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Is This a Masquerading Carcinoma? When a Chalazion Is Just a Chalazion
382 patient that presented for a quick eye exam after cheerleading practice ended up being far from ‘‘routine.’’
Poster 84 Uveitis: When a Vitrectomy Is More Than Just a Treatment Jennie Tran, O.D., Michelle Louie, O.D., Diane Russo, O.D., and Nancy Shenouda-Awad, O.D., West Haven Veterans Affairs, West Haven, Connecticut Background: Uveitis is an ocular inflammatory disease that can present as anterior, intermediate, posterior, or panuveitic. Although the etiology in most cases is idiopathic, many infectious and inflammatory diseases such as Lyme disease, syphilis, tuberculosis, sarcoidosis, and spondyloarthritis can be associated with it. The outcome of untreated uveitis can be vision-threatening, therefore it is important to initiate early treatment and rule out any systemic associations when warranted. Determining the etiology can be difficult, especially in bilateral and non-resolving cases. Diagnostic tools include history, clinical presentation, infectious/inflammatory blood work, and in rare cases, a diagnostic vitrectomy. Case Report: A 51-year-old white male presented to the West Haven Veterans Affairs Medical Center optometry clinic with a chief complaint of unilateral reduction in vision O.D. for 2 weeks. The patient reported no symptoms of pain but complained of new floaters. Ocular history was unremarkable. Systemic health included diabetes mellitus type II without retinopathy, hepatitis C with end-stage cirrhosis, and a kidney infection resulting in kidney failure. Visual acuity at presentation was 20/400 O.D., 20/20 O.S. Slit lamp examination of O.D. showed corneal edema, posterior synechia, and 4+ anterior chamber reaction with plasmoid aqueous. Dilated fundus exam revealed 4+ vitritis. Due to the poor view of the retina O.D., a B-Scan was performed showing intact retina and incomplete vitreous detachment. Differential diagnoses included human leukocyte antigen-B27, Lyme, toxoplasmosis, tuberculosis, syphilis, and endophthalmitis. Topical/oral steroid and antibiotic treatment was initiated and the patient was followed closely without signs of resolution or progression. Systemic work-up was inconclusive of any inflammatory or infectious etiology. Due to poor response with treatment, a diagnostic vitrectomy was warranted that revealed presence of Candida albicans. The patient was then started on antifungal oral therapy. Conclusion: Uveitis secondary to a fungal infection is mostly found in patients who are immunocompromised or have had a history of drug abuse. In this case, clinical findings alone indicated a unilateral anterior and intermediate uveitis of unknown etiology. The diagnostic vitrectomy in addition to systemic history played a significant role in confirming the cause of inflammation as a fungal infection with presumed endogenous etiology, allowing proper treatment.
Optometry, Vol 82, No 6, June 2011 Poster 85 CSME: To Treat or Not to Treat! Diane Russo, O.D., Michelle Louie, O.D., Jennie Tran, O.D., and Nancy Shenouda-Awad, O.D., West Haven Veterans Affairs, West Haven, Connecticut Background: Clinically significant macular edema (CSME) is a sight-threatening condition affecting about 29% of patients who are diabetic for more than 20 years. In most cases, treatment with either laser photocoagulation or intravitreal triamcinolone or bevacizumab injection is essential in the prevention of vision loss. Recent studies have focused on comparing the long-term efficacy of each of the treatment modalities. However, on an individualized basis, treatment may not be the immediate answer. This poster will present one such patient with CSME, in which treatment was not administered; monitoring the course of the disease was the chosen option. Case Report: A 74-year-old black male presented to the optometry service at West Haven Veterans Affairs Medical Center for a diabetic eye exam. The patient had been a type II diabetic for 44 years and his last HBa1c was 7.3%. His previous ocular history included cataract extraction O.U. 5 years prior and focal macular laser O.U. 15 years prior for unknown ‘‘leakage.’’ His best-corrected visual acuities were 20/30+2 O.D. (reduced from 20/25-1) and 20/20- O.S. Dilated fundus examination revealed moderate nonproliferative diabetic retinopathy OU and CSME O.D. Optical coherence tomography (OCT) confirmed macular thickening O.D. The patient was then referred to the retina clinic for consultation and consideration of possible treatment. After ocular examination, OCT, fluorescein angiography, and consideration of past history of macular laser, it was determined that the area of retinal thickening was too close to the fovea for laser treatment. Also, given the minimal reduction in visual acuity and the fact the patient was asymptomatic, injection of bevacizumab was not deemed necessary. This patient is monitored closely every 3-4 months and continues to have no progression of the disease that would warrant treatment. Conclusion: The management of this patient may seem unconventional due to withholding of treatment, but in this case monitoring alone has shown no disease progression. This case is meant to highlight the circumstances upon which CSME may exist but not require immediate intervention. Patients, such as this, should be monitored closely for possible progression of macular edema or further decrease in visual acuity, which may then merit treatment. Poster 86 Is This a Masquerading Carcinoma? When a Chalazion Is Just a Chalazion Diane Russo, O.D., Jennie Tran, O.D., Michelle Louie, O.D., Charles Haskes, O.D., and Nancy Shenouda-Awad, O.D., West Haven Veterans Affairs, West Haven, Connecticut
Poster Presentations Background: A chalazion is a localized area of lipogranulomatous inflammation of the meibomian gland. Diagnosis of a chalazion may seem straightforward, but there is an abundance of literature reporting the contrary. Many malignant and premalignant eyelid lesions have been misdiagnosed as chalazia, such as sebaceous cell carcinoma, basal cell carcinoma, desmoplastic malignant melanoma, and microcystic adnexal carcinoma. This poster will discuss a case with a chalazion that followed all malignancy patterns upon examination. Work-up including biopsy, diagnosis, treatment, and comparison to another similar case will be discussed. Case Report: A 54-year-old white male presented to the optometry service at West Haven Veterans Affairs Medical Center with recurrent ‘‘bumps’’ on the upper right eyelid for 3 months, the most recent onset 1 week. He had ‘‘popped’’ previous ‘‘bumps,’’ but this episode was persistent even with lid hygiene and bacitracin ung. His medical history includes HIV positive with undetected viral load, hepatitis C, non-Hodgkins’ lymphoma, and chronic kidney disease. Anterior segment exam revealed an elevated and hyperemic lesion, having a characteristic appearance of basal cell carcinoma. Its center was umbilicated and ulcerated, bloodied with subsequent madarosis and with irregular borders. A similar patient presented with a suspicious, painless right upper lid chalazion with an atypical elevation and hyperemia observed upon lid eversion. As such, both patients were immediately referred to the oculoplastics clinic for surgical excision and biopsy, which were completed and results returned as nonmalignant. Close follow-up with anterior segment exams will be done to watch for reoccurences and need for rebiopsy. Conclusion: While these patients’ biopsies yielded nonmalignancy, it is important to realize that lid eversion and evaluation of the color, borders, elevation, size, and history of reoccurrence of the chalazion is vital during the ocular examination. Many eyelid malignancies, such as sebaceous cell carcinomas, can masquerade as benign lesions, but one would be remiss to simply assume these presentations are nonmalignant and refrain from biopsy. One study noted that 68% of sebaceous cell carcinomas were initially misdiagnosed, 20% of which were categorized as chalazia. Therefore, biopsy is crucial to definitively diagnose a suspicious eyelid lesion.
Poster 87 Management of a Bacterial Corneal Ulcer in a Child With Atopic Disease Brandi McGraw, O.D., Eye Associates of New Mexico, Gallup, New Mexico Background: A predisposition to allergies and hypersensitivities, usually present in infancy, is known as atopy. Skin lesions caused by atopic disease present similarly on the eyelid as they do elsewhere on the body and are often
383 infected with staphylococci. Common ocular associations are itching, blepharitis, and keratoconjunctivitis. Bacterial corneal ulcers vary in origin and causative bacteria. A common non-contact lens-related cause for ulcers is compromised corneal tissue from trauma. Others include systemic disease, lifestyle factors, and immunocompromise. Frequently cultured bacteria in children are Staphylococcus, Streptococcus, and Pseudomonas. Case Summary: A 10-year-old Native American boy presented with his mother complaining of worsening photophobia in the left eye for 3 weeks. The child was sent by his pediatrician for an ocular examination. Entering acuities were 20/40 with correction O.S. Biomicroscopy examination revealed inferior punctuate epithelial erosions and a 1.5 mm high by 1.3 mm wide corneal ulcer temporal to the pupil with a smaller incipient infiltrate, both with no epithelial defects. Histories were negative for contact lens, systemic disease, or injury. Cultures were performed, topical antibiotics and cycloplegics were initiated, and a next day follow-up was scheduled. Cultures showed staphlike gram positive cocci. While not initially present, the patient presented at follow-up visits with varying degrees of blepharitis and atopic disease. This presentation is the suspected ulcer culprit. Mom later reported ongoing asthma, allergies, and topical steroid cream use, possibly for eczema. Lid hygiene was discussed and an antibiotic steroid ointment for the adnexa areas was initiated 4 times a day for a week, then daily thereafter. Follow-up visits were made for almost 2 months as the ulcer healed slowly. Vision returned to 20/20- O.S. and the cornea was left with a 0.75 mm by 0.5 mm scar. Conclusion: Atopy can lead to varying skin sensitivities, including adnexa areas. It is important to educate patients and monitor for ocular manifestations. While certain ocular presentations are more common, considerations must be made for possible complications such as the increased staphylococci present in atopic conditions in the presence of a compromised corneal surface.
Poster 88 Anemia in the Asymptomatic Patient Ann Patel, O.D., State University of New York State College of Optometry, New York, New York Background: Anemia is the most common blood dyscrasia in the United States. Erythrocytes transport oxygen to tissues throughout the body. The hemoglobin in erythrocytes binds the oxygen molecules making this transport possible. When the erythrocytes are reduced in number, or if there is a hemoglobin deficiency, in situations such as excessive blood loss, decreased or impaired red blood cell production, or destruction of red blood cells, poor oxygen transport results. Symptoms can be mild, but can cause an array of complications including hypoxic organ damage and heart failure.
Poster 84 Uveitis: When a Vitrectomy Is More Than Just a Treatment Jennie Tran, O.D., Michelle Louie, O.D., Diane Russo, O.D., and Nancy Shenouda-Awad, O.D., West Haven Veterans Affairs, West Haven, Connecticut Background: Uveitis is an ocular inflammatory disease that can present as anterior, intermediate, posterior, or panuveitic. Although the etiology in most cases is idiopathic, many infectious and inflammatory diseases such as Lyme disease, syphilis, tuberculosis, sarcoidosis, and spondyloarthritis can be associated with it. The outcome of untreated uveitis can be vision-threatening, therefore it is important to initiate early treatment and rule out any systemic associations when warranted. Determining the etiology can be difficult, especially in bilateral and non-resolving cases. Diagnostic tools include history, clinical presentation, infectious/inflammatory blood work, and in rare cases, a diagnostic vitrectomy. Case Report: A 51-year-old white male presented to the West Haven Veterans Affairs Medical Center optometry clinic with a chief complaint of unilateral reduction in vision O.D. for 2 weeks. The patient reported no symptoms of pain but complained of new floaters. Ocular history was unremarkable. Systemic health included diabetes mellitus type II without retinopathy, hepatitis C with end-stage cirrhosis, and a kidney infection resulting in kidney failure. Visual acuity at presentation was 20/400 O.D., 20/20 O.S. Slit lamp examination of O.D. showed corneal edema, posterior synechia, and 4+ anterior chamber reaction with plasmoid aqueous. Dilated fundus exam revealed 4+ vitritis. Due to the poor view of the retina O.D., a B-Scan was performed showing intact retina and incomplete vitreous detachment. Differential diagnoses included human leukocyte antigen-B27, Lyme, toxoplasmosis, tuberculosis, syphilis, and endophthalmitis. Topical/oral steroid and antibiotic treatment was initiated and the patient was followed closely without signs of resolution or progression. Systemic work-up was inconclusive of any inflammatory or infectious etiology. Due to poor response with treatment, a diagnostic vitrectomy was warranted that revealed presence of Candida albicans. The patient was then started on antifungal oral therapy. Conclusion: Uveitis secondary to a fungal infection is mostly found in patients who are immunocompromised or have had a history of drug abuse. In this case, clinical findings alone indicated a unilateral anterior and intermediate uveitis of unknown etiology. The diagnostic vitrectomy in addition to systemic history played a significant role in confirming the cause of inflammation as a fungal infection with presumed endogenous etiology, allowing proper treatment.
Optometry, Vol 82, No 6, June 2011 Poster 85 CSME: To Treat or Not to Treat! Diane Russo, O.D., Michelle Louie, O.D., Jennie Tran, O.D., and Nancy Shenouda-Awad, O.D., West Haven Veterans Affairs, West Haven, Connecticut Background: Clinically significant macular edema (CSME) is a sight-threatening condition affecting about 29% of patients who are diabetic for more than 20 years. In most cases, treatment with either laser photocoagulation or intravitreal triamcinolone or bevacizumab injection is essential in the prevention of vision loss. Recent studies have focused on comparing the long-term efficacy of each of the treatment modalities. However, on an individualized basis, treatment may not be the immediate answer. This poster will present one such patient with CSME, in which treatment was not administered; monitoring the course of the disease was the chosen option. Case Report: A 74-year-old black male presented to the optometry service at West Haven Veterans Affairs Medical Center for a diabetic eye exam. The patient had been a type II diabetic for 44 years and his last HBa1c was 7.3%. His previous ocular history included cataract extraction O.U. 5 years prior and focal macular laser O.U. 15 years prior for unknown ‘‘leakage.’’ His best-corrected visual acuities were 20/30+2 O.D. (reduced from 20/25-1) and 20/20- O.S. Dilated fundus examination revealed moderate nonproliferative diabetic retinopathy OU and CSME O.D. Optical coherence tomography (OCT) confirmed macular thickening O.D. The patient was then referred to the retina clinic for consultation and consideration of possible treatment. After ocular examination, OCT, fluorescein angiography, and consideration of past history of macular laser, it was determined that the area of retinal thickening was too close to the fovea for laser treatment. Also, given the minimal reduction in visual acuity and the fact the patient was asymptomatic, injection of bevacizumab was not deemed necessary. This patient is monitored closely every 3-4 months and continues to have no progression of the disease that would warrant treatment. Conclusion: The management of this patient may seem unconventional due to withholding of treatment, but in this case monitoring alone has shown no disease progression. This case is meant to highlight the circumstances upon which CSME may exist but not require immediate intervention. Patients, such as this, should be monitored closely for possible progression of macular edema or further decrease in visual acuity, which may then merit treatment. Poster 86 Is This a Masquerading Carcinoma? When a Chalazion Is Just a Chalazion Diane Russo, O.D., Jennie Tran, O.D., Michelle Louie, O.D., Charles Haskes, O.D., and Nancy Shenouda-Awad, O.D., West Haven Veterans Affairs, West Haven, Connecticut
Poster Presentations Background: A chalazion is a localized area of lipogranulomatous inflammation of the meibomian gland. Diagnosis of a chalazion may seem straightforward, but there is an abundance of literature reporting the contrary. Many malignant and premalignant eyelid lesions have been misdiagnosed as chalazia, such as sebaceous cell carcinoma, basal cell carcinoma, desmoplastic malignant melanoma, and microcystic adnexal carcinoma. This poster will discuss a case with a chalazion that followed all malignancy patterns upon examination. Work-up including biopsy, diagnosis, treatment, and comparison to another similar case will be discussed. Case Report: A 54-year-old white male presented to the optometry service at West Haven Veterans Affairs Medical Center with recurrent ‘‘bumps’’ on the upper right eyelid for 3 months, the most recent onset 1 week. He had ‘‘popped’’ previous ‘‘bumps,’’ but this episode was persistent even with lid hygiene and bacitracin ung. His medical history includes HIV positive with undetected viral load, hepatitis C, non-Hodgkins’ lymphoma, and chronic kidney disease. Anterior segment exam revealed an elevated and hyperemic lesion, having a characteristic appearance of basal cell carcinoma. Its center was umbilicated and ulcerated, bloodied with subsequent madarosis and with irregular borders. A similar patient presented with a suspicious, painless right upper lid chalazion with an atypical elevation and hyperemia observed upon lid eversion. As such, both patients were immediately referred to the oculoplastics clinic for surgical excision and biopsy, which were completed and results returned as nonmalignant. Close follow-up with anterior segment exams will be done to watch for reoccurences and need for rebiopsy. Conclusion: While these patients’ biopsies yielded nonmalignancy, it is important to realize that lid eversion and evaluation of the color, borders, elevation, size, and history of reoccurrence of the chalazion is vital during the ocular examination. Many eyelid malignancies, such as sebaceous cell carcinomas, can masquerade as benign lesions, but one would be remiss to simply assume these presentations are nonmalignant and refrain from biopsy. One study noted that 68% of sebaceous cell carcinomas were initially misdiagnosed, 20% of which were categorized as chalazia. Therefore, biopsy is crucial to definitively diagnose a suspicious eyelid lesion.
Poster 87 Management of a Bacterial Corneal Ulcer in a Child With Atopic Disease Brandi McGraw, O.D., Eye Associates of New Mexico, Gallup, New Mexico Background: A predisposition to allergies and hypersensitivities, usually present in infancy, is known as atopy. Skin lesions caused by atopic disease present similarly on the eyelid as they do elsewhere on the body and are often
383 infected with staphylococci. Common ocular associations are itching, blepharitis, and keratoconjunctivitis. Bacterial corneal ulcers vary in origin and causative bacteria. A common non-contact lens-related cause for ulcers is compromised corneal tissue from trauma. Others include systemic disease, lifestyle factors, and immunocompromise. Frequently cultured bacteria in children are Staphylococcus, Streptococcus, and Pseudomonas. Case Summary: A 10-year-old Native American boy presented with his mother complaining of worsening photophobia in the left eye for 3 weeks. The child was sent by his pediatrician for an ocular examination. Entering acuities were 20/40 with correction O.S. Biomicroscopy examination revealed inferior punctuate epithelial erosions and a 1.5 mm high by 1.3 mm wide corneal ulcer temporal to the pupil with a smaller incipient infiltrate, both with no epithelial defects. Histories were negative for contact lens, systemic disease, or injury. Cultures were performed, topical antibiotics and cycloplegics were initiated, and a next day follow-up was scheduled. Cultures showed staphlike gram positive cocci. While not initially present, the patient presented at follow-up visits with varying degrees of blepharitis and atopic disease. This presentation is the suspected ulcer culprit. Mom later reported ongoing asthma, allergies, and topical steroid cream use, possibly for eczema. Lid hygiene was discussed and an antibiotic steroid ointment for the adnexa areas was initiated 4 times a day for a week, then daily thereafter. Follow-up visits were made for almost 2 months as the ulcer healed slowly. Vision returned to 20/20- O.S. and the cornea was left with a 0.75 mm by 0.5 mm scar. Conclusion: Atopy can lead to varying skin sensitivities, including adnexa areas. It is important to educate patients and monitor for ocular manifestations. While certain ocular presentations are more common, considerations must be made for possible complications such as the increased staphylococci present in atopic conditions in the presence of a compromised corneal surface.
Poster 88 Anemia in the Asymptomatic Patient Ann Patel, O.D., State University of New York State College of Optometry, New York, New York Background: Anemia is the most common blood dyscrasia in the United States. Erythrocytes transport oxygen to tissues throughout the body. The hemoglobin in erythrocytes binds the oxygen molecules making this transport possible. When the erythrocytes are reduced in number, or if there is a hemoglobin deficiency, in situations such as excessive blood loss, decreased or impaired red blood cell production, or destruction of red blood cells, poor oxygen transport results. Symptoms can be mild, but can cause an array of complications including hypoxic organ damage and heart failure.