- Email: [email protected]
Poster 51 - Conjunctival Crystalline Deposits Associated with the Use of Talc
POSTERS
weeks, which revealed resolution of the nasal blur of the left optic nerve and an improved visual field O.S. Conclusion: Arteritic AION may be present in an asymptomatic patient, but it is still a vision-threatening condition if not properly managed. Digital fundus photography was beneficial in evaluating the optic nerve and confirming the findings. A large-angle strabismus may complicate pupil testing and detection of an APD.
POSTER 49 Diabetic Papillopathy and Risk for Proliferative Diabetic Retinopathy: A Case Report Charles Davis, Jr., 0 .D., M.E H., Ania Hamp, 0 .D., and Robert Morris, O.D. Salisbury VAMC, 1601 Brenner Avenue (1IG/112E), Salisbury, North Carolina 28144 Background: Despite a growing concern about the ocular complications of diabetes, few articles explore the topic of diabetic papillopathy. Early publications on diabetic papillopathy discuss a transient, unilateral or bilateral optic disk edema, with relatively good visual acuity in young patients diagnosed with type I diabetes. Later publications examine diabetic papillopathy in older patients, with longer duration of type I1 diabetes. The exact cause for diabetic papillopathy is unknown, but two general hypotheses have been proposed: (1)a microangiopathy, involving the optic disk and adjacent retina, with swelling at the optic nerve, and (2) a variation of nonarteritic AION. It is necessary to differentiate diabetic papillopathy from other disorders that cause unilateral or bilateral optic disk edema. Consequently, diabetic papillopathy is considered a diagnosis of exclusion. Case Report: We present the clinical course of a 57-year-old man with a 10-year history of type I1 diabetes. At initial examination. he manifested diabetic macular edema in the right eye and bilateral optic disk edema. Clinical workup included neuro-imaging,laboratory testing, fluorescein angiography, automated visual-field analysis, and retinal photography. Neuro-ophthalmology consultation yielded a diagnosis of bilateral diabetic papillopathy. Methods: Within 90 days, bilateral neovascularization of the optic disks and retinal neovascularization of the right eye developed. Panretinal photocoagulation was performed bilaterally, with resulting improvement of the optic disk neovascularization. Results: Unfortunately, the patient experienced a vitreous hemorrhage of the right eye, and a vitrectomy procedure is scheduled. Conclusion: This case outlines the proper workup for diabetic papillopathy, with a discussion of the differential diagnoses. The discussion includes contemporary ideas regarding the etiology of diabetic papillopathy.
POSTER 50 A Retrospective Study of Veterans Affairs Patients Switched from 0.005% Latanoprost to 0.004% Travoprost Murray Fingeret, 0 .D. St. Albans Veterans Administration Extended Care Center, Linden Boulevard and 179th Street, St. Albans, New York 11425 Background: Due to changes in the Veterans Affairs (VA)Formulary, many patients with glaucoma and ocular hypertension have been switched from 0.005% latanoprost to 0.004% travoprost. One factor that drove the decision to switch to travoprost was the favorable cost of the medication. This was a retrospective study that measured the intraocular pressure (1OP)-loweringefficacy for 37 consecutive patients switched from 0.005% latanoprost to 0.004% travoprost. Methods: Before the switch in therapy, patients were educated with regard to potential signs and symptoms that could occur due to changing to travoprost. Patients were told to telephone or return immediately if any problem(s) occurred. Patients were scheduled to return from 30 to 45 days after they received the new medication. All patients had been on a regimen of latanoprost for a minimum of 120 days and tolerated 0.005% latanoprost. Thirty-seven patients with either ocular hypertension or open-angle glaucoma were switched from 0.005% latanoprost to the 0.004% travoprost in both eyes. Results: The mean IOP (mmHg k standard deviation] for patients on latanoprost was 16.9 + 2.3 in the right eye (O.D.)and 16.7 + 2.5 mmHg in the left eye (O.S.).Following the switch to travoprost, the IOP was 15.7 k 2.0 mmHg in the right eye and 15.5 2.0 mmHg in the left eye. The reduction in IOP following the switch to travoprost was highly significant (P < 0.001 for both the right and left eyes using a paired t-test). One patient out of 37 noted symptoms of irritation, which were not sufficient to discontinue the medication, and one person reported hyperemia that resulted in their discontinuing the medication. Conclusion: VA patients who were switched from 0.005% latanoprost to 0.004% travoprost experienced an average IOP reduction of 1.2 mmHg and excellent tolerability of the new medication. (Investigator is on the Glaucoma Advisory Board for, and was provided research support in the form ofa grant from, Alcon Laboratories, Fort Worth, Texas.)
POSTER 51 Conjunctival Crystalline Deposits Associated with the Use of Talc Samala Khan, O.D. Illinois College of Optometry, 3241 South Michigan Avenue, Chicago, Illinois 60601 Purpose: The purpose of this poster is to document crystalline deposits in the conjunctiva associated with the use of talcum powder. Case Report and Results: A 65-year-old woman came in for a routine eye examination. She had an incidental find-
382 OPTOMETRY
VOLUME 76lNUMBER 6lJUNE 2005
ing of bilateral yellow-gold crystalline deposits, located nasally and temporally on the bulbar conjunctiva. Fundus findings were unremarkable. Her personal history was pertinent for applying talc-containingbody powders three times a week for more than 20 years. Conclusions: '&pically, refractile crystals associated with talc manifest in the retinal microvasculature and are related to intravenous drug abuse. The deposits observed in this patient were clinically similar in appearance with the deposits seen in talc retinopathy or other toxic crystalline retinopathies. In talc retinopathy, the talc particles become caught in retinal capillaries and deposit in the retina. Though rare, depositions in the conjunctiva are possible. In this particular case, the patient's fundus was unremarkable. A possible mode of entry is systemic absorption through inhalation, which may lead to entry of talc into the vascular pathways leading to the deposition of talc particles in the conjunctiva. The patient's crystalline deposition may be related to the excessive and chronic use of talc due to the appearance of the deposits, the patient's history, and the association of anterior segment manifestations with talc and crystalline retinopathies.
POSTER 52 Congenital and Acquired Ocular Toxoplasmosis Erin Nosel, O.D., H. Simon Ghazi-Birry,M.D., O.D., Ph.D., and R. Parkansky, M S . , O.D., M .B.A. Southern College of Optometry, 1245 Madison Avenue, Memphis, Tennessee 38104 Background: Ocular toxoplasmosis is a common etiology of retinochoroiditis, caused by the obligate intracellular protozoan Toxoplasma gondii. Although the majority of cases are congenital secondary to an in utero infection, acquired cases are encountered, especially in immunocompromised or elderly patients. Acquired cases are due to the ingestion of contaminated1undercooked foods or cat feces. The ocular pathology is likely due to active parasite proliferation and immune hypersensitivity. An acquired and a congenital case will be presented. Case Reports: Case 1:A 45-year-old woman came to us with a 5-day history of blurred vision O.S. Her medical history was significant for recent headaches, fever, flu-like symptoms, and cervical lymphadenopathy. Her visual acuities (VAs)were 20120 O.D. and 20130 O.S. Anterior segment, intraocular pressure, and EOM were normal. Funduscopy: Peripheral acute retinochoriodal lesion and (1+ ] vitritis 0,s.; O.D. was normal. C-reactive protein was elevated, and serology was positive for a high toxoplasmosis titer, confirming the diagnosis of acquired ocular toxoplasmosis. A triple therapy protocol was initiated: pyrimethamine, sulfadiazine, and prednisone. Cranial magnetic resonance imaging and chest X-ray were normal. At 6 months, VAs were 20120 O.D. and O.S., with no signs of active retinal disease and mild granulomatous changes. Case 2: A 14-year-old boy with a history of poor acuity was brought to us for an eye examination. His medical history was significant for sporadic seizures, athetoid, and manifestations of mental retardation. His visual acuities were 201300 O.D. and 201400 O.S. Funduscopy revealed chronic retinochoroiditis and vitritis, with scars and areas of localized necrotizing maculopathy OU.
VOLUME 76lNUMBER 61IUNE 2005
Congenital toxoplasmosis was confirmed, and a regimen of oral prednisone was initiated and tapered over 12 weeks. At 3 months, the vitritis had resolved, and acuity had improved slightly and stabilized at 201200 O.D. and O.S. Conclusion: This poster will compare signs, symptoms, testing, treatment, prognosis, and low vision management of congenital and acquired ocular toxoplasmosis. Fundus and cranial imaging and blood tests will be presented for both cases.
POSTER 53 Can the OPTOS Teach Clinicians to be Better Ophthalmoscopists? Jerome Sherman, O.D., Sanjeev Nath, M.D., and Michelle Battaglia State University of New York, State College of Optometry, 33 West 42nd Street, New York, New York 10036 Background: The OPTOS allows viewing of 200 degrees of the fundus in one image with acquisition time of 0.25 second. Hence, the OPTOS can be considered a simultaneous view of much of the fundus, whereas all forms of ophthalmoscopy are really sequential views. With sequential viewing of different locations at different times, it is very difficult to mentally put all the small views together into one big percept and to ensure that all areas of the fundus have been sequentially examined. Tho experienced clinicians in a private practice setting (Jerome Sherman, O.D. and Sanjeev Nath, M.D.] performed ophthalmocopy through a dilated pupil, using either a 78 D or 90 D lens and a BIO, then recorded their findings in a typical fundus drawing. An OPTOS image was also acquired (but not reviewed) by the two clinicians at the time of the fundus drawings. With the patient still present, the OPTOS images were then analyzed by one of the two clinicians and compared to the fundus drawings. Of interest, myriad lesions were missed by the clinicians, but documented with the OPTOS. With the aid of the OPTOS image, the clinician then performed ophthalmoscopy again, with emphasis on the area of the fundus containing the missed findings. Case Reports: Ten cases of missed lesions were documented with the OPTOS. Methods: Review of OPTOS images after the completion of a fundus exam may reveal findings missed during routine dilated ophthalmoscopy. The clinician can then repeat ophthalmoscopy in an attempt to find the lesions previously missed. Conclusions: The two clinicians in the study believe that repeating ophthalmoscopy teaches the clinician about the type and location of lesions missed initially and may improve their skills. If two experienced clinicians can improve their technique, it is highly probable that students could also use the OPTOS images to identify missed lesions, and hence attempt to improve their ophthalmoscopic skills. (Investigatorsreceived grant support provided by OPTOS.]
OPTOMETRY
weeks, which revealed resolution of the nasal blur of the left optic nerve and an improved visual field O.S. Conclusion: Arteritic AION may be present in an asymptomatic patient, but it is still a vision-threatening condition if not properly managed. Digital fundus photography was beneficial in evaluating the optic nerve and confirming the findings. A large-angle strabismus may complicate pupil testing and detection of an APD.
POSTER 49 Diabetic Papillopathy and Risk for Proliferative Diabetic Retinopathy: A Case Report Charles Davis, Jr., 0 .D., M.E H., Ania Hamp, 0 .D., and Robert Morris, O.D. Salisbury VAMC, 1601 Brenner Avenue (1IG/112E), Salisbury, North Carolina 28144 Background: Despite a growing concern about the ocular complications of diabetes, few articles explore the topic of diabetic papillopathy. Early publications on diabetic papillopathy discuss a transient, unilateral or bilateral optic disk edema, with relatively good visual acuity in young patients diagnosed with type I diabetes. Later publications examine diabetic papillopathy in older patients, with longer duration of type I1 diabetes. The exact cause for diabetic papillopathy is unknown, but two general hypotheses have been proposed: (1)a microangiopathy, involving the optic disk and adjacent retina, with swelling at the optic nerve, and (2) a variation of nonarteritic AION. It is necessary to differentiate diabetic papillopathy from other disorders that cause unilateral or bilateral optic disk edema. Consequently, diabetic papillopathy is considered a diagnosis of exclusion. Case Report: We present the clinical course of a 57-year-old man with a 10-year history of type I1 diabetes. At initial examination. he manifested diabetic macular edema in the right eye and bilateral optic disk edema. Clinical workup included neuro-imaging,laboratory testing, fluorescein angiography, automated visual-field analysis, and retinal photography. Neuro-ophthalmology consultation yielded a diagnosis of bilateral diabetic papillopathy. Methods: Within 90 days, bilateral neovascularization of the optic disks and retinal neovascularization of the right eye developed. Panretinal photocoagulation was performed bilaterally, with resulting improvement of the optic disk neovascularization. Results: Unfortunately, the patient experienced a vitreous hemorrhage of the right eye, and a vitrectomy procedure is scheduled. Conclusion: This case outlines the proper workup for diabetic papillopathy, with a discussion of the differential diagnoses. The discussion includes contemporary ideas regarding the etiology of diabetic papillopathy.
POSTER 50 A Retrospective Study of Veterans Affairs Patients Switched from 0.005% Latanoprost to 0.004% Travoprost Murray Fingeret, 0 .D. St. Albans Veterans Administration Extended Care Center, Linden Boulevard and 179th Street, St. Albans, New York 11425 Background: Due to changes in the Veterans Affairs (VA)Formulary, many patients with glaucoma and ocular hypertension have been switched from 0.005% latanoprost to 0.004% travoprost. One factor that drove the decision to switch to travoprost was the favorable cost of the medication. This was a retrospective study that measured the intraocular pressure (1OP)-loweringefficacy for 37 consecutive patients switched from 0.005% latanoprost to 0.004% travoprost. Methods: Before the switch in therapy, patients were educated with regard to potential signs and symptoms that could occur due to changing to travoprost. Patients were told to telephone or return immediately if any problem(s) occurred. Patients were scheduled to return from 30 to 45 days after they received the new medication. All patients had been on a regimen of latanoprost for a minimum of 120 days and tolerated 0.005% latanoprost. Thirty-seven patients with either ocular hypertension or open-angle glaucoma were switched from 0.005% latanoprost to the 0.004% travoprost in both eyes. Results: The mean IOP (mmHg k standard deviation] for patients on latanoprost was 16.9 + 2.3 in the right eye (O.D.)and 16.7 + 2.5 mmHg in the left eye (O.S.).Following the switch to travoprost, the IOP was 15.7 k 2.0 mmHg in the right eye and 15.5 2.0 mmHg in the left eye. The reduction in IOP following the switch to travoprost was highly significant (P < 0.001 for both the right and left eyes using a paired t-test). One patient out of 37 noted symptoms of irritation, which were not sufficient to discontinue the medication, and one person reported hyperemia that resulted in their discontinuing the medication. Conclusion: VA patients who were switched from 0.005% latanoprost to 0.004% travoprost experienced an average IOP reduction of 1.2 mmHg and excellent tolerability of the new medication. (Investigator is on the Glaucoma Advisory Board for, and was provided research support in the form ofa grant from, Alcon Laboratories, Fort Worth, Texas.)
POSTER 51 Conjunctival Crystalline Deposits Associated with the Use of Talc Samala Khan, O.D. Illinois College of Optometry, 3241 South Michigan Avenue, Chicago, Illinois 60601 Purpose: The purpose of this poster is to document crystalline deposits in the conjunctiva associated with the use of talcum powder. Case Report and Results: A 65-year-old woman came in for a routine eye examination. She had an incidental find-
382 OPTOMETRY
VOLUME 76lNUMBER 6lJUNE 2005
ing of bilateral yellow-gold crystalline deposits, located nasally and temporally on the bulbar conjunctiva. Fundus findings were unremarkable. Her personal history was pertinent for applying talc-containingbody powders three times a week for more than 20 years. Conclusions: '&pically, refractile crystals associated with talc manifest in the retinal microvasculature and are related to intravenous drug abuse. The deposits observed in this patient were clinically similar in appearance with the deposits seen in talc retinopathy or other toxic crystalline retinopathies. In talc retinopathy, the talc particles become caught in retinal capillaries and deposit in the retina. Though rare, depositions in the conjunctiva are possible. In this particular case, the patient's fundus was unremarkable. A possible mode of entry is systemic absorption through inhalation, which may lead to entry of talc into the vascular pathways leading to the deposition of talc particles in the conjunctiva. The patient's crystalline deposition may be related to the excessive and chronic use of talc due to the appearance of the deposits, the patient's history, and the association of anterior segment manifestations with talc and crystalline retinopathies.
POSTER 52 Congenital and Acquired Ocular Toxoplasmosis Erin Nosel, O.D., H. Simon Ghazi-Birry,M.D., O.D., Ph.D., and R. Parkansky, M S . , O.D., M .B.A. Southern College of Optometry, 1245 Madison Avenue, Memphis, Tennessee 38104 Background: Ocular toxoplasmosis is a common etiology of retinochoroiditis, caused by the obligate intracellular protozoan Toxoplasma gondii. Although the majority of cases are congenital secondary to an in utero infection, acquired cases are encountered, especially in immunocompromised or elderly patients. Acquired cases are due to the ingestion of contaminated1undercooked foods or cat feces. The ocular pathology is likely due to active parasite proliferation and immune hypersensitivity. An acquired and a congenital case will be presented. Case Reports: Case 1:A 45-year-old woman came to us with a 5-day history of blurred vision O.S. Her medical history was significant for recent headaches, fever, flu-like symptoms, and cervical lymphadenopathy. Her visual acuities (VAs)were 20120 O.D. and 20130 O.S. Anterior segment, intraocular pressure, and EOM were normal. Funduscopy: Peripheral acute retinochoriodal lesion and (1+ ] vitritis 0,s.; O.D. was normal. C-reactive protein was elevated, and serology was positive for a high toxoplasmosis titer, confirming the diagnosis of acquired ocular toxoplasmosis. A triple therapy protocol was initiated: pyrimethamine, sulfadiazine, and prednisone. Cranial magnetic resonance imaging and chest X-ray were normal. At 6 months, VAs were 20120 O.D. and O.S., with no signs of active retinal disease and mild granulomatous changes. Case 2: A 14-year-old boy with a history of poor acuity was brought to us for an eye examination. His medical history was significant for sporadic seizures, athetoid, and manifestations of mental retardation. His visual acuities were 201300 O.D. and 201400 O.S. Funduscopy revealed chronic retinochoroiditis and vitritis, with scars and areas of localized necrotizing maculopathy OU.
VOLUME 76lNUMBER 61IUNE 2005
Congenital toxoplasmosis was confirmed, and a regimen of oral prednisone was initiated and tapered over 12 weeks. At 3 months, the vitritis had resolved, and acuity had improved slightly and stabilized at 201200 O.D. and O.S. Conclusion: This poster will compare signs, symptoms, testing, treatment, prognosis, and low vision management of congenital and acquired ocular toxoplasmosis. Fundus and cranial imaging and blood tests will be presented for both cases.
POSTER 53 Can the OPTOS Teach Clinicians to be Better Ophthalmoscopists? Jerome Sherman, O.D., Sanjeev Nath, M.D., and Michelle Battaglia State University of New York, State College of Optometry, 33 West 42nd Street, New York, New York 10036 Background: The OPTOS allows viewing of 200 degrees of the fundus in one image with acquisition time of 0.25 second. Hence, the OPTOS can be considered a simultaneous view of much of the fundus, whereas all forms of ophthalmoscopy are really sequential views. With sequential viewing of different locations at different times, it is very difficult to mentally put all the small views together into one big percept and to ensure that all areas of the fundus have been sequentially examined. Tho experienced clinicians in a private practice setting (Jerome Sherman, O.D. and Sanjeev Nath, M.D.] performed ophthalmocopy through a dilated pupil, using either a 78 D or 90 D lens and a BIO, then recorded their findings in a typical fundus drawing. An OPTOS image was also acquired (but not reviewed) by the two clinicians at the time of the fundus drawings. With the patient still present, the OPTOS images were then analyzed by one of the two clinicians and compared to the fundus drawings. Of interest, myriad lesions were missed by the clinicians, but documented with the OPTOS. With the aid of the OPTOS image, the clinician then performed ophthalmoscopy again, with emphasis on the area of the fundus containing the missed findings. Case Reports: Ten cases of missed lesions were documented with the OPTOS. Methods: Review of OPTOS images after the completion of a fundus exam may reveal findings missed during routine dilated ophthalmoscopy. The clinician can then repeat ophthalmoscopy in an attempt to find the lesions previously missed. Conclusions: The two clinicians in the study believe that repeating ophthalmoscopy teaches the clinician about the type and location of lesions missed initially and may improve their skills. If two experienced clinicians can improve their technique, it is highly probable that students could also use the OPTOS images to identify missed lesions, and hence attempt to improve their ophthalmoscopic skills. (Investigatorsreceived grant support provided by OPTOS.]
OPTOMETRY