- Email: [email protected]
Poster 36
284 large peripheral hemorrhages OU. The peripheral hemorrhages were felt to be associated with his lymphoma. A detailed history with differential diagnoses, optical coherence tomography, color fundus photos, and visual fields of Waldenstrom macroglobulinemia will be illustrated. Conclusion: Waldenstrom macroglobulinemia has a median survival rate between 5 and 10 years. The most important prognostic factors include age, anemia, leukopenia, and thrombocytopenia. Initiation of treatment is reserved for patients who develop disease-related signs and symptoms. Mild forms of hyperviscosity syndrome can present with peripheral retinal hemorrhages. With progressive severity there is increased dilation of the retinal arteries and veins. Fluorescein angiography demonstrates increased arteriovenous passage time due to reduced retinal circulation. Hemorrhages in the posterior pole are usually only present in severe forms. Ocular changes secondary to hyperviscosity syndrome only become symptomatic when the central retina is involved. Waldenstrom macroglobulinemia– associated retinopathy is a slowly progressive condition directly associated with increasing serum IgM levels and serum viscosity. Poster 34 Asymptomatic Subconjunctival Emphysema Nadia Zalatimo, O.D., VAMC Manchester, 718 Smyth Road, Manchester, New Hampshire 03104 Background: Subconjunctival emphysema is an uncommon condition that typically results from ocular trauma, during which air is trapped beneath the conjunctiva. Other causes include ethmoid osteoma, vigorous coughing, nose blowing, and mechanical ventilation. The condition typically resolves spontaneously. Rarely, serious vision-threatening complications from orbital compression may occur. In the case reported, asymptomatic, unilateral subconjunctival emphysema was found in a 53-year-old woman who presented for routine examination. This is believed to be the first known case report of mild, unilateral subconjunctival emphysema that was discovered on routine examination. Case Summary: A 53-year-old woman presented for routine examination with the complaint of slight blur at distance and near OU. Ocular history was unremarkable. Biomicroscopy revealed clear, round air bubbles in the inferior bulbar conjunctiva, which extended into the inferior corneal midstroma OD. The conjunctiva was otherwise clear without injection or laceration OD. The left eye was uninvolved. She denied vigorous nose blowing, coughing, sneezing, ocular trauma, or sinus problems. Orbital CT with contrast showed no abnormality in the orbits or paranasal sinuses. The patient was diagnosed with subconjunctival emphysema with corneal involvement OD. Follow-up showed complete resolution within 2 weeks. Conclusion: Subconjunctival emphysema is a transient condition that often presents in conjunction with acute ocular signs of trauma. Prognosis is typically excellent. Compre-
Optometry, Vol 78, No 6, June 2007 hensive ocular examination and orbital CT scanning are necessary to properly manage patients with subconjunctival emphysema and prevent vision loss from orbital compression. Poster 35 Fun and Games—Until Somebody Gets Shot in the Eye: Blunt Trauma From a Paintball Causing an Angle Recession and Retinal Tear Elizabeth Sanders, O.D., and Sherrol Reynolds, O.D., Nova Southeastern University, College of Optometry, 3200 South University Drive, Ft. Lauderdale, Florida 33328 Background: Reported cases of blunt force ocular injuries caused by projectile paintball pellets often have a high visual morbidity. Commonly reported paintball ocular injuries include corneal abrasions, cataracts, retinal detachments, hyphemas, and vitreous hemorrhage. Each injury has the potential to markedly decrease vision or cause significant pain, imploring the injured to seek treatment. However, blunt force injuries can also cause damage to structures of the eye with few acute symptoms but significant long-term effects when left untreated. Case Summary: A 13-year-old Hispanic male presented to an urgent care clinic reporting a paintball injury to the left eye 4 days earlier. Acute swelling and discomfort had subsided during the interim, but a moderate photophobia persisted, causing the patient to seek treatment. Upon examination, the left eye was found to have 20/20 acuity, a small, but dense stromal impact scar to the cornea, a corectopic pupil, and an anterior chamber flare. Gonioscopic evaluation followed and revealed a temporal anterior chamber angle recession and a microhyphema. The patient was treated with Lotemax, bedrest, and cool compresses. The retina was examined at the initial visit and at 1- and 2-day follow-ups. During the 2-day follow-up, a peripheral flap tear with a possible choroidal rupture was identified temporally in the left eye. The patient was followed up until the uveitis and hyphema had resolved and was referred for retinal tear repair. Conclusion: This case demonstrates an angle recession and retinal flap tear secondary to a traumatic paintball eye injury that presented with minimal symptomatology. It highlights the importance of a careful evaluation of anterior and posterior ocular structures when a traumatic history is present. Epidemiologic information, paintball eye safety information, gonioscopic photographs, and anterior and posterior segment photographs will be included. Poster 36 Bilateral Papilledema: Case Presentation and Review Luciana Coscione, O.D., and Arlene Gold, O.D., John D. Dingell VAMC, 4646 John Road, Detroit, Michigan 48201
Poster Presentations Background: Papilledema is an important ocular sign for a variety of serious systemic conditions. Ordering appropriate laboratory tests and imaging in a timely manner is crucial to determine the underlying cause of the papilledema and to insure appropriate referrals and treatment. We present a case of bilateral papilledema resulting from lung cancer metastasis to the brain. In addition to the case presentation, we discuss the differential diagnoses for bilateral papilledema. Case Summary: A 48-year-old black male was referred to our clinic with complaints of a spot in his vision. His medical history was positive for esophageal reflux, asthma, chronic back pain, hypercholesterolemia, and a lung neoplasm (non–small cell lung carcinoma) diagnosed 2 months prior. He smoked 1 package of cigarettes per day for the last 30 years and had recently quit. The dilated fundus examination revealed a recent onset of bilateral papilledema. The optic nerves appeared hyperemic and elevated with blurry disc margins. Intraretinal hemorrhages and cotton wool spots were also noted bilaterally. Humphrey visual field results showed a right superior quadranopsia. A computed tomography (CT) scan of the head and orbits was performed and revealed several masses within the temporal-parietal and occipital lobes, which were determined to be metastatic lesions from the non-small cell lung cancer. These lesions caused a mass effect, responsible for the observed ocular sequellae. The patient was treated palliatively and passed away after a few months. Conclusion: This case demonstrates that bilateral papilledema is a significant clinical finding that may indicate several serious systemic conditions. Many of these conditions may potentially lead to permanent vision loss or even death. Proper workup, diagnosis, and management of the underlying etiology can be challenging but is crucial in minimizing devastating complications. In this particular case, the papilledema was an ocular manifestation of the underlying metastatic lung cancer. Unfortunately, the delayed diagnosis was unable to considerably impact the final outcome of this case. Furthermore, many recent studies recommend a CT chest scan for all high-risk patients to increase early detection of lung cancer. Poster 37 A Case of Coexisting Neuropathologies Shannon Huntzberry, O.D., and Michael Henderson, O.D, Seidenberg Protzko Eye Assoc., 601 Thames Way, Bel Air, Maryland 21014 Background: A lesion at any location along the oculosympathetic pathway can produce a Horner’s syndrome, causing paresis of involuntary ocular muscles that are under sympathetic control. A paretic muscle of Muller gives rise to the characteristic eyelid ptosis, and denervation of the iris dilator yields pupillary miosis. In contrast, myasthenia gravis is an immunologic disorder characterized by fluctuating weakness of the voluntary ocular muscles. Failure at the postsynaptic membrane of the neuromuscular junction
285 causes orbicularis fatigue and variable strabismus. The pupil is spared in these cases. This case describes a single patient with Horner’s syndrome, and the subsequent discovery of a superimposed ocular myasthenia gravis on followup. Case Report: A 66-year-old white male presented with an acquired, unilateral ptosis of 1-week duration. Exam revealed ipsilateral pupillary miosis, anisocoria greatest in dim illumination, and a distinct dilation lag. Cocaine testing confirmed the diagnosis of a left-sided Horner’s syndrome, and a positive hydroxyamphetamine test localized a postganglionic lesion. MRI revealed a mucoserous retention cyst at the level of the ethmoid sinus with questionable compression of the sympathetic fibers in that area. Interestingly, on follow-up the patient reported improvement of ptosis after periods of rest and that the lid returned to almost normal level in cold temperature. In-office evaluation revealed worsening of ptosis with prolonged upward gaze, a positive Cogan lid twitch sign, and marked improvement of ptosis following ice-pack application. Serologic testing revealed elevated binding and modulating acetylcholine receptor antibodies, confirming the diagnosis of a coexisting myasthenia gravis. Conclusion: Treatment with oral pyridostigmine, a cholinesterase inhibitor, improved the ptosis, and the patient has developed no symptoms of generalized disease to date. It is probable that the Horner’s syndrome was longstanding and that the ocular symptoms were a result of the myasthenia. Evaluation of the entire clinical picture in this case was critical in determining diagnostic workup, prognosis, and treatment options for these 2 very separate clinical entities. Poster 38 Melanocytoma of the Optic Disc Benjamin Gilsdorf, O.D., James Yi, O.D., Dawn Pewitt, O.D., Stacey Gin, O.D., and Connie Liu, O.D., VA San Diego Healthcare System, Southern California College of Optometry, 3350 La Jolla Village Drive, San Diego, California 92161 Background: Melanocytoma is a benign tumor that is a histologic variant of the choroidal nevus. It is typically flat or slightly elevated, grey to black, and most commonly located at the optic nerve head. Lesions typically are stable in size, but a small percentage of tumors have shown subtle growth over time. Patients with melanocytoma usually are asymptomatic but may present with decreased vision, visual field defects, and pupil abnormalities. Vision loss results from tumor necrosis, optic neuropathy, or retinal vascular obstruction. Rare cases of malignant transformation to choroidal melanoma have been reported. The primary differential diagnosis for melanocytoma is malignant melanoma. Case Report: A 59-year-old Hispanic male presented for a diabetic eye exam and “grey-appearing lamina O.S.” Examination revealed no retinopathy OU with normal findings except for a circular area of flat brownish pigmentation on
Optometry, Vol 78, No 6, June 2007 hensive ocular examination and orbital CT scanning are necessary to properly manage patients with subconjunctival emphysema and prevent vision loss from orbital compression. Poster 35 Fun and Games—Until Somebody Gets Shot in the Eye: Blunt Trauma From a Paintball Causing an Angle Recession and Retinal Tear Elizabeth Sanders, O.D., and Sherrol Reynolds, O.D., Nova Southeastern University, College of Optometry, 3200 South University Drive, Ft. Lauderdale, Florida 33328 Background: Reported cases of blunt force ocular injuries caused by projectile paintball pellets often have a high visual morbidity. Commonly reported paintball ocular injuries include corneal abrasions, cataracts, retinal detachments, hyphemas, and vitreous hemorrhage. Each injury has the potential to markedly decrease vision or cause significant pain, imploring the injured to seek treatment. However, blunt force injuries can also cause damage to structures of the eye with few acute symptoms but significant long-term effects when left untreated. Case Summary: A 13-year-old Hispanic male presented to an urgent care clinic reporting a paintball injury to the left eye 4 days earlier. Acute swelling and discomfort had subsided during the interim, but a moderate photophobia persisted, causing the patient to seek treatment. Upon examination, the left eye was found to have 20/20 acuity, a small, but dense stromal impact scar to the cornea, a corectopic pupil, and an anterior chamber flare. Gonioscopic evaluation followed and revealed a temporal anterior chamber angle recession and a microhyphema. The patient was treated with Lotemax, bedrest, and cool compresses. The retina was examined at the initial visit and at 1- and 2-day follow-ups. During the 2-day follow-up, a peripheral flap tear with a possible choroidal rupture was identified temporally in the left eye. The patient was followed up until the uveitis and hyphema had resolved and was referred for retinal tear repair. Conclusion: This case demonstrates an angle recession and retinal flap tear secondary to a traumatic paintball eye injury that presented with minimal symptomatology. It highlights the importance of a careful evaluation of anterior and posterior ocular structures when a traumatic history is present. Epidemiologic information, paintball eye safety information, gonioscopic photographs, and anterior and posterior segment photographs will be included. Poster 36 Bilateral Papilledema: Case Presentation and Review Luciana Coscione, O.D., and Arlene Gold, O.D., John D. Dingell VAMC, 4646 John Road, Detroit, Michigan 48201
Poster Presentations Background: Papilledema is an important ocular sign for a variety of serious systemic conditions. Ordering appropriate laboratory tests and imaging in a timely manner is crucial to determine the underlying cause of the papilledema and to insure appropriate referrals and treatment. We present a case of bilateral papilledema resulting from lung cancer metastasis to the brain. In addition to the case presentation, we discuss the differential diagnoses for bilateral papilledema. Case Summary: A 48-year-old black male was referred to our clinic with complaints of a spot in his vision. His medical history was positive for esophageal reflux, asthma, chronic back pain, hypercholesterolemia, and a lung neoplasm (non–small cell lung carcinoma) diagnosed 2 months prior. He smoked 1 package of cigarettes per day for the last 30 years and had recently quit. The dilated fundus examination revealed a recent onset of bilateral papilledema. The optic nerves appeared hyperemic and elevated with blurry disc margins. Intraretinal hemorrhages and cotton wool spots were also noted bilaterally. Humphrey visual field results showed a right superior quadranopsia. A computed tomography (CT) scan of the head and orbits was performed and revealed several masses within the temporal-parietal and occipital lobes, which were determined to be metastatic lesions from the non-small cell lung cancer. These lesions caused a mass effect, responsible for the observed ocular sequellae. The patient was treated palliatively and passed away after a few months. Conclusion: This case demonstrates that bilateral papilledema is a significant clinical finding that may indicate several serious systemic conditions. Many of these conditions may potentially lead to permanent vision loss or even death. Proper workup, diagnosis, and management of the underlying etiology can be challenging but is crucial in minimizing devastating complications. In this particular case, the papilledema was an ocular manifestation of the underlying metastatic lung cancer. Unfortunately, the delayed diagnosis was unable to considerably impact the final outcome of this case. Furthermore, many recent studies recommend a CT chest scan for all high-risk patients to increase early detection of lung cancer. Poster 37 A Case of Coexisting Neuropathologies Shannon Huntzberry, O.D., and Michael Henderson, O.D, Seidenberg Protzko Eye Assoc., 601 Thames Way, Bel Air, Maryland 21014 Background: A lesion at any location along the oculosympathetic pathway can produce a Horner’s syndrome, causing paresis of involuntary ocular muscles that are under sympathetic control. A paretic muscle of Muller gives rise to the characteristic eyelid ptosis, and denervation of the iris dilator yields pupillary miosis. In contrast, myasthenia gravis is an immunologic disorder characterized by fluctuating weakness of the voluntary ocular muscles. Failure at the postsynaptic membrane of the neuromuscular junction
285 causes orbicularis fatigue and variable strabismus. The pupil is spared in these cases. This case describes a single patient with Horner’s syndrome, and the subsequent discovery of a superimposed ocular myasthenia gravis on followup. Case Report: A 66-year-old white male presented with an acquired, unilateral ptosis of 1-week duration. Exam revealed ipsilateral pupillary miosis, anisocoria greatest in dim illumination, and a distinct dilation lag. Cocaine testing confirmed the diagnosis of a left-sided Horner’s syndrome, and a positive hydroxyamphetamine test localized a postganglionic lesion. MRI revealed a mucoserous retention cyst at the level of the ethmoid sinus with questionable compression of the sympathetic fibers in that area. Interestingly, on follow-up the patient reported improvement of ptosis after periods of rest and that the lid returned to almost normal level in cold temperature. In-office evaluation revealed worsening of ptosis with prolonged upward gaze, a positive Cogan lid twitch sign, and marked improvement of ptosis following ice-pack application. Serologic testing revealed elevated binding and modulating acetylcholine receptor antibodies, confirming the diagnosis of a coexisting myasthenia gravis. Conclusion: Treatment with oral pyridostigmine, a cholinesterase inhibitor, improved the ptosis, and the patient has developed no symptoms of generalized disease to date. It is probable that the Horner’s syndrome was longstanding and that the ocular symptoms were a result of the myasthenia. Evaluation of the entire clinical picture in this case was critical in determining diagnostic workup, prognosis, and treatment options for these 2 very separate clinical entities. Poster 38 Melanocytoma of the Optic Disc Benjamin Gilsdorf, O.D., James Yi, O.D., Dawn Pewitt, O.D., Stacey Gin, O.D., and Connie Liu, O.D., VA San Diego Healthcare System, Southern California College of Optometry, 3350 La Jolla Village Drive, San Diego, California 92161 Background: Melanocytoma is a benign tumor that is a histologic variant of the choroidal nevus. It is typically flat or slightly elevated, grey to black, and most commonly located at the optic nerve head. Lesions typically are stable in size, but a small percentage of tumors have shown subtle growth over time. Patients with melanocytoma usually are asymptomatic but may present with decreased vision, visual field defects, and pupil abnormalities. Vision loss results from tumor necrosis, optic neuropathy, or retinal vascular obstruction. Rare cases of malignant transformation to choroidal melanoma have been reported. The primary differential diagnosis for melanocytoma is malignant melanoma. Case Report: A 59-year-old Hispanic male presented for a diabetic eye exam and “grey-appearing lamina O.S.” Examination revealed no retinopathy OU with normal findings except for a circular area of flat brownish pigmentation on