathogenesis. The medical literature generally agrees that Grave's disease is essentially an autoimmune phenomenon in which an immune response develops to certain follicular cells of the thyroid gland and/or fibroblasts and myocytes of the orbits. Auto-antibodies to these cells are generally produced, often in the presence of certain abnormal lymphocytic regulation. Certain abnormal HLA markers have also been implicated, although the association is clearly imperfect.
The people most likely to develop Grave's disease are women between their third and fifth decades of life. A familial history of thyroid disease and smolting are further risk factors. While males are only one fifth as likely to develop Grave's disease as women, when it does occur it is far more likely to run a severe course. M. C. was definitely a member of this high- risk group.
Between 20 and 40 percent of Grave's disease patients eventually develop clinically significant Grave's ophthalmopathy, often close in temporal sequence to the recognition of abnormal systemic function (especially thyroid). However, it is important to remember that the ophthalmopathy can either antedate the systemic fmdings or follow successful systemic treatment of the associated thyroid disorder by many months. Here again, the case of M.C. applies. A significant portion of Grave's patients will also remain euthyroid.
From the optometric point of view, the earliest changes to look for in diagnosing Grave's ophthalmopathy are the indicators of soft tissue inflammatory infiltration such as lid retraction, upper lid lag on down gaze, tremor of the closed lid, and decreased blink frequency. Close in temporal sequence to these fmdings will be conjunctival injection or chemosis, especially around the recti insertions, and lid swelling or edema. Next in usual sequence is the development of clinically significant proptosis (generally greater than 22-24 for African Artiericans or showing greater than 3mm asymmetry) which further accentuates the startled appearance of the patient. A further progression of inflammatory infiltration may now involve the extra-ocular muscles, with secondary motility disturbances, restriction, and/ or diplopia. As the disease progresses to its most sight-threatening stages, corneal scarting from exposure Idessication and compressive optic neuropathy from EOM compression at the orbital apex, are possible.
There are a number of clinical optometric tests for detection and monitoring of these fmdings at every stage. There are, however a some key points to remember, overall. One, Grave's ophthalmopathy is not necessarily a linear progression; certain stages can be absent entirely and some can be accentuated out of sequence. Two, instead of trying to tie the clinical picture to an arbitrary numeric scale, the optometrist should monitor for qualitative changes that may herald the possible occurrence of vision-threatening changes, and concentrate on palliating symptoms wherever possible. Patient quality of life is always a priority. Third, Grave's can be a diagnosis of exclusion, and it is important to rule out the presence of other potentially serious medical problems or medication side-effects that may be contributing to the clinical picture. Fourth, it is important to regard patients holistically, especially when attempting to manage a chronic, sometimes nebulous disease entity like Grave's. Long term patience, follow-through, and communication are important.
The above case of M.C. is clearly illustrative of these points. Her clinical presentation of Grave's ophthalmopathy is hardly typical of the linear progression of classification in identiiying stage 5 disease. Her past medical history is rather complex with several uncertainties due to inconsistency of care, and she is utilizing a number of medications that could significantly be altering her clinical presentation. Specialty referral were clearly necessary to rule out certain serious systemic problems and to better monitor her potential visual prognosis. In addition, this patient had enough stress in her life to defmitely impact the potential success of medical or optometric care for a number of reasons. Patient yet aggressive palliative treatment of her symptoms and social service consultation made a tremendous difference in her satisfaction with care and quality of life. Unfortunately, there has been little success in achieving either cooperation or communication with several participating providers of M.C. 's healthcare plan.
|
OD |
STRUCTURE |
OS |
|
clear |
External Lids/ Lashes |
clear |
|
pink, smooth |
Palpebral Conjunctiva |
pink, smooth |
|
no infection |
Bulbar Conjunctiva |
no infection |
|
clear |
Cornea |
clear |
|
open |
Angle Approach |
open |
|
deep and quiet |
Anterior Chamber |
deep and quiet |
|
(+) transillumination |
Iris |
(+) transillumination |
|
clear |
Lens |
clear |
|
soft |
Digital Intraocular Pressures |
soft |
Dilated Fundus Examination
|
OD |
STRUCTURE |
OS |
|
0.1 with distinct borders |
C/D Ratio |
0.1 with distinct borders |
|
Hypoplasia, (-) reflex |
Macula |
Hypoplasia, (-) reflex |
|
(-) tortuosity, normal limits |
Vessels |
(-) tortuositym normal limits |
|
Hypopigmentation of retinal pigment epithelium |
Periphery |
Hypopigmentation of retinal pigment epithelium |
Assessment:
- Oculocutaneous Albinism
- Congenital Nystagmus
- High Myopia OU
- Suspicion of decreased visual acuity secondary to macular hypoplasia OU
- Alternating X(T) at distance and near
- Cocaine and crack toxicity from birth with secondary developmental delays
Plan:
A spectacle Rx of -10.00 was given to AG. The Rx was prescribed for full time wear. Ms. B. was instructed to monitor changes in AG's visual behavior and motor skills and report the results at a 6 week follow-up appointment. The re-evaluation will consist of a repeat attempt to measure visual acuity. Cover testing is to be done with and without the spectacle correction.
Diagnostic Data (Visit #2, Follow-up):
AG has been wearing his -10.00 spectacle Rx for one month. Ms. B. reports that AG rarely removes his glasses. She has noticed significant changes in AG's overall functioning. He has shown a tremendous increase in activity and "gets into everything now". He is now able to sit at a proper viewing distance to enjoy the television. Ms. B notes that the eye turn (XT) is present, but less frequent.
A measure of visual acuity was attempted with Cardiff Visual Acuity cards. A questionable result of 20/64 OD, OS visual acuity was achieved. This is a rather high VA for a child with oculaocutaneous albinism and subsequent macular hypoplasia. To rule out any possible amblyopia a small object (colored sprinkles) was placed in the palm of the examiners hand while the patient was coaxed to pick it up monocularly. AG would not comply with this task. Cover testing (with and without the Rx) revealed an intermittent alternating exotropia at
distance and near. Estimation of magnitude was done by the Kappa /Hirschberg method.
A 20°(XT) was present at distance and near with and without the spectacle prescription.
A pendular nystagmus was present in all fields of gaze. No limitation of eye movements
were noted.
Retinoscopy performed over the current -10.00 prescription was OD plano, OS -0.50 sphere. Again, secondary to the manifestation of the alternating X(T) retinoscopy was done monocularly.
Assessment/Plan:
AG is to continue full time wear of his myopic prescription. Considerable improvements in visual and motoric behavior have been noted since the dispensing of the spectacle Rx. Ms. B was educated on the possibility of a contact lens fitting in the future, as AG matures. The benefits of contact lens wear include maximizing visual acuity and dampening the nystagmus. The management of the exotropia was also discussed. The reasons for treatment include attempting to establish binocular vision and any cosmetic factors which may be of concern (especially in the future). The primary options of a base in prism prescription with or without the incorporation of a vision training program will be addressed as AG matures. Ms. B was also educated on the option of strabismus surgery if all other treatment options were unsuccessful.
AG and Ms. B are to return to our clinic in in order to run a Visually Evoked Potential (VEP) to determine the maximum visual acuity. Due to the patient's age and limited attention span visual acuity evaluation has not been possible. The VEP measure may give some insight regarding the best achievable visual acuity. If visual acuity measures are reduced (as is expected), then proper education and direction regarding low Vision intervention as the patient matures will be in order.
Diagnostic Data (Visit #4, VEP Evaluation):
A Flash Visual Evoked Potential was perfomed. Estimated visual 20/200 OD, OS. No response was elicited to a Pattern VEP.
Case Analysis:
The visual acuity measure found with the flash VEP was reduced. Patients with oculocutaneous albinism suffer with reduced visual acuity secondary to the macular hypoplasia. The patient's care giver was educated about the reduced visual acuity in AG. It was also noted that electrodiagnostic measures in patients of this age are ofien difficult to obtain. The validity of the visual acuity findings will be known when we are able to repeat the test with the patient's increasing maturity.
The necessity of a low vision evaluation and the possible need for low vision aids in the future were discussed. Ms. B was given the number of our LOW vision clinic to contact with any specific questions she may have. We are to see AG in our pediatric clinic for follow-up in 4 months. The determination of when a low vision evaluation is to be performed will be decided as we monitor AG's progress and maturity.
NOTE: I was unable to continue follow-up with AG secondary to my career relocation.
|
|
Lens Type |
Base Curve |
Diameter |
Power |
|
OD |
Acuvue |
8.8 |
14.0 |
-6.50 |
|
OS |
Acuvue |
8.8 |
14.0 |
-6.50 |
Pertinent History:
T.B. presented for a comprehensive examination without any visual or ocular complaints. She desired a new supply of disposable contact lenses. She reported clear and comfortable vision at distance, intermediate, and near with both her glasses and contact lenses. She had achieved 14 hours a day of comfortable contact lenses wear. She reported good compliance with her two week lens replacement schedule and lens care regimen which included daily rubbing, rinsing, and soaking with Renu Multipurpose solution. Her current contact lenses were two weeks old. The patient had experienced a small amount of floaters OS>QD but stated they were long-standing and unchanged for many years. A rare occurrence of photopsia described as a tiny pinpoint of light had also been previously experienced OU, but not recently. She specifically denied any incidence of trauma, diplopia, asthenopia, or headaches. She also denied any personal or famlly history of glaucoma, strabismus, retinal disease, diabetes, hypertension, heart disease, or breathing problems. She was on no medications.
Eye Health Assessment:
Slit lamp examination revealed clean lids with good tonicity and apposition to the globe. The lashes and lid margins were clear of debris or meibomian inspissation OU. The bulbar conjunctiva was clear without chemosis OU. There was no discharge OU. The corneas were clear with no fluorescein starning OU. Nasal and temporal anterior chamber angles were a grade IV OU measured with the Von Herrick method. Pupils were equal, round, and reactive to light and accommodation without afferent defect. Intraocular pressures measured 15mmHg OD,OS at 1:30 p.m. with applanation tonometry. Dilated fundus evaluation (Instruments used: BIO and Superfield) with 2 gtts. Paremyd OU revealed an extremely blond fundus with a flat and intact retinal periphery absent of holes, tears, or degenerations 360 degrees OD. The inferior retinal periphery of the left eye showed a local elevation of sensory retina encompassing an area extending 4 disc diameters from the ora serrata. There was a sharp demarcation line along the posterior border of the elevation and two retinal breaks evident at the anterior border near the ora serrata. There was no pigmentation response around either retinal break or the demarcation line separating elevated from flat retina. There was also no evidence of any intraretinal fibrosis or intraretinal cysts. The superior temporal quadrant of the left eye had a small area of lattice degeneration without retinal breaks. There was no evidence of posterior vitreous detachment, vitreous cells, or vitreous hemorrhage OU. The cup to disc ratio was .3H/ .3V OD and .35H/ .4V OS with well perfused intact rim tissue 36000U. Each macula exhibited a large and bright reflex. The retinal vessels had a 3/5 artery to vein ratio without any evidence of nicking or banking. Automated visual field screening (Humphrey 40 point testing strategy) revealed full fields (40/40 OU). No visual field constriction could be exhibited with confrontations OU.
The contact lens fit showed a stable paralimbal soft lens fit with good centration, 360 degree corneal coverage, and 0.50mm movement OU. Each lens surface contained a trace amount of scattered protein deposits.
Refractive and Binocular Assessment:
The refractive diagnosis was compound myopic astigmatism QU. Binocularly balanced refraction showed no change from the previous spectacle or contact lens prescription. Analysis of binocular oculomotor function showed an orthophoria posture at distance and at near. Thirty seconds of stereoacuity was achieved testing with Randot circles. Negative relative accommodation measured +2.00 while positive relative accommodation measured -2.00. Ocular motility was smooth and full without overaction OU.
Supplementary Pertinent Data:
I have enclosed copies of the correspondence from the retinal specialist detailing the diagnosis and management of the retinal detachment and the ensuing follow-up care in his office.
Analysis and Diagnosis:
The presence of a retinal break with vitreal fluid elevating the sensory retina is consistent with a diagnosis of a rhegmatogenous retinal detachment. Typically, a retinal break is caused by retinal traction or overlying traction from the vitreous. In this case, the degree of myopia and early lattice degeneration served as two sources of traction. The absence of any pigmentation response, intraretinal fibrosis, or intraretinal cysts indicated that it was not a chronic, long-standing lesion. To aid determination of a possible time of onset of the detachment, the issue of flashes and floaters was readdressed. There was no change in the patient's response of denying any increase in the size, number, or frequency of floaters over any definable time period. Without being able to establish any chronicity of the lesion, it was managed as though it were of acute onset.
Optometric Management:
I explained to T.B. the nature of retinal detachment formation. This included tractional stress supplied by myopic stretching and lattice degeneration, retinal hole formation, and the process of vitreal fluid penetrating a retinal break and separating the layers of the retina. The severity of the condition was stressed in that the area of retinal separation can progress and that retinal function is lost in any area that is detached. The need for urgent evaluation and treatment by a retinal specialist was emphasized to prevent any progression of the detachment and any potential loss of vision. It was explained that many forms of treatment are quite successful in preventing further progression. The eventual elected form of treatment depended largely on the size, location, and extent of the detachment and could include scleral buckle surgery, laser surgery, or cryosurgery. Regardless of the treatment procedure, a key factor in successful outcomes is the early intervention of treatment from the time of onset to lirnit the extent of retinal damage.
To that end, T.B. was referred for an immediate evaluation by a retinal specialist. She was instructed to not eat or drink anything and to sit upright as she made her way to the ophthalmologist's office. Later that afternoon, I phoned to confirm that she kept the appointment and arrived safely. As the attached correspondence shows, the retinal specialist chose to perform a laser retinopexy procedure based on the small area, inferior location, and shallow nature of the detachment. The procedure was performed over the course of two separate office visits (5/9/97 and 5/22/97) due to the patient having a vasovagal response during the first application of laser burns. A total of 674 laser burns were successfully applied to seal off the area of retinal elevation.
Follow-up Care:
After follow-up visits with the retinal specialist in June of 1997, September of 1997, and March of 1998, T.B. was released from ophthalmological care and instructed to continue her comprehensive eyecare with the optometry clinic. In doing so, T.B. returned to our clinic on 4/1/98 for comprehensive examination. She reported no change in the size, number, or frequency of floaters and that the retinal specialist was pleased with her treatment outcome. She had no other visual or ocular complaints and there was no change in any ocular or medical health history except for starting on oral contraceptives.
Examination revealed stability of refractive and binocular measurements, as previously noted, with best corrected acuity of 20/15 OD,OS. Pupils were equal, round, and reactive to light and accommodation without afferent defect. Dilated fundus examination revealed a stable optic nerve, retinal vessel, and macular appearance. The retinal periphery OD was flat and intact 360 degrees and absent of retinal breaks or degenerations. A well defined, continuous line of chorioretinal scarring was evident at the posterior border of the retinal detachment OS. The inferiorly detached retina still exhibited rnrld elevation. The remaining area of the left retina was flat and intact. The small area of lattice degeneration in the superior temporal quadrant OS remained free of retinal breaks. The vitreous was clear and quiet OU.
Despite the great success of the prompt referral and treatment, T.B. was educated on her risk of recurrence of a retinal detachment in her left eye as well as developing a similar condition in the right eye. It was stressed to her the importance of being acutely aware of any increase in floaters or any flashes of light. If any such symptom was experienced, she should report to our clinic immediately. If not, she was instructed to return to our clinic each year for comprehensive evaluation including dilated fundus examination.
May 9, 1997
Dear Greg:
TB is a patient who has been a contact lens wearer for a number of years. She has been relatively asymptomatic with the exception of a few floaters that she had in the last six months. Her past medical history is positive for hypoglycemia. She is on no medications and has no allergies.
Her best vision today with a contact was 20/25 0.U. The corneas were clear and thin. The anterior chambers were deep and quiet. There were no cells in the vitreous. The pressures were 19 and 20. The fundus on the right showed a cup to disc ratio of approximately 0.3. The vessels1 macula and periphery were normal. The left eye showed a cup to disc ratio of approximately 0.3 with a normal appearing disc, macula and vessels. The inferior periphery was remarkable for a localized retinal detachment with two holes in the retina inferiorly. There was an early high water mark, indicating some degree of chronicity to the subretinal fluid.
I agree entirely with your assessment that TB has a retinal detachment inferiorly in the left eye. I talked with her about some of the management options that we have available to us and with this localized detachment inferiorly, she elected to go ahead and attempt a prophylaxis with laser retinopexy around the area. We plan on checking her again in about two weeks and will keep you informed of her progress.
RBC:taw
June 5, 1997
Dear Greg:
TB is a patient with a localized detachment of her retina in the left eye. We treated her with laser retinopexy on 5/22/97. She returned today with 20/25 vision in the eye. There was a nice surround of laser photocoagulation burns surrounding the margins of the detachment. There has been no extension and we are going to continue to watch her closely to determine whether or not there is any progression. I think this is a safe decision based on the inferior nature of the detachment and her relative young age. We will keep you informed of her progress.
RBC:tmw
September 9, 1997
Dear Greg:
I saw TB back on 9/9/97 She is a patient with a localized retinal detachment inferiorly in her left eye. I lasered around the detachment back in May and it this point, her vision remains 20/25 in the eye. The detachment has not moved significantly since her visit and in fact, the elevation appears to be somewhat less today than was present on her last visit.
I am very pleased with her progress thus far. I plan on checking her again in about six months.
RBC:unw
July 14, 1998
Dear Greg:
This letter is in response to your request for a more complete accounting of the management of TB localized retinal detachment in the left eye. When we initially saw her on 5/9/97, we attempted a laser retinopexy around the detachment inferiorly in the left eye. TB has a vasovagal reaction after approximately 308 laser spots in that eye. We subsequently had her return on 5/22/97, where the laser photocoagulation session was completed. A total of 674 laser spots were used to provide a barrier to extension of the retinal detachment. She returned on 6/5/97, at which her visual acuity was 20/30 in the eye. There was a nice surround of laser retinopexy scars inferiorly. On 9/9/97, she returned with 20/30 vision in the eye. Again, there was no change in the detachment. On 3/10/98, the vision was 20/40 J1 and the detachment had not extended beyond the boundary of the laser photocoagulation scars. I will mention parenthetically that the choice for laser photocoagulation in the management of retinal detachments is somewhat controversial. The choice for photocagulation was made in this instance based on the asymptomatic nature of the discovery of the detachment, the inferior location and the chronic nature of the detachment. As you know, ordinarily scleral buckling is the management choice but in consultation with the patient we made the choice for laser retinopexy with close follow-up to document any evidence of progression. I hope this answers any questions you may have regarding my management of TB.
Sincerely,
RBC:tmw