- Email: [email protected]
Antiphospholipid Antibody Syndrome and Bilateral Ischemic Optic Neuropathy
284 patients, they may indicate more severe underlying pathology that could easily be overlooked without a thorough history. It is up to the clinician to ask the critical questions necessary to determine if a more detailed examination is needed to rule out any further conditions that may threaten vision or the overall health of the eyes. The purpose of this report is to increase practitioners’ awareness of the benefits to taking a thorough history on all patients regardless of how simple and routine their symptoms may appear.
Poster 32 Vitreo-Retinal Traction (VRT) Causing a Localized Retinal Detachment Meghan Cook, O.D., Crystal DeLuca, O.D., Nirali Patel, O.D., and Nancy Shenouda-Awad, O.D., West Haven VA CT HCS Background: Vitreo-retinal traction (VRT) is a result of an acute incomplete posterior vitreous detachment (PVD). Complications of VRT may include retinal breaks, optic disc hemorrhages, vitreous hemorrhage, and retinal detachment (RD). VRT often occurs at the macula or in the peripapillary area because of the strong adhesions of the vitreous at these sites. This poster discusses an atypical case of a dramatic persistent VRT in a 92-year-old with a resulting localized RD significantly demonstrated with Optical Coherence Tomography (OCT). Disease process, management, and treatment of VRT will be discussed. Case Report: A 92-year-old white man presented to the optometry service at West Haven VAMC for follow-up on a 3month history of floater OD caused by impending PVD. Symptoms of floaters were stable in frequency and size with no associated flashes or loss of vision. Ocular history includes cataract surgery OD 3 years prior. Best-corrected visual acuities were 20/20- OD, 20/20- OS. Dilated fundus examination found an incomplete PVD OD with newly noted VRT just nasal to the disc. OCT line scan showed VRT with a localized RD and vitreous dialysis nasal to the disc. A retina specialist was consulted, who concurred with our diagnosis and plan of frequent monitoring without treatment. The patient is currently followed up closely with dilated examinations and was educated regarding the need to return to the clinic immediately if he experienced any symptoms of flashes, increased floaters, curtain veiling, or decreased vision. Conclusion: This case is atypical because this patient’s vitreo-retinal interface still maintains partial attachment at the advanced age of 92, unlike that of his cohorts, most of whom (63%) have already experienced complete PVD by age 70. Because of the high likelihood of spontaneous resolution and no effect on the vision, no treatment is required at this time. In light of the risk of vision-threatening complications of the VRT, patients with similar clinical findings should be followed up at intervals of 4 to 6 weeks and treated if progression is noted.
Optometry, Vol 81, No 6, June 2010 Poster 33 Inflammatory Cystoid Macular Edema as a Result of Immune-Recovery Uveitis Richard Guzak, O.D., Juilie Rodman, O.D., and Joseph Pizzimenti, O.D., Nova Southeastern University, Ft. Lauderdale, Florida Background: Potent antiretroviral therapy can lead to improved immunity in patients with AIDS. However, ocular inflammation can occur in predisposed individuals as a result of this clinical immune recovery and is called immune recovery uveitis. Cystoid macular edema (CME) is a complication that can result from this inflammation and is emerging as a major cause of visual loss in HIV-infected patients with immune recovery uveitis. Case Report: A 52-year-old man presented with complaints of intermittent decreased vision that had coincided with the initiation of antiviral treatment. He also reported metamorphopsia and floaters in both of eyes of several years’ duration. He had a history of HIV for 20 years and was only recently started on Highly Active Antiretroviral Therapy (HAART). He reported a vague history of ocular problems that he was unsure about. Retinal examination found old areas of peripheral retinal scarring from presumed past ocular inflammation as well as thickening and irregularity at the macula. Ancillary testing was performed and cystoid macular edema was diagnosed. Conclusion: Immune-recovery uveitis is a leading cause of visual disturbance in HIV-infected patients with a history of cytomegalovirus retinitis on HAART. Although the immune recovery associated with the advent of HAART has decreased the need for potent CMV medications, the heightened immune response can be associated with sight-threatening inflammation. Poster 34 Antiphospholipid Antibody Syndrome and Bilateral Ischemic Optic Neuropathy Sarah Wagner, O.D., Columbus VA Outpatient Clinic, Columbus, Ohio Background: Anti-phospholipid antibody syndrome is a thrombophilic state characterized by recurrent arterial and venous thrombosis, recurrent pregnancy loss, and the presence of circulating antiphospholipid antibodies. Thrombosis primarily affects the deep veins of the leg, pulmonary circulation, the inferior vena cava, hepatic and renal systems, and retinal vasculature. The most common ocular signs are flame-shaped hemorrhages, cotton wool spots, vessel tortuosity, venous occlusion, optic disc swelling, and optic neuropathy. Thus, ocular signs of anti phospholipid antibody can resemble diabetic and hypertensive retinopathy. Case Summary: A 52-year-old man presented for a full examination with complaints of poor vision in both eyes since 2001. His medical history was pertinent for hypertension and rare alcohol consumption. Best-corrected acuities were 20/50 OD and OS. No relative afferent papillary
Poster Presentations
285
defect was present. Humphrey Visual Field 24-2 found an overall depression with mild central defect OD and temporal, nonglaucomatous defects OS. Internal examination was remarkable for 0.7H/V cup-to-disc ratios in both eyes with diffuse pallor OU. Extensive workup for bilateral optic neuropathy in this patient was completed. Electroretinogram was within normal limits with the exception of color vision defects along the tritan axis and mildly decreased contrast sensitivity OU. Metabolic panel of a complete blood count, chem. 7 panel, album, RPR, FTAABS, vitamin B12, folate, and thiamine was negative. Lab work was also negative for anti-ds DNA, SSA, SSB, RNP, and ANA. MRI of brain/orbits with and without contrast was also negative. Lab work was positive for 2 circulating antiphospholipid antibodies: anticardiolipin IgG and IgA. Conclusion: Antiphospholipid antibody syndrome was determined to be the etiology of this patient’s bilateral optic neuropathy because of the presence of 2 circulating antiphospholipid antibodies. This patient is currently under the care of hematology to initiate anticoagulant therapy. Thrombophilia should be considered as a differential in cases of unexplained vision loss and transient neurologic disturbances. If antiphospholipid antibody syndrome is present, initiation of anticoagulant therapy may be a suitable option for these patients.
found a vitritis OS, C/D ratio of 0.3 round OD, OS with flat and intact macula OD, OS. The peripheral retina was normal OD, but OS showed peripheral dot hemorrhages superiorly with areas of whitening throughout the fundus. Fluorescein angiography showed perivascular and disc staining OS. The patient had acute retinal necrosis diagnosed and was prescribed oral Valtrex and prednisone. Laboratory studies were ordered to screen for toxoplasmosis, herpes zoster, herpes simplex, and cytomegalovirus. Conclusion: With any ophthalmic examination, it is critical to illicit a thorough medical history. In this case, the patient’s recent systemic infection with the varicella-zoster virus helped to confirm the ocular findings. Because of the progressive nature of ARN, a rapid and accurate diagnosis is crucial for prompt administration of appropriate therapies. This poster includes fundus photos, fluorescein angiography, and laboratory testing.
Poster 35
Background: Ocular itching is a common symptom that may be consistent with several ocular disorders, including allergic conjunctivitis. Because the presentations overlap, patients may use over-the-counter artificial tear preparations in place of anti-allergy drops, unaware that there are substantial differences in both the mechanism of action and efficacy of these products. The goal of this evaluation was to assess the ability of olopatadine HCl ophthalmic solution, 0.2% (OLO), to eliminate ocular itching compared with placebo in the treatment of allergen-mediated conjunctivitis in the conjunctival allergen challenge (CAC) model. Method: The study was a randomized, double-masked trial in subjects dosed in one eye with olopatadine 0.2% and in the contralateral eye with placebo (vehicle). Eligible subjects were challenged with antigen at 27 minutes (to assess onset-of-action) after dosing. This post hoc analysis evaluated the ability of the drug to reduce itching scores to zero upon installation. The safety analysis was based on an evaluation of the exposure to study drug, adverse events, visual acuity, ocular signs, and fundus parameters. Results: The percentages of OLO patients reporting zero itching scores after the onset-of-action allergen challenge were 63% (3 min), 63% (5 min), and 65% (7 min) compared with 3%, 5% and 10%, respectively, for those patients taking placebo. The percentage of patients with zero itch scores was significantly higher for the OLO group than for the placebo group at every time point (p,0.05). No treatment-related adverse events were reported during the study. Conclusion: Olopatadine HCl ophthalmic solution 0.2% provided statistically significant relief from ocular itching when patients were challenged with antigen shortly after dosing.
Acute Retinal Necrosis: An Uncommon Ocular Complication of the Herpes Virus Sylvia E. Sparrow, O.D., and Nataly M. Fahim, O.D., Southern College of Optometry, Memphis, Tennessee Background: Acute retinal necrosis (ARN) is a sightthreatening condition that results from the reactivation of a dormant herpes virus. This typically occurs in immunocompetent individuals ages 20-50. Initial complaints may include pain, decreased vision, and floaters. Clinical presentation includes focal peripheral areas of retinal necrosis that progress rapidly, occlusive vasculopathy and a marked inflammatory reaction in the vitreous and anterior chamber. Retinal detachment occurs in approximately 75% of patients and is a major cause of vision loss. Thirty-six percent of cases are bilateral, and only 30% of patients achieve greater than 20/200 vision. Other vision-threatening complications include optic neuritis and central retinal artery occlusion. Treatment involves antiviral and anti-inflammatory therapy with prophylactic laser photocoagulation. Case Summary: A 54-year-old black man presented with complaints of flashes of light OS for 2 weeks. Last eye examination 4 months prior was unremarkable. Medical history was positive for asthma and a recent episode of systemic shingles for which he did not take antivirals. Unaided acuities were 20/30- OD (PH 20/20-), 20/40 OS (PH 20/2512). Pupils, EOMs, and CFs were normal OD, OS. Slit lamp examination was unremarkable OD, but revealed 11 anterior chamber reaction OS. Goldman tonometry measured 14 mmHg OD, OS. Dilated fundus examination
Poster 36 Elimination of Ocular Itching By Olopatadine HCL Ophthalmic Solution, 0.2% Alan G. Kabat, O.D., Dina Amin, M.S., and Maria J. Tort, Ph.D., Nova Southeastern University, Ft. Lauderdale, Florida
Poster 32 Vitreo-Retinal Traction (VRT) Causing a Localized Retinal Detachment Meghan Cook, O.D., Crystal DeLuca, O.D., Nirali Patel, O.D., and Nancy Shenouda-Awad, O.D., West Haven VA CT HCS Background: Vitreo-retinal traction (VRT) is a result of an acute incomplete posterior vitreous detachment (PVD). Complications of VRT may include retinal breaks, optic disc hemorrhages, vitreous hemorrhage, and retinal detachment (RD). VRT often occurs at the macula or in the peripapillary area because of the strong adhesions of the vitreous at these sites. This poster discusses an atypical case of a dramatic persistent VRT in a 92-year-old with a resulting localized RD significantly demonstrated with Optical Coherence Tomography (OCT). Disease process, management, and treatment of VRT will be discussed. Case Report: A 92-year-old white man presented to the optometry service at West Haven VAMC for follow-up on a 3month history of floater OD caused by impending PVD. Symptoms of floaters were stable in frequency and size with no associated flashes or loss of vision. Ocular history includes cataract surgery OD 3 years prior. Best-corrected visual acuities were 20/20- OD, 20/20- OS. Dilated fundus examination found an incomplete PVD OD with newly noted VRT just nasal to the disc. OCT line scan showed VRT with a localized RD and vitreous dialysis nasal to the disc. A retina specialist was consulted, who concurred with our diagnosis and plan of frequent monitoring without treatment. The patient is currently followed up closely with dilated examinations and was educated regarding the need to return to the clinic immediately if he experienced any symptoms of flashes, increased floaters, curtain veiling, or decreased vision. Conclusion: This case is atypical because this patient’s vitreo-retinal interface still maintains partial attachment at the advanced age of 92, unlike that of his cohorts, most of whom (63%) have already experienced complete PVD by age 70. Because of the high likelihood of spontaneous resolution and no effect on the vision, no treatment is required at this time. In light of the risk of vision-threatening complications of the VRT, patients with similar clinical findings should be followed up at intervals of 4 to 6 weeks and treated if progression is noted.
Optometry, Vol 81, No 6, June 2010 Poster 33 Inflammatory Cystoid Macular Edema as a Result of Immune-Recovery Uveitis Richard Guzak, O.D., Juilie Rodman, O.D., and Joseph Pizzimenti, O.D., Nova Southeastern University, Ft. Lauderdale, Florida Background: Potent antiretroviral therapy can lead to improved immunity in patients with AIDS. However, ocular inflammation can occur in predisposed individuals as a result of this clinical immune recovery and is called immune recovery uveitis. Cystoid macular edema (CME) is a complication that can result from this inflammation and is emerging as a major cause of visual loss in HIV-infected patients with immune recovery uveitis. Case Report: A 52-year-old man presented with complaints of intermittent decreased vision that had coincided with the initiation of antiviral treatment. He also reported metamorphopsia and floaters in both of eyes of several years’ duration. He had a history of HIV for 20 years and was only recently started on Highly Active Antiretroviral Therapy (HAART). He reported a vague history of ocular problems that he was unsure about. Retinal examination found old areas of peripheral retinal scarring from presumed past ocular inflammation as well as thickening and irregularity at the macula. Ancillary testing was performed and cystoid macular edema was diagnosed. Conclusion: Immune-recovery uveitis is a leading cause of visual disturbance in HIV-infected patients with a history of cytomegalovirus retinitis on HAART. Although the immune recovery associated with the advent of HAART has decreased the need for potent CMV medications, the heightened immune response can be associated with sight-threatening inflammation. Poster 34 Antiphospholipid Antibody Syndrome and Bilateral Ischemic Optic Neuropathy Sarah Wagner, O.D., Columbus VA Outpatient Clinic, Columbus, Ohio Background: Anti-phospholipid antibody syndrome is a thrombophilic state characterized by recurrent arterial and venous thrombosis, recurrent pregnancy loss, and the presence of circulating antiphospholipid antibodies. Thrombosis primarily affects the deep veins of the leg, pulmonary circulation, the inferior vena cava, hepatic and renal systems, and retinal vasculature. The most common ocular signs are flame-shaped hemorrhages, cotton wool spots, vessel tortuosity, venous occlusion, optic disc swelling, and optic neuropathy. Thus, ocular signs of anti phospholipid antibody can resemble diabetic and hypertensive retinopathy. Case Summary: A 52-year-old man presented for a full examination with complaints of poor vision in both eyes since 2001. His medical history was pertinent for hypertension and rare alcohol consumption. Best-corrected acuities were 20/50 OD and OS. No relative afferent papillary
Poster Presentations
285
defect was present. Humphrey Visual Field 24-2 found an overall depression with mild central defect OD and temporal, nonglaucomatous defects OS. Internal examination was remarkable for 0.7H/V cup-to-disc ratios in both eyes with diffuse pallor OU. Extensive workup for bilateral optic neuropathy in this patient was completed. Electroretinogram was within normal limits with the exception of color vision defects along the tritan axis and mildly decreased contrast sensitivity OU. Metabolic panel of a complete blood count, chem. 7 panel, album, RPR, FTAABS, vitamin B12, folate, and thiamine was negative. Lab work was also negative for anti-ds DNA, SSA, SSB, RNP, and ANA. MRI of brain/orbits with and without contrast was also negative. Lab work was positive for 2 circulating antiphospholipid antibodies: anticardiolipin IgG and IgA. Conclusion: Antiphospholipid antibody syndrome was determined to be the etiology of this patient’s bilateral optic neuropathy because of the presence of 2 circulating antiphospholipid antibodies. This patient is currently under the care of hematology to initiate anticoagulant therapy. Thrombophilia should be considered as a differential in cases of unexplained vision loss and transient neurologic disturbances. If antiphospholipid antibody syndrome is present, initiation of anticoagulant therapy may be a suitable option for these patients.
found a vitritis OS, C/D ratio of 0.3 round OD, OS with flat and intact macula OD, OS. The peripheral retina was normal OD, but OS showed peripheral dot hemorrhages superiorly with areas of whitening throughout the fundus. Fluorescein angiography showed perivascular and disc staining OS. The patient had acute retinal necrosis diagnosed and was prescribed oral Valtrex and prednisone. Laboratory studies were ordered to screen for toxoplasmosis, herpes zoster, herpes simplex, and cytomegalovirus. Conclusion: With any ophthalmic examination, it is critical to illicit a thorough medical history. In this case, the patient’s recent systemic infection with the varicella-zoster virus helped to confirm the ocular findings. Because of the progressive nature of ARN, a rapid and accurate diagnosis is crucial for prompt administration of appropriate therapies. This poster includes fundus photos, fluorescein angiography, and laboratory testing.
Poster 35
Background: Ocular itching is a common symptom that may be consistent with several ocular disorders, including allergic conjunctivitis. Because the presentations overlap, patients may use over-the-counter artificial tear preparations in place of anti-allergy drops, unaware that there are substantial differences in both the mechanism of action and efficacy of these products. The goal of this evaluation was to assess the ability of olopatadine HCl ophthalmic solution, 0.2% (OLO), to eliminate ocular itching compared with placebo in the treatment of allergen-mediated conjunctivitis in the conjunctival allergen challenge (CAC) model. Method: The study was a randomized, double-masked trial in subjects dosed in one eye with olopatadine 0.2% and in the contralateral eye with placebo (vehicle). Eligible subjects were challenged with antigen at 27 minutes (to assess onset-of-action) after dosing. This post hoc analysis evaluated the ability of the drug to reduce itching scores to zero upon installation. The safety analysis was based on an evaluation of the exposure to study drug, adverse events, visual acuity, ocular signs, and fundus parameters. Results: The percentages of OLO patients reporting zero itching scores after the onset-of-action allergen challenge were 63% (3 min), 63% (5 min), and 65% (7 min) compared with 3%, 5% and 10%, respectively, for those patients taking placebo. The percentage of patients with zero itch scores was significantly higher for the OLO group than for the placebo group at every time point (p,0.05). No treatment-related adverse events were reported during the study. Conclusion: Olopatadine HCl ophthalmic solution 0.2% provided statistically significant relief from ocular itching when patients were challenged with antigen shortly after dosing.
Acute Retinal Necrosis: An Uncommon Ocular Complication of the Herpes Virus Sylvia E. Sparrow, O.D., and Nataly M. Fahim, O.D., Southern College of Optometry, Memphis, Tennessee Background: Acute retinal necrosis (ARN) is a sightthreatening condition that results from the reactivation of a dormant herpes virus. This typically occurs in immunocompetent individuals ages 20-50. Initial complaints may include pain, decreased vision, and floaters. Clinical presentation includes focal peripheral areas of retinal necrosis that progress rapidly, occlusive vasculopathy and a marked inflammatory reaction in the vitreous and anterior chamber. Retinal detachment occurs in approximately 75% of patients and is a major cause of vision loss. Thirty-six percent of cases are bilateral, and only 30% of patients achieve greater than 20/200 vision. Other vision-threatening complications include optic neuritis and central retinal artery occlusion. Treatment involves antiviral and anti-inflammatory therapy with prophylactic laser photocoagulation. Case Summary: A 54-year-old black man presented with complaints of flashes of light OS for 2 weeks. Last eye examination 4 months prior was unremarkable. Medical history was positive for asthma and a recent episode of systemic shingles for which he did not take antivirals. Unaided acuities were 20/30- OD (PH 20/20-), 20/40 OS (PH 20/2512). Pupils, EOMs, and CFs were normal OD, OS. Slit lamp examination was unremarkable OD, but revealed 11 anterior chamber reaction OS. Goldman tonometry measured 14 mmHg OD, OS. Dilated fundus examination
Poster 36 Elimination of Ocular Itching By Olopatadine HCL Ophthalmic Solution, 0.2% Alan G. Kabat, O.D., Dina Amin, M.S., and Maria J. Tort, Ph.D., Nova Southeastern University, Ft. Lauderdale, Florida