1 / 38

Grand Rounds

Grand Rounds. Joseph Reck VAMC Wilkes-Barre, PA November 3, 2006. Clinical Presentation. Seen in Texas six weeks ago; GAT- 54 Current Medications: Diamox 500mg b.id.; ran out 5d ago Cosopt b.id. Atropine b.id. Brimonidine b. id. Ocular history:

hasad-bryan
Download Presentation

Grand Rounds

An Image/Link below is provided (as is) to download presentation Download Policy: Content on the Website is provided to you AS IS for your information and personal use and may not be sold / licensed / shared on other websites without getting consent from its author. Content is provided to you AS IS for your information and personal use only. Download presentation by click this link. While downloading, if for some reason you are not able to download a presentation, the publisher may have deleted the file from their server. During download, if you can't get a presentation, the file might be deleted by the publisher.

E N D

Presentation Transcript

  1. Grand Rounds Joseph Reck VAMC Wilkes-Barre, PA November 3, 2006

  2. Clinical Presentation • Seen in Texas six weeks ago; GAT- 54 • Current Medications: • Diamox 500mg b.id.; ran out 5d ago • Cosopt b.id. • Atropine b.id. • Brimonidine b. id. • Ocular history: • Cataract extraction without implantation, 1983. • Anterior chamber IOL implantation, 1987.

  3. Acuity and Externals • VA cc: O.D. 20/60, PH 20/40 O.S. 20/20 • Pupils: O.D. pharm fixed; O.S. RRL –APD • EOM: Full and smooth, O.U. • Confrontation fields; Full, O.U.

  4. Clinical Findings • Slit Lamp Exam: • 1+ injection. • Diffuse microcysts and SPK. • 1+ AC Reaction. • Iris atrophy with exposed iris vessels near ACIOL haptic foot.

  5. O.D. - 52 O.S.- 13 Tonometry

  6. Uveitic Glaucoma • Unilateral, red eye. • Pain and photosensitivity. • Corneal edema. • AC reaction. • Increased IOP.

  7. Inflammatory Cells • Decrease aqueous outflow • Physically obstruct trabecular meshwork.

  8. Synechiae

  9. Topical steroid. Pred Forte q15min; then taper. Strong cycloplegia. Atropine 1% b.id. Break synechiae. Phenylephrine 10%. Beta-blocker Alpha-agonist CAI Avoid Prostaglandins. Inflammation, then Pressure

  10. Assessment/Plan: • Lotemax q2h • Atropine t.id. • Cosopt b.id. • Diamox 500mg, b.id. • Follow-up in 1 week.

  11. One Week Follow-Up • VA cc: O.D. 20/100, PH 20/40 O.S. 20/20 • GAT: O.D. 52, O.S. 12 • 1+ AC Reaction

  12. Updated Treatment Plan • Continue meds as scheduled. • Add Alphagan t.id. • Run full uveitis work-up. • Follow-up next day.

  13. Return Visit • Patient experiencing some pain. • VA cc: O.D. 20/80, ph 20/30 O.S. 20/20 • GAT: O.D. 55, O.S. 11. • 1+ AC reaction.

  14. Differential • Unilateral increase in IOP • Steroid response • PAS • Endopthalmitis • Chronic inflammation • Retained lens material

  15. Gonioscopy • Lens position in iris; not angle • Small areas of synechiae. • Small areas of bleeding. • Peripheral rubeosis, superiorly. • Dilated iris tissue rolled into angle. • ACIOL haptics appear to have pushed peripheral iris directly into angle • Discontinue Atropine.

  16. UVEITIS • GLAUCOMA • HYPHEMA

  17. UGH Syndrome • Inflammation after anterior chamber IOL implantation, caused by the haptics of the IOL. • Misplaced or misdirected haptics from the anterior chamber IOL erode the tissues of the angle, causing bleeding and inflammation.

  18. UGH Syndrome • Excessive lens movement • Small size • Decentration or dislocation • Poorly manufactured edges • Iris-clipped IOL • Rigid, closed loop haptics

  19. Open Loop IOL -good finish/polish -easy to size -less area of contact Closed Loop IOL -difficult to fit -erosion chaffing -large contact zone -poorly finished/ sharp edges Open v. Closed Loop

  20. UGH with PCIOL’s • Unstable sulcus fixation • PCIOL decentration • zonular weakness • trauma

  21. UGH Etiology; Uveitis • Activation of innate immunity. • Theories • Cytokine and eicosanoid synthesis triggered by mechanical excoriation of the angle or iris by the haptics or optic • Plasma-derived enzymes (especially complement or fibrin) activated by the surface of the IOLs • Adherence of bacteria and leukocytes to the IOL surface • Toxicity caused by contaminants on the IOL surface during manufacturing or implantation

  22. Post-Operative Timing • UGH Development • Usually weeks to months. • Literature suggests 1-8 yrs. • This patient; 1987 to 2006 – 19 years.

  23. Clinical Spectrum • Iris pigment epithelial defects • Pigment dispersion • Microhypema • Macrohyphema I • Increase in IOP

  24. Presenting Symptoms • Intermittant blurring • ‘Redness’ to vision • Eye pain • Red eye • Photophobia

  25. UGH Complications • Pseudophakic bullous keratopathy • Corneal staining; recurrent hyphema • Chronic inflammation • Cystoid macular edema • Glaucoma

  26. UGH Management • Bed rest with elevated head position to encourage hyphema settling • Topical steroid • Reduce increased IOP • Ultimately, the lens may have to be repositioned or removed.

  27. UGH Treatment Options • Observe, treat episodes individually. • Pharmacologically reposition IOL • IOL rotation • IOL explanation +/- replacement.

  28. Patient Returns • VA cc: O.D. 20/50, ph 20/30 O.S. 20/20 • GAT: 22, O.D.; 13 O.S. • 2+ AC reaction. • Patient scheduled for IOL removal.

  29. STUDY:Indications for IOL Explanation (FL) • The majority of the removed IOLs were anterior chamber styles (53.9%), followed by iris-fixated lenses (33.7%) • The most common indications for surgery included: • Pseudophakic bullous keratopathy, 69% • UGH syndrome, 9% • IOL instability, 7%.

  30. Surgical Timing with ACIOL • Time between implantation and explanation with ACIOL complications: • 1 to 8 years.

  31. Surgical Outcome • The poorest visual outcome was seen in patients with the UGH syndrome. • 83% had a final acuity of 20/200 or worse. • Resolution of pain and inflammation • Better control of their IOP as a result of the surgery.

  32. 1- Day Post-Operative • Surgery without incident • VA- 20/400, PH 20/100 • Some corneal edema; 3+ AC reaction. • GAT- 13. • Continue with meds: • Cosopt b.id. - Tobradex ung q.id. • Alphagan P b.id. - Atropine b.id. • Diamox 500mg b.id.

  33. Follow-Ups • Seen on Day 2, 4, then 1 week, 2 week. • VA improves to 20/100 with pinhole and +15D lens. • Cornea improves; AC reaction diminishes to grade 1. • IOP in mid to low teens. • Continuing all meds.

  34. 3 Week Follow-Up • VA- 20/80 • Refracts to 20/30. • Trace AC reaction. • GAT- 13. • SLOW taper off all meds.

  35. Review: Key Points • Be suspicious of misplaced IOL • ACIOL with Uveitis • Gonioscopy

  36. THE END

More Related