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Do No Harm?. Adam Lee Clint Wolk. 2/13/06. 52yo African Male CC: “eye pain”, OD, constant, years, severe
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Do No Harm? Adam Lee Clint Wolk
2/13/06 52yo African Male CC: “eye pain”, OD, constant, years, severe Patient was told that he was hit in the right eye at age 7. He occasionally has pain in that eye. He says that his peripheral vision has dramatically decreased in his right eye over the past four years. Patient recalls passing out while driving twenty years ago in Philadelphia. He said that he was taken to a hospital and told that "blood moved to his eye." A peripheral iridectomy was performed at that time.
2/13/06 ROS: no medical conditions NKDA Food allergies (not listed what) No meds
2/13/06 VAcc: OD: Light perception, OS: 20/30 OD pupil fixed at 5mm Constricted VF OU Low myope, BVA 20/20 OS Ant Seg WNL, except IOP: 46 OD, 12 OS Peripheral Iridectomy OD superior/temporal Optic disc cupped out OD Peripheral hemhorrages OD
2/13/06 Dx: Ocular Trauma Glaucoma Near end-stage OD. Hemorrhages in mid-periphery of right eye possibly related to carotid occlusive disease. Immediate consult with internist should be scheduled. Schedule glaucoma evaluation--fields, OCT-- after visit to MD (in 1-2 months). Rx: Xalatan .005% OD qhs
5/31/07 CC: Annual Exam, mild tearing OD Pt wants Progressives instead of Flat Top Bifocals "Right eye is gone"-referred to right eye being totally blind Patient notes that at time of his LEE he could see a little in the right eye, but about 4-6 months later, "it was all gone“ Never took Xalatan gtts he was given at last exam No mention of food allergies at this exam
5/31/07 VAcc: OD: NLP, OS: 20/20 No changes since last exam Ant Seg: WNL, except IOP 58/16 Small (~3mm) scar on temple near right eye (patient states this was not from the trauma that caused loss of vision in OD) some sort of family ritual 3 rounds of Lumigan, Betoptic, Azopt used in attempt to bring down IOP (IOP stayed 58 OD) /attempted gonio compression and IOP 40 OD (perhaps also sec to meds) 4-mirror OD: angle appeared recessed, heavily pigmented
5/31/07 Sent patient home w/sample of Azopt for bid instillation. Scheduled for co-mgt consult 6/6/07, EHMS clinic. Pt ordered SV specs.
6/13/07 Pt had an allergic reaction (hives) which began Thursday, about a week after starting the Azopt, yesterday came to UMSL and was unable to see a doctor, collapsed outside of building, taken to DePaul Health Center, told he had an allergic reaction to the eye drops and was given Benadryl q6hr, oral Prednisone, and Epinephrine. Pt states that only other med was Advil (which he has taken in the past without problems), entire body was swollen and itching. Rash started around eyes, then spread to entire body. Asked pt about food and medication allergies, pt stated none and has never had anything like this happen before.
6/13/07 Front Desk: “Pt came to pick up his glasses on Tues 6/12/07 at 10:15 am. At that time he stated that he would like to see a doctor for the rash on his arms and legs. Front desk personnel sent him to health services on North Campus.”
6/13/07 IOP: 35/14 Delayed hypersensitivity reaction to Azopt which resulted in hospitalization Pt education on glaucoma and the increased risk of POAG in OS due to traumatic glaucoma OD. Pt states no pain OD, told to RTC if OD becomes painful and begin glaucoma therapy at that time. Checking on getting funding for fundus photos OU and a HVF 30-2 OS.
The Big Bad Drop Azopt (brinzolamide) 1% ophthalmic suspension Mechanism: Carbonic Anhydrase inhibitor Class: Sulfonamide Preservative: Benzalkonium chloride
Adverse Reactions 5-10% of patients experience side effects such as blurred vision, stinging, bitter taste, or sticky lids <1% experience an allergic reaction, alopecia, chest pain, diarrhea, diplopia, dizziness...on and on
Systemic Absorption From the insert: "Azopt is a sulfonamide and although administered topically it is absorbed systemically. Therefore, the same types of adverse reactions that are attributable to sulfonamides may occur with topical administration of Azopt"
Systemic Absorption 1 drop 3x/day OU is equivalent in systemic absorption to taking a 1mg capsule 2x/day The amount of absorption is detectable in RBC's: saturation is achieved about 4 weeks after therapy is initiated It has a long half-life of approximately 111 days Excreted in urine
The Hypersensitivity Reaction Timing suggests either: Type III (immune complex mediated) or Type IV (delayed type) Type III is more often associated with drugs and its onset can be "delayed"
Type III IgG antibodies bind with the antigen, in our case the drug or its byproducts Antibody-Antigen complex is deposited locally in the tissues, usually the basement membrane The complex triggers anaphylotoxins resulting in mast cell degranulation, neutrophil recruitment and their liberation of lytic enzymes This local response is known as an Arthus reaction
Type III The complexes may also enter the bloodstream, this is known as a generalized reaction Deposition is common on vascular endothelium, synovial tissue, and glomerular b.m. As the complexes are accumulated serum sickness may develop Fever, weakness, vasculitis, rashes with edema and erythema, lymphadenopathy, arthritis, and glomerulonephritis can occur The severity of either the local or general reaction is directly related to the amount of complexes
Treatment of Hypersensitivity Rxn Suppress the inflammation and immune response Our pt. was given just about everything: corticosteroid, anti-histamine, epinephrine Corticosteroids prevent the formation of arachidonic acid and therefore the cyclooxygenase and lipoxygenase pathways which are responsible for virtually every inflammatory product Anti-histamines are competitive inhibitors of H1 sites on vascular endothelium preventing dilation and reducing permeability Epinephrine relaxes smooth muscle of the airways and inhibits bronchospasm as well as constrict arteries slowing the dissemination of inflammatory products
Take Home Message(s) This patient is allergic to Sulfa drugs, make sure pt’s know their allergies. Be aware that allergic reactions to medications you prescribe can occur, but don’t let that keep you from prescribing, you know how to manage the allergic reaction as well. “Buy a digital camera and bring it with you to clinic, you wont have to run around like an idiot looking for one when something interesting comes up”----Dr. Crane
