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Poster 61: Temporal Field Loss Associated With Tilted Optic Nerve
326 immunoglobulin (IVIg) 400 mgs/kg x 5 days and a referral sent to optometry/ophthalmology for a refraction and spectacles fitted with ptosis crutches. Three weeks later, the patient presented to optometry for a refraction, and he was found to have a slight astigmatic refractive error with presbyopia OU. The patient was prescribed glasses fitted with a ptosis crutch. Later the same day at the optometric examination, the patient presented in neurology to review his most recent lab work and it was determined he was indeed positive for seronegative MG. A physician or neurologist should ultimately make the diagnosis of MG. Nevertheless, due to the susceptibility of the ocular muscles to the disease process, eye care providers are on the front line, especially since it is suggested ⬃85% to 90% of all individuals diagnosed with MG have ocular involvement. Furthermore, ⬃20% to 50% of all cases of MG are purely ocular, in which case, a distinction is made and is specifically said to be ocular MG. Therefore, because optometrists are most likely to be the first to encounter an undiagnosed patient, they must be able to maximally provide the care within their scope of practice. As for ptosis, outside of surgical intervention, the ptosis crutch is a viable option. A ptosis crutch is a good and inexpensive, less invasive option for those with complications secondary to ptosis that are not yet at the point of surgical intervention. Poster 60 A Case of Bilateral Idiopathic Central Serous Chorioretinopathy Elizabeth D. Jones, B.S., and Kimberly D. Kohne, O.D., Indiana University School of Optometry, 800 East Atwater, Bloomington, Indiana 47401 Background: Idiopathic central serous chorioretinopathy (ICSC) is a condition in which there is leakage of fluid from the choroid into the subretinal space, under the RPE, or both. Symptoms present can be blurred or dim vision, metamorphopsia, and central scotoma. Typically it is unilateral, with bilateral presentation in only about 14% to 30% of cases. It is of unknown etiology, affecting predominately males between the ages of 20 and 50 years. It can be associated with type-A personality, stress, hypochondriasis, and steroid use. Among the differentials are AMD, choroidal inflammatory disorders, optic nerve pits, macular detachment as a result of an RRD or macular hole, choroidal tumor, or pigment epithelial detachment. Case History: This case looks at the diagnosis and management of a patient with bilateral ICSC. A 20-year-old male patient reported to the primary care clinic because he had noticed a spot of light in the vision of his left eye adjacent to his central vision. His BVA was 20/25 O.D. and 20/40-2 O.S., with NIPH OU. External and pupil evaluation revealed a grade 1 afferent pupillary defect OS. Slit lamp examination was unremarkable. Dilated fundus examination revealed dim foveal light reflex O.D., - FLR O.S., and an asymmetrical macular appearance between the 2 eyes.
Optometry, Vol 79, No 6, June 2008 Amsler grid was normal O.D. with metamorphopsia O.S. The patient denied steroid or ephedra usage, but was still suspect as possibly having ICSC. Optical coherence tomography (OCT) of both eyes revealed serous detachments of the neurosensory retina in both eyes, confirming bilateral ICSC. Conclusion: The patient was educated about his condition, that it typically resolves on its own, and may worsen before final resolution. Follow-up evaluation 2 weeks later revealed improved VAs and ⫹ FLR OU, as well as almost complete resolution of macular swelling O.D. and much improved swelling O.S. upon OTC evaluation. Poster 61 Temporal Field Loss Associated With Tilted Optic Nerve Richard Steven Savoy, O.D., Southern College of Optometry, 1245 Madison Avenue, Memphis, Tennessee 38104 Background: Its etiology being a common board question, bitemporal field loss can be an alarming finding during an optometric examination. The most common and certainly most well-known etiology defining this ocular sign is a chiasmal lesion, specifically a pituitary adenoma or other potentially morbid lesion. Indeed, every first-year optometry student recognizes that the optic nerve decussates behind the eye and that the 2 nasal nerve fiber bundles combine to form the optic chiasm. This pinpoints the chiasm as a unique landmark where the nasal optic nerve fibers of both eyes can be compromised by a solitary lesion. Thankfully, in some cases, bilateral temporal field loss can actually manifest from a simple anatomic anomaly commonly seen as malinserted or “tilted” optic discs instead of a cranial mass. Case History: Following is a summary of the significant findings related to this case report. This patient was a 51-year-old man who presented for examination complaining only of reading blur. His ocular history was remarkable for previous LASIK surgery. Predilation examination was essentially normal except for a noticeably constricted left temporal visual field by finger counting and “extent of field” confrontation testing. Dilated fundus examination revealed tilted optic nerves with white, reflective peripapillary changes noted nasally to the nerve in each eye. Refractile bodies, tentatively identified as optic nerve drusen, were also noted bilaterally. Automated field testing (particularly the seldom used “screening field,” which extends to 60 degrees temporally) showed significant temporal field loss on both sides. B-scan confirmed mild bilateral drusen. MRI was normal. The oblique optic nerve insertion, possibly complicated by optic nerve drusen, was diagnosed as the cause of the field loss. Conclusion: A case such as this can present a diagnostic dilemma for the clinician. Prudence may dictate MRI in all similar cases as the implications for the patient are obviously serious should the clinician overlook chiasmal pathology. Nevertheless, awareness of this “normal” anatomical
Poster Presentations variant, particularly in an asymptomatic patient, may keep the clinician from assuming the worst and instead could impart cautious optimism to the patient. Poster 62 How to Effectively Communicate With the Native American Patient Without Undermining Culture: A Mini Case Series S. Hetu, Family Practice Resident, NSUOCO Background: There are more than 4 million Native Americans or Alaskan Indians living in the United States. This number constitutes 1.5% of the total population. This cultural group is spread among the 550 separate tribes, bands, and villages that span the United States. Many of these Native Americans need routine eye care, as they are more susceptible to certain ocular diseases than the average American. For example, Native American adults are 2 times as likely as non–Native American adults to have diabetes. The rate increases to 4 times as likely to have diabetes for Native American children. Health care practitioners must think about the way in which they communicate with this culturally rich population, as these indigenous people have their own way of speaking, listening, and communicating nonverbally. The following mini case series will enable optometrists to better understand Native American patients, so as to communicate more effectively with them and ensure higher rates of patient compliance. Case Report: A 77-year-old Native American patient presented to clinic with primary open-angle glaucoma and a history of noncompliance with topical treatment. When questioned as to how he controlled his glaucoma, the patient stated that he boiled the root of a strawberry plant and instilled the resultant fluid in both eyes. He did not see the need for additional therapy. The optometrist explained the mechanism by which topical glaucoma medications lower eye pressure as well as the need to prevent further vision loss from glaucoma. A compromise was reached when the patient agreed to use the topical prescription-strength medication, and the optometrist agreed that the herbal therapy was important to the patient’s cultural background. The patient was instructed to return to clinic immediately if any eye pain or discomfort was experienced, especially after using his herbal therapy. Conclusion: The previous case serves as an important introduction to the need for both compromise and an understanding of culture when treating the Native American population. The typical American way of life differs greatly from the community-centered lifestyle of Native Americans. When examining a Native American patient, the health care professional must be aware that he or she may make a treatment decision based not on himself, but on how the treatment may benefit his tribe as a whole. By understanding Native American patients, the optometrist can better help them to cope with the ocular diseases they are more likely to develop.
327 Poster 63 Myopic Shift in a Child Receiving Growth Hormone Therapy Geoffrey Goodfellow, O.D., Robert Steinmetz, O.D., and Dennis Ireland, O.D., Illinois College of Optometry, 3241 South Michigan Avenue, Chicago, Illinois 60616 Background: Recombinant human growth hormone is primarily used in the treatment of children with idiopathic growth hormone deficiency. There are few known ocular complications associated with growth hormone therapy, most of which are related to retinopathies and papilledema. Although some researchers have hypothesized that growth hormone plays a role in the emmetropization process, a comprehensive review of the literature reveals little to no documentation describing exogenous growth hormone therapy’s effect, if any, on refractive error. Case Summary: A 4-year-old male presented with reduced vision and a significant myopic shift several months after beginning recombinant human growth hormone therapy. The patient was born severely premature and had a history of laser treatment for stage 3⫹ retinopathy of prematurity. Cycloplegic refractive error at ages 8 months, 12 months, 18 months, 2 years, and 3 years showed myopia ranging from -4.00 DS to ⫺6.00 DS. Growth hormone therapy was initiated at 3 years. Cycloplegic refractive error at ages 4 years, 4.5 years, 5 years, and 6 years showed myopia stable at ⫺12.00 DS. All dilated fundus evaluations showed no media opacities, macular pathologies, or optic nerve anomalies. Neuroimaging revealed no pathology along the visual pathway from the orbit to the occipital cortex. Conclusion: Refractive error in children receiving recombinant human growth hormone therapy should be monitored carefully. Particular attention may be needed in patients with a history of retinopathy of prematurity. More research is needed to determine if growth hormone therapy contributes to increased axial length and subsequent myopic shift. Poster 64 Withdrawn
Scientific Poster Abstracts Poster 65 Evaluation of a Contact Lens Disinfecting Solution Against Fusarium Solani and Acanthamoeba Spp Roya N. Borazjani, Ph.D., Roya Nicole Borazjani, Ph.D., Sally L. Buck, B.S., Cindy L. McAnally, B.S., Ron L. Smith, Ph.D., and Barry A. Schlech, Ph.D., Alcon Research Ltd., 6201 South Freeway, TC-49, Fort Worth, Texas 76134
Optometry, Vol 79, No 6, June 2008 Amsler grid was normal O.D. with metamorphopsia O.S. The patient denied steroid or ephedra usage, but was still suspect as possibly having ICSC. Optical coherence tomography (OCT) of both eyes revealed serous detachments of the neurosensory retina in both eyes, confirming bilateral ICSC. Conclusion: The patient was educated about his condition, that it typically resolves on its own, and may worsen before final resolution. Follow-up evaluation 2 weeks later revealed improved VAs and ⫹ FLR OU, as well as almost complete resolution of macular swelling O.D. and much improved swelling O.S. upon OTC evaluation. Poster 61 Temporal Field Loss Associated With Tilted Optic Nerve Richard Steven Savoy, O.D., Southern College of Optometry, 1245 Madison Avenue, Memphis, Tennessee 38104 Background: Its etiology being a common board question, bitemporal field loss can be an alarming finding during an optometric examination. The most common and certainly most well-known etiology defining this ocular sign is a chiasmal lesion, specifically a pituitary adenoma or other potentially morbid lesion. Indeed, every first-year optometry student recognizes that the optic nerve decussates behind the eye and that the 2 nasal nerve fiber bundles combine to form the optic chiasm. This pinpoints the chiasm as a unique landmark where the nasal optic nerve fibers of both eyes can be compromised by a solitary lesion. Thankfully, in some cases, bilateral temporal field loss can actually manifest from a simple anatomic anomaly commonly seen as malinserted or “tilted” optic discs instead of a cranial mass. Case History: Following is a summary of the significant findings related to this case report. This patient was a 51-year-old man who presented for examination complaining only of reading blur. His ocular history was remarkable for previous LASIK surgery. Predilation examination was essentially normal except for a noticeably constricted left temporal visual field by finger counting and “extent of field” confrontation testing. Dilated fundus examination revealed tilted optic nerves with white, reflective peripapillary changes noted nasally to the nerve in each eye. Refractile bodies, tentatively identified as optic nerve drusen, were also noted bilaterally. Automated field testing (particularly the seldom used “screening field,” which extends to 60 degrees temporally) showed significant temporal field loss on both sides. B-scan confirmed mild bilateral drusen. MRI was normal. The oblique optic nerve insertion, possibly complicated by optic nerve drusen, was diagnosed as the cause of the field loss. Conclusion: A case such as this can present a diagnostic dilemma for the clinician. Prudence may dictate MRI in all similar cases as the implications for the patient are obviously serious should the clinician overlook chiasmal pathology. Nevertheless, awareness of this “normal” anatomical
Poster Presentations variant, particularly in an asymptomatic patient, may keep the clinician from assuming the worst and instead could impart cautious optimism to the patient. Poster 62 How to Effectively Communicate With the Native American Patient Without Undermining Culture: A Mini Case Series S. Hetu, Family Practice Resident, NSUOCO Background: There are more than 4 million Native Americans or Alaskan Indians living in the United States. This number constitutes 1.5% of the total population. This cultural group is spread among the 550 separate tribes, bands, and villages that span the United States. Many of these Native Americans need routine eye care, as they are more susceptible to certain ocular diseases than the average American. For example, Native American adults are 2 times as likely as non–Native American adults to have diabetes. The rate increases to 4 times as likely to have diabetes for Native American children. Health care practitioners must think about the way in which they communicate with this culturally rich population, as these indigenous people have their own way of speaking, listening, and communicating nonverbally. The following mini case series will enable optometrists to better understand Native American patients, so as to communicate more effectively with them and ensure higher rates of patient compliance. Case Report: A 77-year-old Native American patient presented to clinic with primary open-angle glaucoma and a history of noncompliance with topical treatment. When questioned as to how he controlled his glaucoma, the patient stated that he boiled the root of a strawberry plant and instilled the resultant fluid in both eyes. He did not see the need for additional therapy. The optometrist explained the mechanism by which topical glaucoma medications lower eye pressure as well as the need to prevent further vision loss from glaucoma. A compromise was reached when the patient agreed to use the topical prescription-strength medication, and the optometrist agreed that the herbal therapy was important to the patient’s cultural background. The patient was instructed to return to clinic immediately if any eye pain or discomfort was experienced, especially after using his herbal therapy. Conclusion: The previous case serves as an important introduction to the need for both compromise and an understanding of culture when treating the Native American population. The typical American way of life differs greatly from the community-centered lifestyle of Native Americans. When examining a Native American patient, the health care professional must be aware that he or she may make a treatment decision based not on himself, but on how the treatment may benefit his tribe as a whole. By understanding Native American patients, the optometrist can better help them to cope with the ocular diseases they are more likely to develop.
327 Poster 63 Myopic Shift in a Child Receiving Growth Hormone Therapy Geoffrey Goodfellow, O.D., Robert Steinmetz, O.D., and Dennis Ireland, O.D., Illinois College of Optometry, 3241 South Michigan Avenue, Chicago, Illinois 60616 Background: Recombinant human growth hormone is primarily used in the treatment of children with idiopathic growth hormone deficiency. There are few known ocular complications associated with growth hormone therapy, most of which are related to retinopathies and papilledema. Although some researchers have hypothesized that growth hormone plays a role in the emmetropization process, a comprehensive review of the literature reveals little to no documentation describing exogenous growth hormone therapy’s effect, if any, on refractive error. Case Summary: A 4-year-old male presented with reduced vision and a significant myopic shift several months after beginning recombinant human growth hormone therapy. The patient was born severely premature and had a history of laser treatment for stage 3⫹ retinopathy of prematurity. Cycloplegic refractive error at ages 8 months, 12 months, 18 months, 2 years, and 3 years showed myopia ranging from -4.00 DS to ⫺6.00 DS. Growth hormone therapy was initiated at 3 years. Cycloplegic refractive error at ages 4 years, 4.5 years, 5 years, and 6 years showed myopia stable at ⫺12.00 DS. All dilated fundus evaluations showed no media opacities, macular pathologies, or optic nerve anomalies. Neuroimaging revealed no pathology along the visual pathway from the orbit to the occipital cortex. Conclusion: Refractive error in children receiving recombinant human growth hormone therapy should be monitored carefully. Particular attention may be needed in patients with a history of retinopathy of prematurity. More research is needed to determine if growth hormone therapy contributes to increased axial length and subsequent myopic shift. Poster 64 Withdrawn
Scientific Poster Abstracts Poster 65 Evaluation of a Contact Lens Disinfecting Solution Against Fusarium Solani and Acanthamoeba Spp Roya N. Borazjani, Ph.D., Roya Nicole Borazjani, Ph.D., Sally L. Buck, B.S., Cindy L. McAnally, B.S., Ron L. Smith, Ph.D., and Barry A. Schlech, Ph.D., Alcon Research Ltd., 6201 South Freeway, TC-49, Fort Worth, Texas 76134