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Poster 18: End-Stage Acute Retinal Necrosis in a Young Patient With History of Herpes Simplex Virus Encephalitis
Poster Presentations tation and can include laser ablation, surgical excision, or observation. Poster 17 Congenital Optic Nerve Pit Masquerading as Glaucoma Alison Palmer, O.D., and David Bejot, O.D., The Eye Center of Toledo, 3000 Regency Ct., Suite 100, Toledo, Ohio 43623 Background: Congenital optic pits are an optic disc anomaly thought to be a variant of an optic nerve coloboma. They typically are unilateral and most commonly found in the inferotemporal quadrant. Temporally located optic pits have an increased risk for serous macular detachments that can lead to a lamellar hole. The presentation can lead to an abnormal C/D appearance, which can falsely suggest glaucomatous damage. Also making the diagnosis difficult is the accompanying visual field that, although variable, is often an arcuate or a paracentral scotoma. This defect is thought to result from a loss of the retinal ganglion cells or a secondary atrophy of neural tissue from the depressed pit. Congenital optic pits are often pigmented, have well-defined borders, and average one third of a disc diameter in size. Congenital pits must be differentiated from acquired pits that are the direct result of glaucomatous damage. Visual field defects associated with congenital optic pits should not worsen with time, whereas progression is expected with acquired pits. Acquired pits, although similar in position, are not pigmented and are not associated with serous detachments. Case Summary: A 66-year-old white woman was referred to The Eye Center of Toledo for a glaucoma evaluation. She reported no systemic conditions. Best-corrected visual acuity yielded 20/30 O.D. and 20/25 O.S. Pertinent ocular history included radial keratotomy OU in 1992, and uncomplicated cataract surgery OU in 2007. Past records from 2 other optometrists labelled her as a glaucoma suspect because of C/D asymmetry. Previous records indicated an IOP range of 11 mmHg to 17 mmHg OU, and no family history of glaucoma was reported. Her IOP at this visit was 16 mmHg O.D. and 14 mmHg O.S. Pachymetry readings were .542 O.D. and .546 O.S. Anterior segment findings were positive for trace posterior capsular haze OU. Dilated retinal examination was unremarkable except for a noted C/D asymmetry of 0.3H/0.5V O.D. and 0.3 O.S. A Humphrey 24-2 visual field revealed a superior paracentral defect O.D. and was unremarkable O.S. OCT testing was performed and revealed thinning in the inferior part of the right retinal nerve fiber layer. Conclusion: This patient was found to have a small optic pit in her right eye that mimicked glaucoma in terms of vertical elongation and defects seen with visual field and OCT testing. When the classic risk factors of glaucoma like intraocular pressures, pachymetry, family history,
307 OCT, and visual field results were taken into account, it seemed likely that the optic pit was masquerading as glaucoma in this case. She was educated on the condition and the likeliness that her OCT and visual field results should remain constant over time, something that one would expect to progress and worsen if a glaucomatous condition were present. Patients with the initial diagnosis of optic pits should be kept on 6-month re-evaluations that include a dilated fundus examination, intraocular pressure measurement, and auxiliary testing, which may include optic disc photos. Patients should be educated on home Amsler grid use and signs and symptoms of macular pathology. Poster 18 End-Stage Acute Retinal Necrosis in a Young Patient With History of Herpes Simplex Virus Encephalitis Sanjeet K. Shahi, O.D., and Ryan K. Patel, O.D., Lake City VAMC, 619 South Marion, Lake City, Florida 32025 Background: Besifloxacin is a novel fluoroquinolone being investigated for the topical treatment of bacterial conjunctivitis (BC). The objective of this study was to compare the clinical and microbial efficacy of besifloxacin with that of vehicle alone in the treatment of BC. Two definitions for clinical resolution were explored. Methods: This was a multicenter, randomized, doublemasked, parallel group study. Adults and children 1 year of age and older with clinical manifestations of BC were randomized to besifloxacin (n⫽137) or vehicle (n⫽132) instilled 3 times daily for 5 days. Ocular signs and symptoms, visual acuity (VA), and biomicroscopy were assessed and cultures were taken at visits 1 (day 1), 2 (days 3-5), and 3 (day 8 or 9). Ophthalmoscopy was conducted at visits 1 and 3. The primary efficacy endpoints were clinical resolution and eradication of baseline bacterial infection at visit 3 in subjects with culture-confirmed conjunctivitis. Safety measures included adverse events (AEs), VA changes, biomicroscopy evaluations and ophthalmoscopy. Results: Clinical resolution— defined as the absence of conjunctival discharge, bulbar conjunctival injection, and palpebral conjunctival injection—was observed in 61.7% (37/60) vs. 35.7% (20/56) of subjects randomized to besifloxacin and vehicle, respectively, at visit 3 (P⫽0.0013), and 23.3% (14/60) vs. 14.3% (8/56) of subjects randomized to besifloxacin and vehicle, respectively, at visit 2 (P⫽0.3144). Applying the definition of clinical resolution more commonly used in the literature (which excludes palpebral conjunctival injection from the above definition), clinical resolution was observed in 73.3% (44/60) vs. 46.4% (26/56) of subjects randomized to besifloxacin and vehicle, respectively, at visit 3 (P⫽0.0019), and 33.3% (20/60) vs. 17.9% (20/56) of subjects randomized to besifloxacin and vehicle, respectively, at visit 2 (P⫽0.1090). The proportion of subjects randomized to besifloxacin experiencing clinical resolution was similar to that reported in subjects treated
308 with other ophthalmic fluoroquinolones (i.e., moxifloxacin, gatifloxacin) when using this definition. Bacterial species eradication was observed in 90% (54/60) vs. 69.1% (38/55) of patients randomized to besifloxacin and vehicle, respectively, at visit 3 (P⫽0.0041) and 90% (54/60) vs. 51.8% (28/54) of subjects randomized to besifloxacin and vehicle at visit 2 (P⬍0.0001). Treatment with besifloxacin was well tolerated, with the frequency of AEs similar to that with vehicle. There were no differences in VA, biomicroscopy, or ophthalmoscopy findings. Conclusions: Clinical resolution and bacterial eradication were significantly higher among subjects treated with besifloxacin than those treated with vehicle. Clinical resolution with besifloxacin is comparable to that reported with other ophthalmic fluoroquinolones. Besifloxacin was well tolerated and safe with no unexpected AEs. Poster 19 Compressive Optic Neuropathy in Low-Tension Glaucoma Suspect Kevin Talaga, O.D., and David Reed, O.D., Seidenberg Protzko Eye Associates, 601 Thames Way, Bel Air, Maryland 21014 Background: Acquired optic neuropathy can arise from many causes, and the differential diagnosis includes glaucoma as well as compressive etiologies, among others. In cases of monocular optic neuropathy of unexplained etiology in an ocular normotensive patient, an MRI is often obtained to rule out compressive lesions, as reports indicate up to 6.5% of patients diagnosed with low-tension glaucoma (LTG) may have such a lesion. Case Summary: A 51-year-old white woman presented on August 24, 2007, with complaints of blurry vision O.S. at distance and near for the past 6 weeks. She also complained of left-sided facial numbness and tingling that started at the same time as the visual symptoms. Her systemic history is significant for arthritis, asthma, thyroid disease, and a recently diagnosed left parasellar meningioma. Her family ocular history is significant for glaucoma in her father. Distance VA was measured at 20/20 O.D. and 20/40 O.S. Pupil testing revealed a mild APD O.S. IOPs were 17 mmHg OU. Pachymetry readings were 514 m O.D. and 521 m O.S. Dilated fundus exam found optic nerve cupping of 0.55 H x 0.55 V O.D. and 0.55 H x 0.65 V O.S., with superior notching and temporal pallor of the nerve O.S. A Humphrey visual field 24-2 found a normal visual field O.D. and a dense inferior arcuate scotoma O.S. with split fixation. All other examination findings were within normal limits. MRI results from August 15, 2007, showed a homogenously enhanced focal mass lesion in the left cavernous sinus and parasellar/suprasellar cistern region. Subsequent field testing on October 17, 2007, produced stable findings for both eyes. Conclusion: The differential diagnosis of this patient’s ac-
Optometry, Vol 79, No 6, June 2008 quired optic neuropathy includes glaucoma and optic neuropathy from the recently diagnosed meningioma. Given the speed of onset and the highly asymmetric nature of the condition it was felt that compression by the meningioma was the most likely etiology. This case demonstrates a clear example of the rationale for obtaining MRI testing on certain LTG suspects. Poster 20 Disparity in Orbital Positioning: Case Report and Review Luciana Coscione, O.D., John D. Dingell VAMC, 4646 John Road, Detroit, Michigan 48201 Background: Proptosis may be a harbinger for a number of potentially serious ocular and systemic conditions. Because proptosis is a relative condition, enophthalmos of the fellow eye should always be considered when diagnosing. Although patient history is critical in refining the list of differentials, it is important for the clinician to consider all possible diagnoses. Appropriate imaging done in a timely manner is crucial to determine the underlying cause of the change in orbital positioning and to ensure appropriate referrals and treatments. I will discuss a case of apparent proptosis, which imaging revealed as not only a retrobulbar mass in one eye, but also an orbital floor fracture in the fellow eye. In addition to the case presentation, the differential diagnoses for proptosis and enophthalmos will be discussed. Case Summary: A 71-year-old black man was consulted to our clinic with complaints of a swollen, painful right eye for the last 2 weeks. The patient reported falling out of a tree and being struck near the right eye, possibly with a tree branch. His medical history was positive for diabetes mellitus, hypertension, dyslipidemia, osteoarthritis, benign prostatic hypertrophy, and dementia. Ocular history was remarkable for immature cataracts and glaucoma suspicion. Because of the patient’s dementia, the history of the injury was not detailed or reliable, as it changed throughout the course of the examination. The right eye appeared proptotic on gross examination. Hertel exophthalmometry measured 23 mm O.D. and 15 mm O.S. with base 105. The dilated fundus examination showed optic nerve cupping of 0.7 horizontal and vertical in each eye, posterior vitreal detachments in each eye, and an operculated retinal hole in the right eye that appeared to be longstanding. There was no evidence of papilledema, retinal tears, or detachments. A computed tomography (CT) scan of the head and orbits was performed and found a large soft tissue mass in the superior lateral aspect of the orbit causing anterior displacement of the right globe. The scan also showed a large orbital fracture in the left eye with soft tissue displacement into the maxillary sinus. An orbital biopsy of the mass was performed, which determined the etiology of the mass as benign lymphoid hyperplasia. The patient was started on
307 OCT, and visual field results were taken into account, it seemed likely that the optic pit was masquerading as glaucoma in this case. She was educated on the condition and the likeliness that her OCT and visual field results should remain constant over time, something that one would expect to progress and worsen if a glaucomatous condition were present. Patients with the initial diagnosis of optic pits should be kept on 6-month re-evaluations that include a dilated fundus examination, intraocular pressure measurement, and auxiliary testing, which may include optic disc photos. Patients should be educated on home Amsler grid use and signs and symptoms of macular pathology. Poster 18 End-Stage Acute Retinal Necrosis in a Young Patient With History of Herpes Simplex Virus Encephalitis Sanjeet K. Shahi, O.D., and Ryan K. Patel, O.D., Lake City VAMC, 619 South Marion, Lake City, Florida 32025 Background: Besifloxacin is a novel fluoroquinolone being investigated for the topical treatment of bacterial conjunctivitis (BC). The objective of this study was to compare the clinical and microbial efficacy of besifloxacin with that of vehicle alone in the treatment of BC. Two definitions for clinical resolution were explored. Methods: This was a multicenter, randomized, doublemasked, parallel group study. Adults and children 1 year of age and older with clinical manifestations of BC were randomized to besifloxacin (n⫽137) or vehicle (n⫽132) instilled 3 times daily for 5 days. Ocular signs and symptoms, visual acuity (VA), and biomicroscopy were assessed and cultures were taken at visits 1 (day 1), 2 (days 3-5), and 3 (day 8 or 9). Ophthalmoscopy was conducted at visits 1 and 3. The primary efficacy endpoints were clinical resolution and eradication of baseline bacterial infection at visit 3 in subjects with culture-confirmed conjunctivitis. Safety measures included adverse events (AEs), VA changes, biomicroscopy evaluations and ophthalmoscopy. Results: Clinical resolution— defined as the absence of conjunctival discharge, bulbar conjunctival injection, and palpebral conjunctival injection—was observed in 61.7% (37/60) vs. 35.7% (20/56) of subjects randomized to besifloxacin and vehicle, respectively, at visit 3 (P⫽0.0013), and 23.3% (14/60) vs. 14.3% (8/56) of subjects randomized to besifloxacin and vehicle, respectively, at visit 2 (P⫽0.3144). Applying the definition of clinical resolution more commonly used in the literature (which excludes palpebral conjunctival injection from the above definition), clinical resolution was observed in 73.3% (44/60) vs. 46.4% (26/56) of subjects randomized to besifloxacin and vehicle, respectively, at visit 3 (P⫽0.0019), and 33.3% (20/60) vs. 17.9% (20/56) of subjects randomized to besifloxacin and vehicle, respectively, at visit 2 (P⫽0.1090). The proportion of subjects randomized to besifloxacin experiencing clinical resolution was similar to that reported in subjects treated
308 with other ophthalmic fluoroquinolones (i.e., moxifloxacin, gatifloxacin) when using this definition. Bacterial species eradication was observed in 90% (54/60) vs. 69.1% (38/55) of patients randomized to besifloxacin and vehicle, respectively, at visit 3 (P⫽0.0041) and 90% (54/60) vs. 51.8% (28/54) of subjects randomized to besifloxacin and vehicle at visit 2 (P⬍0.0001). Treatment with besifloxacin was well tolerated, with the frequency of AEs similar to that with vehicle. There were no differences in VA, biomicroscopy, or ophthalmoscopy findings. Conclusions: Clinical resolution and bacterial eradication were significantly higher among subjects treated with besifloxacin than those treated with vehicle. Clinical resolution with besifloxacin is comparable to that reported with other ophthalmic fluoroquinolones. Besifloxacin was well tolerated and safe with no unexpected AEs. Poster 19 Compressive Optic Neuropathy in Low-Tension Glaucoma Suspect Kevin Talaga, O.D., and David Reed, O.D., Seidenberg Protzko Eye Associates, 601 Thames Way, Bel Air, Maryland 21014 Background: Acquired optic neuropathy can arise from many causes, and the differential diagnosis includes glaucoma as well as compressive etiologies, among others. In cases of monocular optic neuropathy of unexplained etiology in an ocular normotensive patient, an MRI is often obtained to rule out compressive lesions, as reports indicate up to 6.5% of patients diagnosed with low-tension glaucoma (LTG) may have such a lesion. Case Summary: A 51-year-old white woman presented on August 24, 2007, with complaints of blurry vision O.S. at distance and near for the past 6 weeks. She also complained of left-sided facial numbness and tingling that started at the same time as the visual symptoms. Her systemic history is significant for arthritis, asthma, thyroid disease, and a recently diagnosed left parasellar meningioma. Her family ocular history is significant for glaucoma in her father. Distance VA was measured at 20/20 O.D. and 20/40 O.S. Pupil testing revealed a mild APD O.S. IOPs were 17 mmHg OU. Pachymetry readings were 514 m O.D. and 521 m O.S. Dilated fundus exam found optic nerve cupping of 0.55 H x 0.55 V O.D. and 0.55 H x 0.65 V O.S., with superior notching and temporal pallor of the nerve O.S. A Humphrey visual field 24-2 found a normal visual field O.D. and a dense inferior arcuate scotoma O.S. with split fixation. All other examination findings were within normal limits. MRI results from August 15, 2007, showed a homogenously enhanced focal mass lesion in the left cavernous sinus and parasellar/suprasellar cistern region. Subsequent field testing on October 17, 2007, produced stable findings for both eyes. Conclusion: The differential diagnosis of this patient’s ac-
Optometry, Vol 79, No 6, June 2008 quired optic neuropathy includes glaucoma and optic neuropathy from the recently diagnosed meningioma. Given the speed of onset and the highly asymmetric nature of the condition it was felt that compression by the meningioma was the most likely etiology. This case demonstrates a clear example of the rationale for obtaining MRI testing on certain LTG suspects. Poster 20 Disparity in Orbital Positioning: Case Report and Review Luciana Coscione, O.D., John D. Dingell VAMC, 4646 John Road, Detroit, Michigan 48201 Background: Proptosis may be a harbinger for a number of potentially serious ocular and systemic conditions. Because proptosis is a relative condition, enophthalmos of the fellow eye should always be considered when diagnosing. Although patient history is critical in refining the list of differentials, it is important for the clinician to consider all possible diagnoses. Appropriate imaging done in a timely manner is crucial to determine the underlying cause of the change in orbital positioning and to ensure appropriate referrals and treatments. I will discuss a case of apparent proptosis, which imaging revealed as not only a retrobulbar mass in one eye, but also an orbital floor fracture in the fellow eye. In addition to the case presentation, the differential diagnoses for proptosis and enophthalmos will be discussed. Case Summary: A 71-year-old black man was consulted to our clinic with complaints of a swollen, painful right eye for the last 2 weeks. The patient reported falling out of a tree and being struck near the right eye, possibly with a tree branch. His medical history was positive for diabetes mellitus, hypertension, dyslipidemia, osteoarthritis, benign prostatic hypertrophy, and dementia. Ocular history was remarkable for immature cataracts and glaucoma suspicion. Because of the patient’s dementia, the history of the injury was not detailed or reliable, as it changed throughout the course of the examination. The right eye appeared proptotic on gross examination. Hertel exophthalmometry measured 23 mm O.D. and 15 mm O.S. with base 105. The dilated fundus examination showed optic nerve cupping of 0.7 horizontal and vertical in each eye, posterior vitreal detachments in each eye, and an operculated retinal hole in the right eye that appeared to be longstanding. There was no evidence of papilledema, retinal tears, or detachments. A computed tomography (CT) scan of the head and orbits was performed and found a large soft tissue mass in the superior lateral aspect of the orbit causing anterior displacement of the right globe. The scan also showed a large orbital fracture in the left eye with soft tissue displacement into the maxillary sinus. An orbital biopsy of the mass was performed, which determined the etiology of the mass as benign lymphoid hyperplasia. The patient was started on