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An Eye Exam can Save a Life

An Eye Exam can Save a Life. Potentially fatal conditions found on eye exam. Disclaimers. No financial interests Any reference to branded pharmaceuticals is unintentional This is not an exhaustive list

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An Eye Exam can Save a Life

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  1. An Eye Exam can Save a Life Potentially fatal conditions found on eye exam

  2. Disclaimers • No financial interests • Any reference to branded pharmaceuticals is unintentional • This is not an exhaustive list • This type of lecture will drive you crazy: skipping right past what’s common, what’s likely, and highlighting what is fatal. This can be unsettling. • You may never see these diagnoses in practice, but it’s best to be prepared

  3. Detect potentially fatal conditions

  4. CNIII Palsy http://www.mrcophth.com/ptosis/thirdnerveplasy.html https://www.aafp.org/afp/2010/0715/p187.html

  5. Parasympathetic pupillomotor fibers: Peripheral/compression Vaso Nervorum: Microvascular Disease/diabetes/hypertension https://twitter.com/alaamri14121/status/752168425217200128

  6. Posterior Communicating Artery Aneurysm https://www.researchgate.net/figure/MRI-showing-a-posterior-communicating-artery-aneurysm_fig4_5411575

  7. CNIII Palsy Management • Who to treat as emergencies: • Pupil-involving CNIII palsy  ER • Evolving CNIII  ER • “Over the last few weeks this eyelid keeps drooping more and my double vision is getting worse and worse” • Who can be monitored • Some clinicians image everyone for liability reasons • A 70-year-old diabetic hypertensive with an acute onset, pupil-sparing CNIII palsy can be watched. Follow-up is needed.

  8. CNIV Palsy • Usually: trauma, congenital, vasculopathy • But, rarely… tumor (often other signs/symptoms) • Watch for: • no improvement over weeks to a couple months • Progression over time

  9. CNVI Palsy • Usually due to intracranial hypertension, microvascular disease, trauma or idiopathic • But, rarely… tumor • Watch for: • no improvement over weeks to a couple months • Progression over time

  10. CNVII Palsy: Bell vs Stroke https://www.slideshare.net/CpArya/facial-nerve-palsy-by-dr-chandra-prakash-arya-bsc-bds-mds-pms-rntcp

  11. Stroke: forehead sparing https://www.jems.com/articles/print/volume-39/issue-5/features/differentiating-facial-weakness-caused-b.html

  12. Bell palsy: forehead involving https://www.jems.com/articles/print/volume-39/issue-5/features/differentiating-facial-weakness-caused-b.html

  13. CNVII Palsy • Also consider sarcoidosis, lyme disease • With hearing loss consider Ramsay Hunt Syndrome/Zoster • If frontalis function is preserved with facial droop  ER • If entire hemiface affected, highly likely Bell Palsy  treat K exposure

  14. Muscle Entrapment: Oculocardiac reflex (OCR) https://entokey.com/15-3/

  15. EOM Entrapment in kids • Suspected entrapment of a muscle in a child  ER • The OCR: • V1 relays through the ciliary ganglion and the vagus nerve is activated, decreasing cardiac output • Worsened with hypercarbia (CO2), hypoxia (O2), opiate ingestion, younger age (increased vagal tone), and light anesthesia • Norco/Percocet/Oxycodone not recommended for pain en route to ER • Frequently encountered with strabismus surgery, and occasionally with any operation near branches of the trigeminal nerve (ENT, Plastics etc)

  16. Visual Fields: tumors https://www.neec.com/neuro-ophthalmology-boston/pituitary-tumor/

  17. Melanoma http://morancore.utah.edu/basic-ophthalmology-review/eyelid-masses/ https://www.aao.org/diagnose-this/diagnose-this-malignant-melanoma-of-eyelid-2

  18. Eyelids • Easy to look past the eyelids straight to the eyes • Discipline affords opportunities to detect rare, life altering and life threatening conditions • Cicatricial changes • Madarosis • Lack of cysts (nevi have cysts—melanoma doesn’t) • Lymph node enlargement

  19. Sebaceous cell carcinoma • Mortality between 5-25% • Pagetoid spread—meanders between cells • Tumors <12mm not associated with distant metastases • Early detection if possible • Recurrent pterygia in same spot despite surgery: red flag • 3rd most common eyelid malignancy (1. basal 2. squamous) • Masquerades, can be difficult to diagnose

  20. http://www.ijo.in/viewimage.asp?img=IndianJOphthalmol_2018_66_9_1235_239331_f2.jpghttp://www.ijo.in/viewimage.asp?img=IndianJOphthalmol_2018_66_9_1235_239331_f2.jpg https://eyecancer.com/eye-cancer/conditions/eyelid-tumors/sebaceous-carcinoma-eyelid/ https://www.aad.org/public/diseases/skin-cancer/sebaceous-carcinoma http://www.ijo.in/viewimage.asp?img=IndianJOphthalmol_2018_66_9_1235_239331_f2.jpg

  21. Vascular tumors Capillary hemangioma: Consider Kasabach-Merritt PHACE Syndrome http://webeye.ophth.uiowa.edu/eyeforum/cases/57-Capillary-Hemangioma-Eyelid.htm https://www.dermatologyadvisor.com/home/decision-support-in-medicine/dermatology/phaces-syndrome/

  22. Fatality is rare with capillary hemangiomas on the eyelids—the hemangioma would have to be large enough to cause a consumptive coagulopathy/thrombocytopenia • Kasaback-Merrit: 35% mortality rate • PHACE Syndrome: usually non-fatal • But watch out for airway hemangiomas, arterial anomalies • Deserves imaging of head, neck, chest

  23. Juvenile Cystinosis https://www.aao.org/image/cystinosis https://disorders.eyes.arizona.edu/disorders/cystinosis

  24. Juvenile Cystinosis • Retinal crystals  nephropathic • Kidney transplantation in 1st decade of life • likely to exhibit dwarfism • Not to be confused with Meesman, Lisch keratopathies

  25. Multiple Myeloma https://www.thelancet.com/article/S0140-6736(12)60162-7/abstract

  26. Multiple Myeloma • Life expectancy between 2-7 years depending on stage • Also consider: Monoclonal gammopathy of undetermined significance (MGUS)

  27. Interstitial keratitis Leprosy Tuberculosis Syphilis https://emedicine.medscape.com/article/1213853-overview http://pubs.sciepub.com/ajmcr/4/5/4/index.html https://eyerounds.org/atlas/pages/syphilis-congenital-interstitial-keratitis.html

  28. Interstitial Keratitis: Cogan Syndrome https://www.nejm.org/doi/full/10.1056/NEJMicm1709103 http://www.djo.harvard.edu/site.php?url=/physicians/cr/2197

  29. Cogan syndrome • Bilateral hearing loss, vertigo, interstitial keratitis • Often with medium/large vessel vasculitis, myalgias, arthralgias • Interstitial keratitis: often concentric in mid-periphery with central sparing

  30. Conjunctival tumors Benign melanosis (racial melanosis) Primary acquired melanosis https://www.willseye.org/disease_condition/conjunctival-primary-acquired-melanosis/ https://eyecancer.com/eye-cancer/conditions/conjunctival-tumors/pigmented-conjunctival-cancers-primary-acquired-melanosis/

  31. PAM • 47% of PAM with atypia go on to become melanoma • More common in individuals with lighter pigmentation • May arise on palpebral conjunctiva—this is a more troublesome finding and is more likely to be missed • Small lesions (1-2 clock hours) without nodularity, vascularization or thickening may be observed annually. Photographs recommended. • >2 clock hours  biopsy, cryotherapy of the margins

  32. Melanoma Melanoma Melanoma Melanoma https://www.reviewofoptometry.com/article/a-guide-to-conjunctival-tumors

  33. Conjunctival Melanoma • Risk factors for poorer outcome • Male • De novo lesion (didn’t arise from nevus or PAM) • Non-limbal location (examine fornices, caruncle) • Older age • 50% recurrence rate at 7 years • 5-17% mortality at 5 years • 9-35% mortality at 10 years

  34. Ocular surface squamous neoplasia http://webeye.ophth.uiowa.edu/eyeforum/atlas/pages/CIN-Conjunctival-intraepithelial-neoplasia.htm

  35. OSSN vs Pterygium • Location: pterygium 3 & 9 o’clock • Pterygium: wing-shaped • Pattern of evolution (old photographs, previous examinations)

  36. Ophthalmia Neonatorum https://emedicine.medscape.com/article/1192190-overview https://en.wikipedia.org/wiki/Neonatal_conjunctivitis

  37. Ophthalmia Neonatorum • Causes: • Chemical (silver nitrate): day 1 • Gonococcal: days 3-5 • Chlamydial: days 7-14 • HSV: variable, usually latest • HSV, chlamydia pose highest mortality risk • Concomitant chlamydial pneumonia • Systemic HSV, neurological sequelae

  38. 62 yo ♂ w/ eye pain https://www.merckmanuals.com/professional/eye-disorders/conjunctival-and-scleral-disorders/scleritis

  39. Scleritis • Potentially fatal conditions include: • Granulomatosis with polyangiitis • Polyarteritis nodosa • Inflammatory bowel disease • Tuberculosis • Lyme disease • Necrotizing anterior scleritis: likely to have underlying systemic inflammatory disease https://www.merckmanuals.com/professional/eye-disorders/conjunctival-and-scleral-disorders/scleritis

  40. Scleritis • History: • Bloody noses/blood in urine? (GPA/Wegner) • Blood in stool/abdominal pain (Inflammatory bowel disease) • Tick bites? (Lyme) • Recent travel to developing countries? Visited a prison? (TB)

  41. Lens • Cataracts: mortality by all causes has a slight decrease after cataract surgery • No surgery: mortality risk 2.78 per 100 person years • Surgery: mortality risk 2.98 per 100 person years

  42. Refractive Error • The mortality benefit of the correction of refractive errors is so obvious that it will never be studied rigorously • No specialty contributes to the safety of society as much as optometry

  43. Neuroblastoma http://www.ijdvl.com/viewimage.asp?img=ijdvl_2012_78_6_740_102370_f1.jpg

  44. Neuroblastoma • Metastatic disease, usually from adrenal glands • ~20% of advanced neuroblastoma cases develop orbital metastases • Periorbital eccymoses are likely from obstructed palpebral blood vessels

  45. Orbital cellulitis http://eyerounds.org/cases/103-Pediatric-Orbital-Cellulitis.htm

  46. Orbital cellulitis • Look for sinusitis, subperiosteal abscess, diabetes, nasal black eschar http://eyerounds.org/cases/103-Pediatric-Orbital-Cellulitis.htm

  47. Orbital cellulitis • Look for: rAPD, decreased vision, EOM changes, diplopia, proptosis, fever • Extension of sinus disease • In non-diabetics usually a single pathogen • In diabetics, often polymicrobial • Subperiostial abscesses often require surgical drainage

  48. Retinoblastoma Image in public domain

  49. Retinoblastoma • Inherited cases • 90% penetrance AD inheritance of RB1 • 45% chance of siblings being affected • Higher risk of bilateral disease, pinealoblastoma (trilateral RB), primitive neuroectodermal tumors (poor prognosis), osteosarcoma. • Sporadic cases • 85-90% of cases • Less likely bilateral • Less risk of other cancers

  50. Choroidal melanoma https://www.sciencedirect.com/topics/medicine-and-dentistry/choroid-melanoma

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