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Poster 55
292 Poster 53 Conjunctival Metastasis as the Presenting Sign for Stage IV Lung Cancer Raymond Chew, O.D., and Jessica Potter, O.D., VA Medical Center, 718 Smyth Road, c/o Eye Clinic, Manchester, New Hampshire 03104 Introduction: Lung cancer is the leading cause of cancerrelated death in North America. It is often diagnosed at advanced stages, lending to a poor prognosis. Symptoms of lung cancer often do not present until more advanced stages. Common sites of lung cancer metastasis are the bones, liver, and brain. Eyelid tumors are often difficult to diagnose clinically. This case highlights the importance of more detailed workup, including biopsy to determine the exact nature of the lesion. Case Report: A 50-year-old white male was referred for evaluation of a bump on his right upper lid on November 15, 2006. He had noticed it for 1 month and noted enlargement over the past 2 weeks. He also reported that he had been smoking about 1-pack of cigarettes per day since 1969. External examination was remarkable for a 1.5-cm nodule pushing up from under the right upper lid. When the lid was everted, there was an approximately 1-cm red and black vascularized sessile lesion on the palpebral conjunctiva. The patient was referred to an oculoplastics specialist to rule out malignant versus metastatic conjunctival neoplasm. The oculoplastics service diagnosed the lesion as a “RUL (right upper lid) tumor.” The lesion was excised, and the pathology report revealed a “poorly differentiated, highly aggressive cancer with no clear margins.” It was subsequently discovered that the patient had stage IV nonsmall cell carcinoma of the left lung with metastasis to the right eyelid, brain, liver, and right lung. He underwent multiple radiotherapy sessions. He died about 5 months after our initial examination. Discussion: Stage IV lung cancer is incurable and its treatment is often palliative. Conjunctival metastasis of stage IV lung cancer is rare. Eyelid tumors are difficult to diagnose by clinical examination alone. This case highlights the importance of a thorough workup to rule out neoplasm in a patient at high risk for carcinoma. Poster 54 Evaluation of Lubricity of Marketed Dry Eye Products Using a Tissue-on-Tissue Model Huagang Chen, M.S., Owen Gan, Ph.D., David Meadows, Ph.D., Ann Meyer, Ph.D., and Robert E. Baier, Ph.D., Alcon Laboratories, Ltd., 6201 South Freeway, Fort Worth, Texas 76134 Background: Clinically relevant lubrication evaluation of dry eye products is a key measure to assist the early development of a dry eye product. Methods: Tissues used as surrogates for the corneal and conjunctival surfaces of the eye were segments of stabilized
Optometry, Vol 78, No 6, June 2007 human umbilical vein grafts, (“Biograft,” UCVG), with established intimal surface in a tissue-on-tissue model system for lubricity testing of a list of currently marketed lubricant dry eye products. The test tissue surface was attached to a vertically loaded “pin,” and opposing test surface fixed horizontally to a “disk” that oscillated at 1 Hz. Friction between the two surfaces was monitored via a calibrated strain gauge and strip chart recorder. Coefficients of friction were calculated. Previous tests were performed on tissue-on-germanium and germanium-on-germanium lubricated couples. In these studies, supporting analyses included subsequent MAIR-IR, contact angle, light and scanning electron microscopic inspections of transferred and retained residues. Results: Mean coefficient of friction (n⫽6, lower is better) were 0.35 ⫾ 0.11, 0.13 ⫾ 0.04, 0.38 ⫾ 0.13 (n⫽5), 0.44 ⫾ 0.18, 0.33 ⫾ 0.12 for Optive™ (Allergan), Systane® (Alcon), GenTeal® (Novartis), Refresh Tears® (Allergan), and Refresh Liquigel® (Allergan), respectively. Statistically significant differences were found between Systane and Optive (p⬍0.003) and between Systane and Refresh Liquigel (p⬍0.008). No statistically significant differences were found between Optive and Refresh Liquigel (p⫽0.76). Friction coefficients revealed significant friction reducing with Systane even after rinsing the original formulation with saline. Conclusion: The “comfort feeling” reported by dry eye patients is related to retention of Systane, in tissue-on-tissue interphase zones that produces low frictional coefficients indicative of minimized bioadhesion. (Investigators received grant support funded by Alcon R&D Consumer Products.) Poster 55 Multifocal Electroretinography Reveals Late-Onset Cone Dystrophy Joseph Pizzimenti, O.D., Albert D. Woods, O.D., M.S., Lori Vollmer, O.D., and Michael Fendick, O.D., Ph.D., Nova Southeastern University, College of Optometry, 3200 South University Drive, Ft. Lauderdale, Florida 33328 Background: Cone dystrophy (CD) is an inherited retinal degenerative disease that affects cone system function. CD is characterized by symptoms of gradually reduced vision, photophobia, and poor color vision. These symptoms usually begin in the second decade of life. Clinical signs include a bilateral atrophic “bull’s eye” maculopathy with accompanying central visual field deficits. Multifocal electroretinography (mfERG) shows large reductions in amplitude and delayed implicit times, and a ring-shaped depression may be present. Case Report: A 32-year-old black female presented with complaints of gradual, bilateral reduced vision, photophobia, and poor color vision. Ocular history was positive for previous episodes of pars planitis and anterior uveitis OU.
Poster Presentations There was a history of head trauma, as the patient was involved in an auto accident as a child. Health history was positive for mitral valve prolapse of 10 years’ duration and occasional migraines. The patient was taking no medications at the time of the visit. Her moderate myopia was corrected with soft daily wear disposable contact lenses. Best-corrected visual acuities were 20/25 O.D. and 20/30 O.S. with no improvement on pinhole. Amsler testing revealed a central ring-shaped defect O.D. and an area of inferotemporal distortion O.S. The patient was unable to identify shapes and numbers on Ishihara color testing. Automated perimetry revealed paracentral defects O.D. and O.S. Dilated fundoscopy showed a bilateral, irregular, atrophic, “bull’s eye” maculopathy. Optical coherence tomography (OCT) revealed an unusually deep foveal depression O.D. and O.S. MfERG testing revealed a “ring-depression” surrounding a small central peak in each eye. The patient is currently being followed up with periodic mfERG, central threshold perimetry, contrast sensitivity, OCT, color vision, and dilated fundoscopy. The patient continues to enjoy successful contact lens wear. Conclusions: This case underscores the importance of electrodiagnostic testing when photoreceptor disease is suspected. MfERG in particular may be of significant value in the detection of CD in patients that develop symptoms later in life than is typical. Poster 56 Roth Spots Associated With Bacterial Endocarditis Brian Gerlach, O.D., Grand Lake Eyecare, LLC, 1059 Grand Lake Road, P.O. Box 377, Celina, Ohio 45822 Background: Bacterial endocarditis is a life-threatening infection that affects the lining and/or valves of the heart. It is diagnosed based on patient symptoms (fever, malaise, headache, weight loss, myalgias, arthralgias, flu-like symptoms, and fatigue) and laboratory tests (CBC, ESR, CRP, at least two blood cultures, urinalysis, and echocardiogram). Roth spots are found on retinal examination in 3% to 5% of cases. Treatment of bacterial endocarditis consists of highdose IV antibiotic therapy lasting 4 to 6 weeks. Case Report: A 42-year-old white male presented to our clinic with new onset of bilateral photopsia, floaters, and blurred vision. His past ocular history was negative. His past medical history was significant for newly diagnosed rheumatoid arthritis and prediabetes. He stated that he had a “bad cold” for the past month and had lost 40 pounds over the last few months without explanation. He was taking Naprosyn and had no known drug allergies. Best-corrected visual acuities measured O.S. 20/30 and O.D. 20/30-. Pupils, binocular vision testing, and confrontation visual fields were normal. Slit-lamp examination of the anterior segments was essentially normal OU. Dilated fundus examination revealed white blood cells in the vitreous OU, edematous optic nerves OU, scattered flame hemorrhages with
293 white centers OU, and an operculated retinal hole at 2 o’clock at the equatorial region O.D. He was referred immediately for retinal consultation. Laboratory tests were ordered and confirmed the diagnoses of bacterial endocarditis. Treatment of the operculated retinal hole O.D. was deferred. He was treated with high-dose antibiotics and continues to be monitored. Conclusions: Bacterial endocarditis is a life-threatening infection with a mortality rate of 25%. This case demonstrates the need for prompt workup when Roth spots are encountered. Poster 57 Polypoidal Choroidal Vasculopathy Treated With Intravitreous Avastin Scott Huffer, O.D., and Nadia Zalatimo, O.D., VA Medical Center, 718 Smyth Road, c/o Eye Clinic, Manchester, New Hampshire 03104 Background: Polypoidal choroidal vasculopathy (PCV) is a unique form of occult choroidal neovascular membrane (CNVM) originating from abnormal inner choroidal vessels. PCV typically presents with a large serosanguinous pigment epithelial detachment (PED) in the absence of drusen, and a CNVM present on the edge of the PED, revealed by indocyanine green angiography. Although there is potential for significant vision loss with PCV, most patients do well with observation, as many of the lesions resolve without treatment. Photodynamic therapy with Visudyne has been shown to have some benefit but can cause damage to the overlying neurosensory retina. Treatment with intravitreal anti-angiogenic factors such as Avastin (Bevacizumab) and Lucentis (Ranibizumab) have been shown to improve vision in patients with CNVM caused by macular degeneration but are still being investigated for other causes of CNVM. Case Summary: A 62-year-old white male presented with complaints of blurry distance vision OU. A comprehensive eye examination was performed. Entrance testing was remarkable for a trace APD O.S. Subjective refraction yielded best-corrected visual acuity of 20/20 O.D. with ⫹1.25-0.75 x 062 and 20/25 O.S. with ⫹3.00-0.50 x 130. Slit-lamp biomicroscopy of the anterior segment was unremarkable. Dilated fundus examination was remarkable for a cotton wool spot along the superior temporal arcade attributed to uncontrolled hypertension O.D., and a 3 disc diameter PED in the central macula O.S. Fluorescein angiography revealed an occult CNVM at the medial edge of the PED in the left eye. Indocyanine green angiography confirmed an occult CNVM in the left eye, and polypoidal choroidal vasculopathy was diagnosed. The patient was treated with Avastin 1.25 mg/0.05 cc O.S. by intravitreous injection, which was well tolerated. One week later, a subjective improvement in vision in the left eye was noted, and there were no signs of complications secondary to the injection. Treatment with Avastin is ongoing.
Optometry, Vol 78, No 6, June 2007 human umbilical vein grafts, (“Biograft,” UCVG), with established intimal surface in a tissue-on-tissue model system for lubricity testing of a list of currently marketed lubricant dry eye products. The test tissue surface was attached to a vertically loaded “pin,” and opposing test surface fixed horizontally to a “disk” that oscillated at 1 Hz. Friction between the two surfaces was monitored via a calibrated strain gauge and strip chart recorder. Coefficients of friction were calculated. Previous tests were performed on tissue-on-germanium and germanium-on-germanium lubricated couples. In these studies, supporting analyses included subsequent MAIR-IR, contact angle, light and scanning electron microscopic inspections of transferred and retained residues. Results: Mean coefficient of friction (n⫽6, lower is better) were 0.35 ⫾ 0.11, 0.13 ⫾ 0.04, 0.38 ⫾ 0.13 (n⫽5), 0.44 ⫾ 0.18, 0.33 ⫾ 0.12 for Optive™ (Allergan), Systane® (Alcon), GenTeal® (Novartis), Refresh Tears® (Allergan), and Refresh Liquigel® (Allergan), respectively. Statistically significant differences were found between Systane and Optive (p⬍0.003) and between Systane and Refresh Liquigel (p⬍0.008). No statistically significant differences were found between Optive and Refresh Liquigel (p⫽0.76). Friction coefficients revealed significant friction reducing with Systane even after rinsing the original formulation with saline. Conclusion: The “comfort feeling” reported by dry eye patients is related to retention of Systane, in tissue-on-tissue interphase zones that produces low frictional coefficients indicative of minimized bioadhesion. (Investigators received grant support funded by Alcon R&D Consumer Products.) Poster 55 Multifocal Electroretinography Reveals Late-Onset Cone Dystrophy Joseph Pizzimenti, O.D., Albert D. Woods, O.D., M.S., Lori Vollmer, O.D., and Michael Fendick, O.D., Ph.D., Nova Southeastern University, College of Optometry, 3200 South University Drive, Ft. Lauderdale, Florida 33328 Background: Cone dystrophy (CD) is an inherited retinal degenerative disease that affects cone system function. CD is characterized by symptoms of gradually reduced vision, photophobia, and poor color vision. These symptoms usually begin in the second decade of life. Clinical signs include a bilateral atrophic “bull’s eye” maculopathy with accompanying central visual field deficits. Multifocal electroretinography (mfERG) shows large reductions in amplitude and delayed implicit times, and a ring-shaped depression may be present. Case Report: A 32-year-old black female presented with complaints of gradual, bilateral reduced vision, photophobia, and poor color vision. Ocular history was positive for previous episodes of pars planitis and anterior uveitis OU.
Poster Presentations There was a history of head trauma, as the patient was involved in an auto accident as a child. Health history was positive for mitral valve prolapse of 10 years’ duration and occasional migraines. The patient was taking no medications at the time of the visit. Her moderate myopia was corrected with soft daily wear disposable contact lenses. Best-corrected visual acuities were 20/25 O.D. and 20/30 O.S. with no improvement on pinhole. Amsler testing revealed a central ring-shaped defect O.D. and an area of inferotemporal distortion O.S. The patient was unable to identify shapes and numbers on Ishihara color testing. Automated perimetry revealed paracentral defects O.D. and O.S. Dilated fundoscopy showed a bilateral, irregular, atrophic, “bull’s eye” maculopathy. Optical coherence tomography (OCT) revealed an unusually deep foveal depression O.D. and O.S. MfERG testing revealed a “ring-depression” surrounding a small central peak in each eye. The patient is currently being followed up with periodic mfERG, central threshold perimetry, contrast sensitivity, OCT, color vision, and dilated fundoscopy. The patient continues to enjoy successful contact lens wear. Conclusions: This case underscores the importance of electrodiagnostic testing when photoreceptor disease is suspected. MfERG in particular may be of significant value in the detection of CD in patients that develop symptoms later in life than is typical. Poster 56 Roth Spots Associated With Bacterial Endocarditis Brian Gerlach, O.D., Grand Lake Eyecare, LLC, 1059 Grand Lake Road, P.O. Box 377, Celina, Ohio 45822 Background: Bacterial endocarditis is a life-threatening infection that affects the lining and/or valves of the heart. It is diagnosed based on patient symptoms (fever, malaise, headache, weight loss, myalgias, arthralgias, flu-like symptoms, and fatigue) and laboratory tests (CBC, ESR, CRP, at least two blood cultures, urinalysis, and echocardiogram). Roth spots are found on retinal examination in 3% to 5% of cases. Treatment of bacterial endocarditis consists of highdose IV antibiotic therapy lasting 4 to 6 weeks. Case Report: A 42-year-old white male presented to our clinic with new onset of bilateral photopsia, floaters, and blurred vision. His past ocular history was negative. His past medical history was significant for newly diagnosed rheumatoid arthritis and prediabetes. He stated that he had a “bad cold” for the past month and had lost 40 pounds over the last few months without explanation. He was taking Naprosyn and had no known drug allergies. Best-corrected visual acuities measured O.S. 20/30 and O.D. 20/30-. Pupils, binocular vision testing, and confrontation visual fields were normal. Slit-lamp examination of the anterior segments was essentially normal OU. Dilated fundus examination revealed white blood cells in the vitreous OU, edematous optic nerves OU, scattered flame hemorrhages with
293 white centers OU, and an operculated retinal hole at 2 o’clock at the equatorial region O.D. He was referred immediately for retinal consultation. Laboratory tests were ordered and confirmed the diagnoses of bacterial endocarditis. Treatment of the operculated retinal hole O.D. was deferred. He was treated with high-dose antibiotics and continues to be monitored. Conclusions: Bacterial endocarditis is a life-threatening infection with a mortality rate of 25%. This case demonstrates the need for prompt workup when Roth spots are encountered. Poster 57 Polypoidal Choroidal Vasculopathy Treated With Intravitreous Avastin Scott Huffer, O.D., and Nadia Zalatimo, O.D., VA Medical Center, 718 Smyth Road, c/o Eye Clinic, Manchester, New Hampshire 03104 Background: Polypoidal choroidal vasculopathy (PCV) is a unique form of occult choroidal neovascular membrane (CNVM) originating from abnormal inner choroidal vessels. PCV typically presents with a large serosanguinous pigment epithelial detachment (PED) in the absence of drusen, and a CNVM present on the edge of the PED, revealed by indocyanine green angiography. Although there is potential for significant vision loss with PCV, most patients do well with observation, as many of the lesions resolve without treatment. Photodynamic therapy with Visudyne has been shown to have some benefit but can cause damage to the overlying neurosensory retina. Treatment with intravitreal anti-angiogenic factors such as Avastin (Bevacizumab) and Lucentis (Ranibizumab) have been shown to improve vision in patients with CNVM caused by macular degeneration but are still being investigated for other causes of CNVM. Case Summary: A 62-year-old white male presented with complaints of blurry distance vision OU. A comprehensive eye examination was performed. Entrance testing was remarkable for a trace APD O.S. Subjective refraction yielded best-corrected visual acuity of 20/20 O.D. with ⫹1.25-0.75 x 062 and 20/25 O.S. with ⫹3.00-0.50 x 130. Slit-lamp biomicroscopy of the anterior segment was unremarkable. Dilated fundus examination was remarkable for a cotton wool spot along the superior temporal arcade attributed to uncontrolled hypertension O.D., and a 3 disc diameter PED in the central macula O.S. Fluorescein angiography revealed an occult CNVM at the medial edge of the PED in the left eye. Indocyanine green angiography confirmed an occult CNVM in the left eye, and polypoidal choroidal vasculopathy was diagnosed. The patient was treated with Avastin 1.25 mg/0.05 cc O.S. by intravitreous injection, which was well tolerated. One week later, a subjective improvement in vision in the left eye was noted, and there were no signs of complications secondary to the injection. Treatment with Avastin is ongoing.