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Can Pinhole Acuity be Used to Predict the Level of Refractive Error?
318 unremarkable. A Humphrey visual field was full in the right eye, and revealed peripheral field constriction in the left eye. Fundus photographs showed stability of the left fundus compared with previous visits. The patient has no known family history of RP. Conclusion: The rarity of unilateral RP warrants extensive testing to rule out all differentials before concluding on this diagnosis. Electrodiagnostic testing and repeated dilated fundus examinations are also necessary. This case report explores the appropriate workup, criteria for diagnosis, and management of unilateral RP. A literature review of unilateral RP and its differentials, including DUSN, is discussed.
Poster 75 Do Unilateral Sectoral Pigment Spicules Indicate Retinitis Pigmentosa? Jennifer Marie Holman, B.A., and Daniel Smith, O.D., Southern College of Optometry, 1245 Madison Avenue, Memphis, Tennessee 38104 Chorioretinal scarring is a common clinical sign of various ocular conditions and may exist in a multitude of configurations. One possible appearance is that of pigmented spicules. Conditions typically characterized by pigmented spicules include retinitis pigmentosa (RP), pigmented paravenous retinochoriodal atrophy (PPRCA), inflammation, and trauma. The following case report is that of a 10-year-old black boy who presented for an annual examination with no major vision complaints but had significant chorioretinal scarring on the inferior temporal left fundus. Uncorrected visual acuities were 20/20 O.D., 20/20 O.S., 20/15 OU at distance and 20/20 O.D., O.S., OU at near. Confrontational visual fields indicated a defect in the superior temporal field of the left eye only. Ophthalmoscopy and fundus photography showed pigment spicules in the inferior nasal quadrant of the left eye and a normal right eye appearance. The patient experienced extreme photophobia, left eye greater than right eye, on ophthalmoscopy. Color vision was tested utilizing a Farnsworth D15, which showed no defect in either eye. Automated visual field testing indicated a significant visual field defect corresponding to the retinal findings of the left eye. An electroretinogram (ERG) was performed, the results of which indicated decreased photopic and scotopic waveforms of the left eye compared with the normal right eye. Differential diagnoses included unilateral sector RP, PPRCA, and trauma. The controversial existence of unilateral RP and the results of the ERG led to the exclusion of RP as the possible cause of this patient’s pigment spicules. PPRCA is usually bilateral and shows color defects so the lack of these allowed us to rule this diagnosis out. History found no known prior inflammatory condition or trauma. However, it is plausible to suspect a male child incurred trauma from normal play. Therefore, the diagnosis of prior retinal detachment that had spontaneously reattached was
Optometry, Vol 80, No 6, June 2009 made. All differential diagnoses other than trauma have been shown to be progressive, so the lack of positive evidence for a specific cause indicates that management should include re-examination of posterior segment findings every 3 to 6 months with repeat visual fields to monitor for vision/field loss.
Poster 76 Can Pinhole Acuity be Used to Predict the Level of Refractive Error? Soraya Keshmiri, Judith A. Perrigin, O.D., and David M. Perrigin, O.D., The University of Houston, College of Optometry, 505 J. Davis Armistead Building, Houston, Texas 77204-2020 Purpose: Many clinicians include the pinhole test procedure when patients present with decreased unaided visual acuity and/or a decreased habitual visual acuity. This test is used to quickly determine if the decreased acuity is caused by uncorrected refractive error or to pathology. The assumption is that an improvement in the acuity through the pinhole indicates uncorrected refractive error, and the same or decreased acuity is an indication of pathology. Despite the widespread use of the pinhole test procedure, standards have not been established for the expected improvement in acuity in patients without pathology and acuity that can be improved to 20/20 with refraction. The goal of this study was to determine if there is a consistent expected amount of improvement with pinhole acuity for different levels of uncorrected refraction in a healthy group of patients. If true, this method could be used to predict or estimate spectacle powers for individuals being screened when manpower and equipment are limited. Methods: Eighteen healthy patients between the ages of 20 and 35 were recruited and prescreened for this study. All were adapted spherical soft contact lens wearers with less than -0.75 D of residual astigmatism and correctable to 20/20 visual acuity. Soft spherical disposable contact lenses were then selected for each patient to induce refractive errors from -1.00 DS to -8.00 DS in 1.00 D intervals. Visual acuity for each of the 8 induced refractive errors was then determined in dim and bright illumination with and without the pinhole. The acuity was determined with randomly presented letters using a digital visual acuity system. Results: All subjects had improved visual acuity with the pinhole in place for all induced refractive errors in both dim and bright illumination. However, the level of improvement within each induced refractive error varied greatly from subject to subject. Except for lower levels of myopia (-2.00 and -3.00), there was not a correlation between corrected pinhole acuity and degree of refractive error. Additionally, there was much overlap of pinhole acuity achieved between levels of induced refractive error. There was greater inconsistency between subject responses at higher refractive errors with some subjects reporting the
Poster Presentations
319
same pinhole acuity as other subjects despite a high difference in the induced refractive error. Conclusions: Pinhole acuity testing is considered useful in quickly differentiating between pathologic and refractive reasons for decreased acuity. However, our test results suggest pinhole acuity findings are too variable to predict the degree of uncorrected refractive error.
Poster 78
Poster 77
Background: Birdshot chorioretinopathy (BCR) is a chronic intraocular inflammatory disorder that often manifests as a bilateral posterior uveitis. It is characterized by multiple, distinctive, oval creamy-hypopigmented lesions at the level of the retinal pigment epithelium (RPE) and choroid. Other associated ocular findings include retinal vasculitis, optic disc edema, and cystoid macular edema (CME). Symptoms include blurred vision, reduced contrast sensitivity, and varying degrees of nyctalopia. Automated visual field testing (VFE) and optical coherence tomography (OCT) can provide essential additional objective measures for monitoring disease activity. The OCT is an exceptional tool in detecting macular changes associated with BCR. Case Summary: A 59-year-old man presented to the eye clinic at West Haven VAMC for a follow-up complaining of longstanding floaters, difficulty with light-dark adaptation, and glare during the nighttime. He had BCR diagnosed with several reoccurrences for which he was treated with oral prednisone. Best-corrected visual acuity was 20/25 in both eyes. Fundus examination found baseline grade 1 vitreal cells and multiple, distinct, cream-colored spots in both retinas. Utilizing OCT found epiretinal membranes in both maculas and hyper-reflectivity at the level of the retinal nerve fiber layer and choroid when scanned through a cream-colored spot. Conclusion: BCR is attributed to an autoimmune process and has a strong correlation to the HLA-A29 allele. Active stages of the disease merit a retinal consultation for steroidal or immunosuppressive treatment. Because of the chronicity of this condition, frequent follow-ups, along with visual field testing and OCT, are important in detecting exacerbations of BCR. Consideration of low vision rehabilitation in the late stages can improve a patient’s quality of life. This poster examines clinical findings and usage of OCT for proper diagnosis and management of BCR.
Bevacizumab (Avastin) Versus Grid Laser for Treatment of Longstanding Diabetic Clinically Significant Macular Edema (CSME) Eileen Bush, O.D., Theresa Chong, O.D., Kevin So, O.D., Diana Nguyen, O.D., and Nancy Shenouda-Awad, O.D., West Haven VA Connecticut Healthcare System, 950 Campbell Ave., West Haven, Connecticut 06516 Background: Clinically significant macular edema (CSME) associated with proliferative diabetic retinopathy (PDR) is a significant sight-threatening manifestation of uncontrolled diabetes. Approximately 50% of patients with CSME will experience a decrease of at least 2 lines of best-corrected visual acuity after 2 years. CSME is caused by increased retinal vascular permeability and vascular endothelial growth factor (VEGF). Current treatments of diabetic retinopathy with CSME include focal/grid laser photocoagulation, panretinal laser photocoagulation (PRP), pars plana vitrectomy (PPV), and intravitreal Kenelog injection. New treatment with anti–vascular endothelial growth factor (anti-VEGF) intravitreal injections of Bevacizumab (Avastin) is currently being investigated. Case Report: A 57-year-old white man presented to the Optometry service at West Haven VAMC for a routine eye examination. Ocular history included PDR with vitreal hemorrhage O.S., CSME O.S. and nonproliferative diabetic retinopathy (NPDR) O.D. The patient had history of past grid laser treatment O.S. and PRP treatment OU. Dilated fundus examination found active PDR with CSME OU. Based on Fluorescein Angiography (FA) and Optical Coherence Tomography (OCT), the patient received an Avastin injection OU. Results of subjective testing, FA and OCT demonstrated short-term improvement in visual acuity and macular edema. At the 2-month follow-up, edema had not resolved, and vision showed no improvement. Subsequently, the patient received grid laser OU. Conclusion: Longstanding CSME is difficult to treat and may cause irreversible vision loss. Therefore, early and aggressive treatment is required for good prognosis. New therapies such as intravitreal anti-VEGF injections are currently being investigated. However, focal and grid laser photocoagulation remain the gold standard of treatment. This case shows the short-term efficacy of Avastin injection compared with the continued long-term efficacy of grid laser photocoagulation for CSME. Pathophysiology, clinical testing, and treatments are discussed. Ocular findings from this case are supported with fundus photography, OCT, and FA.
Optical Coherence Tomography Findings in Patients With Birdshot Chorioretinopathy (BCR) Diana Nguyen, O.D., Kevin So, O.D., Eileen Bush, O.D., Theresa Chong, O.D., and Nancy Shenouda-Awad, O.D., West Haven VA Connecticut Healthcare System, 950 Campbell Ave, West Haven, Connecticut 06516
Poster 79 Epithelial Ingrowth After a Photorefractive Keratectomy Enhancement Lori Gray, O.D., and Curt Gottlieb, O.D., TLC Laser Eye Centers, 600 W. Germantown Pike, Ste. 160, Plymouth Meeting, Pennsylvania 19462 Background: Epithelial ingrowth occurs when the epithelial cells that typically cover the outside of the cornea begin to
Poster 75 Do Unilateral Sectoral Pigment Spicules Indicate Retinitis Pigmentosa? Jennifer Marie Holman, B.A., and Daniel Smith, O.D., Southern College of Optometry, 1245 Madison Avenue, Memphis, Tennessee 38104 Chorioretinal scarring is a common clinical sign of various ocular conditions and may exist in a multitude of configurations. One possible appearance is that of pigmented spicules. Conditions typically characterized by pigmented spicules include retinitis pigmentosa (RP), pigmented paravenous retinochoriodal atrophy (PPRCA), inflammation, and trauma. The following case report is that of a 10-year-old black boy who presented for an annual examination with no major vision complaints but had significant chorioretinal scarring on the inferior temporal left fundus. Uncorrected visual acuities were 20/20 O.D., 20/20 O.S., 20/15 OU at distance and 20/20 O.D., O.S., OU at near. Confrontational visual fields indicated a defect in the superior temporal field of the left eye only. Ophthalmoscopy and fundus photography showed pigment spicules in the inferior nasal quadrant of the left eye and a normal right eye appearance. The patient experienced extreme photophobia, left eye greater than right eye, on ophthalmoscopy. Color vision was tested utilizing a Farnsworth D15, which showed no defect in either eye. Automated visual field testing indicated a significant visual field defect corresponding to the retinal findings of the left eye. An electroretinogram (ERG) was performed, the results of which indicated decreased photopic and scotopic waveforms of the left eye compared with the normal right eye. Differential diagnoses included unilateral sector RP, PPRCA, and trauma. The controversial existence of unilateral RP and the results of the ERG led to the exclusion of RP as the possible cause of this patient’s pigment spicules. PPRCA is usually bilateral and shows color defects so the lack of these allowed us to rule this diagnosis out. History found no known prior inflammatory condition or trauma. However, it is plausible to suspect a male child incurred trauma from normal play. Therefore, the diagnosis of prior retinal detachment that had spontaneously reattached was
Optometry, Vol 80, No 6, June 2009 made. All differential diagnoses other than trauma have been shown to be progressive, so the lack of positive evidence for a specific cause indicates that management should include re-examination of posterior segment findings every 3 to 6 months with repeat visual fields to monitor for vision/field loss.
Poster 76 Can Pinhole Acuity be Used to Predict the Level of Refractive Error? Soraya Keshmiri, Judith A. Perrigin, O.D., and David M. Perrigin, O.D., The University of Houston, College of Optometry, 505 J. Davis Armistead Building, Houston, Texas 77204-2020 Purpose: Many clinicians include the pinhole test procedure when patients present with decreased unaided visual acuity and/or a decreased habitual visual acuity. This test is used to quickly determine if the decreased acuity is caused by uncorrected refractive error or to pathology. The assumption is that an improvement in the acuity through the pinhole indicates uncorrected refractive error, and the same or decreased acuity is an indication of pathology. Despite the widespread use of the pinhole test procedure, standards have not been established for the expected improvement in acuity in patients without pathology and acuity that can be improved to 20/20 with refraction. The goal of this study was to determine if there is a consistent expected amount of improvement with pinhole acuity for different levels of uncorrected refraction in a healthy group of patients. If true, this method could be used to predict or estimate spectacle powers for individuals being screened when manpower and equipment are limited. Methods: Eighteen healthy patients between the ages of 20 and 35 were recruited and prescreened for this study. All were adapted spherical soft contact lens wearers with less than -0.75 D of residual astigmatism and correctable to 20/20 visual acuity. Soft spherical disposable contact lenses were then selected for each patient to induce refractive errors from -1.00 DS to -8.00 DS in 1.00 D intervals. Visual acuity for each of the 8 induced refractive errors was then determined in dim and bright illumination with and without the pinhole. The acuity was determined with randomly presented letters using a digital visual acuity system. Results: All subjects had improved visual acuity with the pinhole in place for all induced refractive errors in both dim and bright illumination. However, the level of improvement within each induced refractive error varied greatly from subject to subject. Except for lower levels of myopia (-2.00 and -3.00), there was not a correlation between corrected pinhole acuity and degree of refractive error. Additionally, there was much overlap of pinhole acuity achieved between levels of induced refractive error. There was greater inconsistency between subject responses at higher refractive errors with some subjects reporting the
Poster Presentations
319
same pinhole acuity as other subjects despite a high difference in the induced refractive error. Conclusions: Pinhole acuity testing is considered useful in quickly differentiating between pathologic and refractive reasons for decreased acuity. However, our test results suggest pinhole acuity findings are too variable to predict the degree of uncorrected refractive error.
Poster 78
Poster 77
Background: Birdshot chorioretinopathy (BCR) is a chronic intraocular inflammatory disorder that often manifests as a bilateral posterior uveitis. It is characterized by multiple, distinctive, oval creamy-hypopigmented lesions at the level of the retinal pigment epithelium (RPE) and choroid. Other associated ocular findings include retinal vasculitis, optic disc edema, and cystoid macular edema (CME). Symptoms include blurred vision, reduced contrast sensitivity, and varying degrees of nyctalopia. Automated visual field testing (VFE) and optical coherence tomography (OCT) can provide essential additional objective measures for monitoring disease activity. The OCT is an exceptional tool in detecting macular changes associated with BCR. Case Summary: A 59-year-old man presented to the eye clinic at West Haven VAMC for a follow-up complaining of longstanding floaters, difficulty with light-dark adaptation, and glare during the nighttime. He had BCR diagnosed with several reoccurrences for which he was treated with oral prednisone. Best-corrected visual acuity was 20/25 in both eyes. Fundus examination found baseline grade 1 vitreal cells and multiple, distinct, cream-colored spots in both retinas. Utilizing OCT found epiretinal membranes in both maculas and hyper-reflectivity at the level of the retinal nerve fiber layer and choroid when scanned through a cream-colored spot. Conclusion: BCR is attributed to an autoimmune process and has a strong correlation to the HLA-A29 allele. Active stages of the disease merit a retinal consultation for steroidal or immunosuppressive treatment. Because of the chronicity of this condition, frequent follow-ups, along with visual field testing and OCT, are important in detecting exacerbations of BCR. Consideration of low vision rehabilitation in the late stages can improve a patient’s quality of life. This poster examines clinical findings and usage of OCT for proper diagnosis and management of BCR.
Bevacizumab (Avastin) Versus Grid Laser for Treatment of Longstanding Diabetic Clinically Significant Macular Edema (CSME) Eileen Bush, O.D., Theresa Chong, O.D., Kevin So, O.D., Diana Nguyen, O.D., and Nancy Shenouda-Awad, O.D., West Haven VA Connecticut Healthcare System, 950 Campbell Ave., West Haven, Connecticut 06516 Background: Clinically significant macular edema (CSME) associated with proliferative diabetic retinopathy (PDR) is a significant sight-threatening manifestation of uncontrolled diabetes. Approximately 50% of patients with CSME will experience a decrease of at least 2 lines of best-corrected visual acuity after 2 years. CSME is caused by increased retinal vascular permeability and vascular endothelial growth factor (VEGF). Current treatments of diabetic retinopathy with CSME include focal/grid laser photocoagulation, panretinal laser photocoagulation (PRP), pars plana vitrectomy (PPV), and intravitreal Kenelog injection. New treatment with anti–vascular endothelial growth factor (anti-VEGF) intravitreal injections of Bevacizumab (Avastin) is currently being investigated. Case Report: A 57-year-old white man presented to the Optometry service at West Haven VAMC for a routine eye examination. Ocular history included PDR with vitreal hemorrhage O.S., CSME O.S. and nonproliferative diabetic retinopathy (NPDR) O.D. The patient had history of past grid laser treatment O.S. and PRP treatment OU. Dilated fundus examination found active PDR with CSME OU. Based on Fluorescein Angiography (FA) and Optical Coherence Tomography (OCT), the patient received an Avastin injection OU. Results of subjective testing, FA and OCT demonstrated short-term improvement in visual acuity and macular edema. At the 2-month follow-up, edema had not resolved, and vision showed no improvement. Subsequently, the patient received grid laser OU. Conclusion: Longstanding CSME is difficult to treat and may cause irreversible vision loss. Therefore, early and aggressive treatment is required for good prognosis. New therapies such as intravitreal anti-VEGF injections are currently being investigated. However, focal and grid laser photocoagulation remain the gold standard of treatment. This case shows the short-term efficacy of Avastin injection compared with the continued long-term efficacy of grid laser photocoagulation for CSME. Pathophysiology, clinical testing, and treatments are discussed. Ocular findings from this case are supported with fundus photography, OCT, and FA.
Optical Coherence Tomography Findings in Patients With Birdshot Chorioretinopathy (BCR) Diana Nguyen, O.D., Kevin So, O.D., Eileen Bush, O.D., Theresa Chong, O.D., and Nancy Shenouda-Awad, O.D., West Haven VA Connecticut Healthcare System, 950 Campbell Ave, West Haven, Connecticut 06516
Poster 79 Epithelial Ingrowth After a Photorefractive Keratectomy Enhancement Lori Gray, O.D., and Curt Gottlieb, O.D., TLC Laser Eye Centers, 600 W. Germantown Pike, Ste. 160, Plymouth Meeting, Pennsylvania 19462 Background: Epithelial ingrowth occurs when the epithelial cells that typically cover the outside of the cornea begin to