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Admissions Conference

Admissions Conference. Karen Faye M. Serrano July 30, 2011. Patient Data. E. D. Female 55 yo Tandang Sora , QC. Chief Complaint . “ Mahapdi ang kaliwang mata na parang may nakaharang .”. History of Present Illness. 4 months PTA March 24, 2011  Cataract surgery OS

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Admissions Conference

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  1. Admissions Conference Karen Faye M. Serrano July 30, 2011

  2. Patient Data • E. D. • Female • 55 yo • TandangSora, QC

  3. Chief Complaint • “Mahapdiangkaliwangmatanaparang may nakaharang.”

  4. History of Present Illness • 4 months PTA • March 24, 2011 Cataract surgery OS • March 25, 2011  IOL displacement • March 26, 2011  swelling of the lens • Something is blocking her center vision • Painful (‘mahapdi’), redness, and tearing • No itchiness and discharge • Prescribed with 4 eyedrops • Minimal improvement

  5. History of Present Illness • 3 months PTA • Weekly check-up • 2 months PTA • May 28, 2011  scheduled for operation  was postponed due to persistence of swelling • 1 month PTA • June 22, 2011  scheduled for operation  was postponed due to persistence of swelling and schedule did not coincide with the doctors

  6. History of Present Illness • 5 days PTA • scheduled for operation  was postponed due to persistence of swelling and schedule did not coincide with the doctors • Day of admission (July 27, 2011) • Went to OPD • Got CP clearance • Scheduled for surgery the next day

  7. Past Medical History • Diabetic • 24 years ago • Metformin 500 mg; 3x a day • Glicazide (Diamicron) 80 mg; 4x a day

  8. Past Medical History • Hospitalizations/Surgeries • 2009 Nov • Felt cold during the night • Fever • Admitted for 2 weeks • Wound in the L foot was already gangrenous and was excavated • 2010 Jan • Operation was done • Autograft from abdomen to L foot • Admitted for a week

  9. Family History • Father • Hypertension • Died of cancer

  10. Personal and Social History • Housewife • Never smoked • Never drank or tried drinking alcohol • Never used illegal drugs • Maintained on a healthy diet

  11. Physical Examination • ROS unremarkable • Highest BP: 150/100 • Normal BP: 130/70 • Current BP: 140/80 • RR: 16 • HR: 82 • Glucose 9.75 (NV: 4.1-5.9)

  12. Physical Examination • DVA • NVA

  13. Physical Examination • Full and equal EOMs

  14. Physical Examination • Gross • OD • Arcussenilis • Anictericsclerae • Pinkish conjunctiva • PRL, 2-3 mm pupil

  15. Physical Examination • Gross • OS • Arcussenilis • Hyperemic limbal area • Swelling of cornea • Clouding on the cornea • Bullae on cornea • Hypermicsclerae • Indentations on the pupil border

  16. Physical Examination • Gross • OS • Arcussenilis • Hyperemic limbal area • Swelling of cornea • Clouding on the cornea • Bullae on cornea • Hypermicsclerae • Indentations on the pupil border

  17. Physical Examination • Tonometry • OD: 10 mmHg • OS: 10 mmHg

  18. Physical Examination • Slit Lamp • OD • Grade 4

  19. Physical Examination • Slit lamp • OS • Grade 4

  20. Admitting Diagnosis • Dropped IOL, OS • BullousKeratopathy

  21. IOL Dislocation • Early = before 3 months after surgery • Late = 3 months after surgery • Posterior dislocation • Posterior capsular rupture or zonular dialysis • Improper fixation within the capsular bag and instability of the IOL (capsular bag complex) • Solution: Continuous Curvilinear Capsulorrhexis

  22. Differentials

  23. PseudophakicBullousKeratopathy • Corneal edema from cataract extraction • Corneal endothelium is damaged  corneal swelling • Damaged endothelium  irregularly shaped and enlarged cells  pump function fail • Unable to pump to deturgesence the cornea  stroma swell (central)  folding of Descernet’s membrane  fluid accumulation  blisters and bullae  fluid to anterior chamber

  24. PseudophakicBullousKeratopathy • Pain • Degree of pleomorphism and polymegathism increases

  25. Surgical Procedure • Penetrating Keratoplasty OS and Vitrectomy with IOL retrieval

  26. Specular Microscopy • Number of endothelial corneal cells per square millimeter inch • Percentage of hexagonal cells • Polymegathism • Polymorphism

  27. Specular Microscopy • Endothelial cell count is normal if 2600-2800 cells per square millimeter • If below this level  greater likelihood of complications • Corneal edema • Loss of visual acuity

  28. Specular Microscopy 799 001 599 002 799 001 785 001 785 001

  29. Penetrating Keratoplasty • Complete corneal transplant • Entire cornea is removed  replaced by a complete donor cornea • With decreased visual acuity due to corneal opacity • Pseudophakic corneal edema

  30. Penetrating Keratoplasty

  31. Penetrating Keratoplasty • Possible Complications • Wound leak • Glaucoma • Primary endothelial failure • Persistent epithelial defect • Microbial keratitis • Late failure • Recurrence of primary disease

  32. Penetrating Keratoplasty • Corneal graft rejection • Symptoms • Decreased vision, pain, redness, photophobia • Signs • Keratic precipitates, stromal edema, subepithelial edema, conjunctival injection, cells and flare, neovascularization • Treatment • Topical steroid (Prednisolone 1%) • Cycloplegics

  33. Vitrectomy • Surgical removal of the vitreous humor

  34. Pre-op • BP 140-150/70-80 • Moxifloxacin q4 • At the OR: • BP 200-240/130-140 • Nicardipine 10mg 10gtts • Uncontrolled BP • Deferred

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