Case of the Week

The New England Eye Center Residents have prepared the following cases from weekly Grand Rounds for your education:

All newer cases can be found at TUSK (the Tufts University Sciences Knowledgebase).

June 2, 2005

Cristiana Pieroni, MD

Michael B. Raizman, MD

Shazia Ahmed, MD

May 26, 2005

Supriya Goyal, MD

Izumi Yamamoto, MD

Mitchell Strominger, MD

May 19, 2005

My Hanh T. Nguyen, MD – Uveitis-Hyphema-Glaucoma Syndrome Abstract: This is a case of an 80-year-old female who was referred from an outside institution for recurrent episodes of blurry vision and hyphema in her right eye. Each episode was associated with high intraocular pressures. Past medical history significant for bilateral cataract extraction and lens implantation 22 years ago. On examination, her BCVA was 20/20 OU and pressures were 20 OU. In the right eye, she had 2+ cells (mostly rbc?s), a patent PI, a sulcus PCIOL in the vertical position, an intact posterior capsule, and an area of blood staining between optic and capsule. In the left eye, there was no cell or flare, two patent PI?s, an ACIOL in the vertical position, and an open posterior capsule. There was no rubeosis, transillumination defects OU, pseudophakodonesis or pseudoexfoliation OU. Gonioscopy revealed open structures 360 degrees OU with no PAS. A UBM revealed the inferior haptic of the right eye sulcus IOL pressing on the ciliary body / iris junction. The superior haptic was ok. The patient was diagnosed with Uveitis-glaucoma-hyphema (UGH) syndrome OD. UGH Syndrome is caused by mechanical excoriation of uveal tissue by the IOL optic or haptic. It often occurs weeks to months after the cataract surgery, however, there are reports in the literature of UGH presenting 1 to 8 years postoperatively. Our patient presented with UGH 22 years s/p her cataract surgery. Clinical presentation, differential diagnosis, pathogenesis, and treatment of UGH Syndrome are discussed. <b class="maroon">Key Words:</b> UGH, uveitis, recurrent hyphema, glaucoma, intraocular lens, ACIOL, sulcus PCIOL, ultrasound biomicroscopy (UBM), high IOP

Rhonda B. Rosenberg, MD

Victor Chin, MD

May 12, 2005

Stefanie Schuman, MD

Jane Loman, MD

Johanna Choremis, MD

May 5, 2005

Cristiana Pieroni, MD – Peripheral ulcerative keratitis associated with rheumaotid arthritis Abstract: 68 year-old woman with a history of severe rheumatoid arthritis presented with peripheral ulcerative keratitis. She responded well to treatment with lubrication, conjunctival resection, oral steroids and increased methotrexate. However, the manifestation of rheumatoid associated PUK reflects a more aggressive systemic disease with higher morbidity and mortality. Key Words: peripheral ulcerative keratitis, corneal melt, rheumatoid arthritis.

Zinaria Y. Williams, MD

Nancy L. Flattem, MD – Best's Disease Abstract: A six year old girl was referred for retinal examination. She denied any change in her vision, and her mother noted no noticeable visual difficluty. Past ocular and medical histories were unremarkable. Family history was negative for any known eye disease. Clinical exam revealed 20/40 vision bilaterally and a normal anterior segment. Fundus examination showed bilateral discrete yolk-like macular lesions. OCT displayed RPE thickening bilaterally. ERG was normal,and the EOG was unreliable. The clinical presentation was classic for Best's vitelliform macular dystrophy. The mother and older brother had normal appearing fundi. Upon further question, the mother recalled a maternal cousin that had an unknown eye disease. Key Words: Best's disease, vitelliform macular dystrophy, Arden ration, electrooculogram, bestrophin, VMD2.

April 28, 2005

Dal Chun, MD – Punctate Inner Choroidopathy Abstract: A 44 year-old mildly myopic white woman presented complaining of recurrent blurring of her vision in her right eye over the course of 3 weeks. She also reported occasional photopsia, but no floaters. Her vision was 20/15 in each eye, but she had a paracentral scotoma on visual field testing. Anterior segment examination was normal. Dilated exam of the right eye revealed a few small yellow lesions at the level of the RPE in the parafoveal zone. There was no subretinal fluid, hemorrhage, or neovascular membranes. These lesions were hyperfluorescent on fluorescein angiography with minimal leakage late. The multifocal ERG recordings for the right eye were depressed in the area of the retina corresponding to the scotoma on visual field testing. The clinical findings and testing suggested a diagnosis of punctate inner choroidopathy which is more commonly found in myopic women with no prior viral prodrome or any signs of anterior uveitis of vitritis. Key Words: White dot syndrome, punctate inner choroidopathy, myopic female.

Zinaria Y. Williams, MD – Bilateral branch retinal artery occlusions and stroke due to multiple embolic events Abstract: This is a 55 year old woman with recurrent bilateral branch retinal artery occlusions and stroke with amnesia. She was diagnosed with presumed paradoxical embolism through a patent foramen ovale. She is was treated with Coumadin and aspirin. Key Words: branch retinal artery occlusion, patent foramen ovale, paradoxical embolism, stroke.

April 7, 2005

My Hanh T. Nguyen, MD – Hansen's Disease Abstract: This is a case of a 38 year old male from Cape Verde Islands who presented with bilateral irritated eyes. On evaluation, he was found to have lagophthalmos with exposure keratopathy, low grade, chronic, anterior bilateral uveitis, peripheral neuropathy, and seven hypopigmented, hypoanesthetic skin lesions. The patient was diagnosed with leprosy or Hansen's Disease. Hansen's Disease is a chronic, granulomatous disease affecting patients of all ages and both genders, however, predominantly those between ages 10 - 14 and 35 - 44. The disease is caused by Mycobacterium leprae, which has an affinity for skin, peripheral nerves, mucous membranes, and anterior segments of eyes. Clinical presentation, differential diagnosis, pathogenesis, and treatment of Hansen's disease are discussed. Keywords: tuberculoid, lepromatous, leprosy, lagophthalmos, iris pearls, chronic uveitis, ENL, mycobacterium leprae, peripheral neuropathy.

Nancy L. Flattem, MD– CMV Optic Neuropathy Abstract: A 29-year-old man diagnosed with HIV one month prior presents with poor vision OD. Exam reveals no light perception and optic neuropathy OD. Intravenous ganciclovir was initiated and changed to oral ganciclovir for prophylaxis of the remaining eye. Two months later the patient pesented with retinopathy of anemia in his remaining good eye. The patient responded well to blood transfusions and cessation of ganciclovir. The patient has remained free of CMV retinitis or other retinal pathology in his remaining good eye for eight years. Key Words: HIV, AIDS, cytomegalovirus, retinitis, optic neuropathy, retinopathy of anemia, ganciclovir .

Shazia Ahmed, MD

March 31, 2005

Jyotsom Ganatra, MD– Superior Limbic Keratoconjunctivitis Abstract: 68 yo man with a history of Graves Ophthalmopathy presented with a chief complaint of chronic eye pain in both eyes. He had a history of orbital radiation, orbital decompression, and strabismus surgery. Rose Bengal staining revealed filamentary keratitis secondary to superior limbic keratoconjunctivitis. Treatment with Predforte eye drops was initiated and conjunctival resection was recommended. Key Words: Superior Limbic Keratoconjunctivitis, Filamentary Keratitis, Graves Ophthalmopathy.

Dal Chun, MD – Retroiridal Mass Abstract: A 71 year-old white male was referred to our retina service for evaluation of an incidental mass found during routine cataract surgery of the right eye 1 week prior. The patient was asymptomatic and denied any history of ocular trauma or surgery. He was found to have a pigmented mass abutting an otherwise normal-appearing posterior capsule at the 3:30 position of the right eye. No iris architectural changes or scleral transillumination was noted. On ultrasound biomicroscopy, the mass appeared as a ribbon-shaped linear structure extending from the ciliary body. On dilated fundoscopy, a persistent hyaloid artery was noted to extend anteriorly toward the ciliary body mass. Based upon the history, clinical findings, and ultrasound biomicroscopic appearance of the lesion, it was determined that the patient had a very mild presentation of persistence of fetal vasculature. He will be reexamined in 6 months for any changes to the mass. Key Words: Persistence of fetal vasculature, persistent hyperplastic primary vitreous, ciliary body melanoma, double linear echo.

Rhonda B. Rosenberg, MD – An Unusual Case of Unilateral Open Angle Glaucoma Abstract: A fifty four year old woman with pevious ocular history significant for cataract extraction with Posterior Chamber Intraocular Lens Implant OU, pars plana vitrectomy OU for vitreous opacites was referred for the managment of unilateral open ange glaucoma. Patient's past medical history was significant for CHF, HTN, Liver Transplant, Familial Amyloidosis. Patient had unilateral elevated intraocular pressure with visual field loss on maximal medical therapy. Open angle glaucoma believed to be due to depostion amyloid material in angle. Patient's only other ocular manifestation of the amyloidosis was vitreous opacities. Due to conjunctival scarring from previous surgeries patient underwent a tube shunt instead of a trabeculectomy. Patient requires close observation of the contralateral eye for the developement of secondary open angle glaucoma. Key Words: Secondary Open Angle Glaucoma, Familial Amyloidosis.

March 24, 2005

Nancy L. Flattem, MD – Squamous cell carcinoma of the lids and orbit Abstract: An 82 year old presented with a large right tumor involving the right upper and lower lids. On CT scanning, the lesion invaded the right medial rectus muscle, the globe, and the zygomatic and temporal regions including the temporalis muscle. A second primary tumor was also identified in the hypopharynx. Biopsy revealed well differentiang squamous cell carcinoma. Exenteration was considered for treatment, but due to the extent of the lesion and the patient's general medical health, observation was chosen. The patient was placed in hospice care. The patient died within 3 months. Key Words: squamous cell carcinoma, eyelid lesion, basal cell carcinoma, sebaceous cell carcinoma, eyelid tumors, exenteration.

Izumi Yamamoto, MD – Lacrimal gland amyloidosis Abstract: 55 yo F with 2 month history of upper eye lid mass presented with increasing pain. Presumed diagnosis was chalazion, however Initial I&D showed no drainage. CT of the orbit showed sharply defined low attenuating mass in lacrimal fossa. Excisional biopsy was performed and showed amyloidosis of the lacrimal gland, which is a rare condition with handful reported cases in the past. It is most likely primary amyloidosis, however patient needs evaluation to rule out secondary causes of amyloidosis. Key Words: primary amyloidosis, lacrimal gland mass, lid mass, chalazion, lacrimal gland amyloidosis

Victor Chin, MD

March 17, 2005

Stefanie Schuman, MD – Basal cell carcinoma (BCC) Abstract: 44 year old woman complains of left lower lid lesion for 2 months, now notices she has lost lashes in that area. No vision change, no eye pain. Key Words: Basal cell carcinoma, Hughes procedure, MOHS micrographic surgery

David Rhee, MD

March 10, 2005

My Hanh T. Nguyen, MD – Bilateral facial palsy with Sjogren's syndrome Abstract: This is a case of a 50 year old female who presented with sudden onset ofbilateral facial palsy. She also had xerophthalmia, xerostomia, Raynaud's phenomenon, arthralgia, myalgia, and fatigue. Careful examination was unremarkable except moderate exposure keratopathy OU. Systemic workup was significant for positive anti- Ro / SS-A, rheumatoid factor, and ANA in a speckled pattern. Lower lip biopsy revealed lymphocytic infiltration of salivary glands. The patient was diagnosed with Sjogren's syndrome withsimultaneous bilateral seventh cranial neuropathy. In Sjogren's syndrome, there are many possible extraglandularmanifestations.The occurrence of an associated neuropathy with Sjogren's syndrome is not uncommon. The peripheral nervous system is more typically involved, particularly the distal sensory nerves. Sjogren's syndrome has been described to cause neuropathy of all the cranial nerves except VIII (vestibular), XI (spinal accessory), and XII (hypoglossal). The most common involvement is with the trigeminal nerve. A thorough search of the literature revealed only fourteen cases of facial nerve involvement associated with Sjogren's syndrome. Only two described bilateral facial paresis. We report the third known case of bilateral facial palsy associated with Sjogren's syndrome. Key Words: Sjogren's syndrome, facial palsy, cranial nerve paresis, Lyme disease, sarcoidosis, sicca complex, keratoconjunctivitis sicca, Bell's palsy, exposure keratopathy, Shirmer's.

March 3, 2005

Shazia Ahmed, MD – North Carolina Macular Dystrophy Abstract: North Carolina macular dystrophy was originally described by Lefler in a large pedigree of patients thought to descend from 3 Irish brothers who settled in the North Carolina mountains in the 1830's. Despite its name, this disease is not specific to people from North Carolina, but has been documented in unrelated families from Germany, France, Britain, and Belize. It is an autosomal dominant disease that has been mapped to chromosome 6q16. Affected patients may be completely asymptomatic or complain of poor visual acuity. The disease process normally starts in infancy and stabilizes by the teenage years. This macular dystrophy has been known to have high phenotypic variability. A grading system classifying the disease is currently in use. Grade I patients have drusen concentrated in the fovea. Grade II disease has confluent elevated subretinal material. Grade III disease has chorioretinal atrophy with hypertrophic fibrous tissue and pigmentation at edge of lesion. In addition, regardless of staging patients may show evidence of peripheral drusen. Complications such as choroidal neovascularization has been known to occur. Diagnosis of this disease relies on clinical exam, an extenive family history, and genetic testing. Currently there is no known treatment for North Carolina Macular Dystrophy. Key Words: North Carolina, macular dystrophy, inherited dystrophy.

Victor Chin, MD – Papilledema with a subacute presentation. Abstract: A 13 year old boy presents to NEEC with papilledema secondary to a large chronic subdural hemorrhage caused by a left temporal fossa arachnoid cyst. The patient underwent surgery to evacuate the hematoma and arachnoid fluid collection with resolution of his symptoms. Trauma induced rupture of bridging veins overlying the cyst is the postulated mechanism of his decompensation. Key Words: subarachnoid cyst; papilledema; subarachnoid hemorrhage .

February 24, 2005

Jane Loman, MD – Third Nerve Palsy in 90 year old woman. Abstract: 90 year old woman who presented with 4 month history of left frontal-temporal pain, binocular vertical diplopia, and mild ptosis. Ophthalmic exam revealed a partial third nerve palsy with symmetric pupils but slightly sluggish OS. MRI/MRA revealed a 1.5cm left cavernous sinus aneurysm below the dural ring. Embolization was unsuccessful. Parasympathetic and sympathetic nerve fibers to the pupil were thought to be involved. Key Words: Third Nerve Palsy, Cavernous sinus aneurysm, internal carotid artery, pupil sparing.

My Hanh T. Nguyen, MD – Candida Endophthalmitis Abstract: This is a case of a 55 year old male with HIV, DM, hepatitis C, and IVDA who presented with progressively worsening blurry vision, pain, and black spots in his left eye. On examination, he had visual acuities of 20/20 OD and 20/60 OS, panuveitis OS, choroidal infiltrate OD, and string of pearls OS. The patient was diagnosed with Candida endophthalmitis OU, OS > OD. n Candida endophthalmitis is the most common form of endogeneous endophthalmitis. Risk factors include history of invasive procedures, immunosuppressive diseases and therapy, and chronic immune compromising, debilitating illnesses. Clinical presentation, differential diagnosis, pathogenesis, and treatment of Candida endophthalmitis are discussed. Key Words: Candida albicans, candidiasis, endophthalmitis, endogeneous, string of pearls, uveitis, antifungal, choroidal infiltrate, vitreous opacities, Roth spot.

Dal Chun, MD

February 17, 2005

Nancy Flattem, M.D. – Pseudoexfoliation Glaucoma. Abstract: A 72 year old woman complains of episodes of blurry, graying vision bilaterally for several months. Examination reveals very high intraocular pressures bilaterally and end stage pseudoexfoliation glaucoma. Her pressures were significantly improved with medical therapy. She will be closely followed and will likely require additional medications amd possibly laser surgery and filtration surgery. Key Words: Pseudoexfoliation glaucoma, beta blockers, prostaglandin analogs, alpha-2 agonists, carbonic anhydrase inhibitors, pharmacokinetics, pilocarpine, mannitol, miochol, miostat.

Ioannis P. Glavas, MD– Metastatic eyelid mass from lung primary. Abstract: 70 yo asian male pt was referred to the oculoplastics service for evaluation of a rapidly growing painless eyelid lesion associated with bleeding and ectropion. The lesion first appeared 3 weeks prior to presentation. Excisional biopsy was performed and histopathology diagnosis was consistent with neuroendocrine carcinoma of lung origin. Full body CT scan revealed a 7mm right upper lobe lung nodule, questional mediastinal adenopathy, hepatic cyst and adrenal masses. PET scan confirmed involvement of lung, mediastinum, adrenals and right clavicle. The eyelid lesion regrew to the prebiopsy size in less than 3 weeks. The patient was referred to oncology. He is currently undergoing treatment with radio- and chemotherapy for disseminated small cell carcinoma of the lung. This case represents an unusual eyelid metastasis as the first presentation of primary small cell carcinoma of the lung. Key words: Small cell carcinoma, Lung metastasis, metastatic eyelid tumor.

February 3, 2005

Rhonda B. Rosenberg, M.D. -- Cystoid Macula Edema Associated with Latanoprost Use Abstract: An 84 year old white woman had decreased vision in right eye 2 weeks after being prescribed latanoprost for choric open-angular glaucoma. Her ocular history included OAG, S/P ECCE OU with iris capture OD. Anterior exam was stable OU. Biomicroscopic fundus exam of the right eye revealed prominent cystoid spaces in the macula. Fluorescein angiography was consstent with CME. Latanoprost was stopped and patient was started on Acular. Eight weeks later her vision had recovered to her pre-CME level. Key Words: Latanoprost, Cystoid Macula Edema, Adverse Effects, Aphakic, Pseudophakic

Izumi Yamamoto, MD – Mooren's Ulcer Abstract: 50 yo male was referred to NEEC for sudden worsening of previously well healing peripheral ulcer, which had overlying epithelial defect and significant crescent-shaped thinning along the limbus. Corneal culture and extensive autoimmune work up were both negative. Another area of peripheral epithelial defect developed adjacent to the original ulcer along the limbus. Mooren's ulcer was diagnosed and successfully treated with topical steroid without perforation. Key Words: Morren's ulcer, Peripheral ulcerative keratitis, peripheral corneal ulcer

James Hung, M.D.

January 27, 2005

Stefanie Schuman, MD – Graves Ophthalmopathy Visual field defect Abstract: Abstract: Pseudotumor cerebri, or idiopathic intracranial hypertension (IIH), is a disorder associated with increased intracranial pressure of greater than 250 mm of water, normal neuroradiologic imaging apart from possible small ventricles, and normal cerebrospinal fluid analysis. Patients with IIH may have pulsatile tinnitus, abducens nerve palsies, and transient obscuration of vision, all of which tend to resolve with improvement of IIH. In contrast, visual acuity and visual field loss may persist despite resolution of IIH. Treatment of IIH has included weight loss, diuretics, Digoxin, Corticosteroids, and repeated lumbar puncture. When vision threatened, optic nerve sheath decompression and lumboperitoneal or ventriculoperitoneal shunts are considered. Key Words: Idiopathic Intracranial Hypertension (Pseudotumor Cerebri)

David Y Rhee, MD -- Non Arteritic Ischemic Optic Neuropathy. Abstract: A 71 year old Albanian male presented with "a new white cloud" in his vision in the left eye. On examination, the patient exhibited an afferent pupillary defect, optic nerve swelling and an inferior arcuate visual field defect. This presentation will discuss the diagnosis of ischemic optic neuropathy, cover the differential diagnosis, including non-arteritic and arteritic optic neuropathy, and discuss the management and proposed pathophysiology. Key Words: ischemic optic neuropathy, non-arteritic, giant cell arteritis

January 20, 2005

Arlene Bagga, MD – A 38-year-old man with an eyebrow lesion Abstract: A 38-year-old man was referred to the Oculoplastics Service with a mass on his eyebrow that he noticed growing over the past 3 years. Biopsy revealed histology consistent with chondroid syringoma, a benign lesion with malignant potential. The entire lesion was subsequently removed with clean margins, and the patient will be followed. Key Words: Chondroid Syringoma, Benign Lid Lesion, Pilomatrical Differentiation

My Hanh T. Nguyen, M.D. – Eales Disease Abstract: This is a case of a 33 year old healthy Asian male who presented with bilateral blurry vision and photophobia. On examination, he had visual acuities of 20/200 OD and 20/400 OS, bilateral vitritis, retinal vasculitis, and macular edema. -A systemic workup was negative for sarcoidosis, toxoplasmosis, syphilis, hemoglobinopathies, leukemia, and HIV. PPD was positive, however chest CT and blood and urine cultures for AFB were negative. The patient was diagnosed with Eales Disease. Eales Disease, a diagnosis of exclusion, is a primary idiopathic obliterative retinal vasculopathy, affecting predominantly the peripheral retina. There is a male predominance with peak age of onset between 20 and 40. It is bilateral in 50-90% of cases. Clinical presentation, differential diagnosis, pathogenesis, and treatment of Eales Disease are discussed. Key Words: Eales, retinal diseases, vasculitis, phlebitis, ischemia, neovascularization, vitritis, uveitis, mycobacterium tuberculosis, vitreous hemorrhage

January 13, 2005

Jane Loman, MD– Conjunctival Lesion Abstract: Purpose: To describe a non-severe case of the uncommon conjunctival involvement of lichen planus. Design: Case Report Methods: Description and clinical course of a patient presenting with a conjunctival lesion. Results: The patients clinical symptoms, medical history, and conjunctival biopsy were all consistent with a diagnosis of conjunctival lichen planus. Her symptoms and lesion were self-limited and no treatment was necessary. Her symptoms included conjunctivitis and sore gums. Her biopsies of both gingiva and conjunctiva were consistent with lichen planus that included subepithelial band of lymphocytes. Conclusion: There is a wide range of variabiility and severity in symptoms and signs of lichen planus. Lichen planus is uncommonly found on conjunctiva and this is a detailed report of the self-limited form of this disease on the conjunctiva. Patients should be aware of the signs and symptoms of lichen planus affecting other parts of the body such as the skin, oral mucosa, esophagus, and genitalia. Key Words: Conjunctiva, Lichen Planus, Conjunctivitis, Conjunctival Lesion, Conjunctival keratinization, T cell-mediated

Victor Chin, MD Abstract: An 80 year old woman presents to the New England Eye Center with acute painless monocular vision loss. Evaluation reveals a central retinal artery occlusion but workup does not reveal a clear etiology. Paracentesis and IOP lowering medications did not improve the patient’s vision and she remains at light perception in her right eye.

January 6, 2005

Jyotsom Ganatra. MD -- Limbal Dermoid. Abstract: 9 yo girl referred for excision of mass on right eye. Mass present since birth. Located inferotemporally. Large elevated w/ cystic component invading sclera, cornea, anterior chamber, iris and indenting lens. Diagnosed as Dermoid. Decsion to defer excision given that eye is amblyopic and surgery would involve risks of retinal detachment, vitreous hemorrhage, and significant anterior segment reconstruction. Key Words: Dermoid, Conjunctival Mass, Corneal Mass, Congenital Lesion, Limbal Mass.

Nancy Flattem, M.D. -- Ocular Toxocariasis. Abstract: A 46-year-old man with a history of amblyopia OS was referred for vitritis OS. Examination revealed 20/200 acuity OS with trace vitreous cells, chorioretinal atrophy, and with an old granulomatous choroidal scar extending into the vitreous. Fluorescein angiography revealed no leakage. This granulomatous lesion was consistent with toxocariasis. Toxocariasis usually occurs in young children who are exposed to Toxocara carni cysts from young puppies or unwashed root vegetables. In the intestines the cysts develop into larvae which spread throughout the vasculature to the lungs, brains, liver, or eye. The classic ocular toxocariasis findings are choroidal granulomatous lesions with fibrovascular stalks into the vitreous. Inflammation may be controlled with steroids. Anthelmintic agents may also be used, though an increase in inflammation may be incited. Key Words: ocular toxocariasis, granuloma, parasite, roundworm, Toxocara canis, vitritis

David Rhee, MD -- Submacular Hemorrhage. Abstract: A 71-year-old female presents with decreased vision due to submacular hemorrhage. The submacular hemorrhage may be due to choroidal neovascularization from age related macular degeneration or idiopathic polypoidal choroidal neovascularization. This talk discuss this etiology, diagnosis and management of submacular hemorrhage, including pneumatic displacement, submacular surgery and tissue plasminogen activator. Key Words: submacular hemorrhage, submacular surgery, laser photocoagulation, tissue plasminogen activator, retinotomy, pneumatic displacement, age related macular degeneration, idiopathic polypoidal choroidal vasculopathy.

December 23, 2004

Zinaria Williams, MD -- Infectious crystallinekeratopathy in a corneal graft -- 72-year-old man with a complicated past ocular history including penetrating keratoplasty (PK) in 1995 for cornealdecompensation OS, recurrent uveitis OU, and advanced inflammatory glaucoma OS presented for a regular follow-up visit complaining of pain OS for 1 week. Infectious crystallinekaratopathy found within corneal graft OS. Despite aggressive treatment with topical antibiotics, his condition worsened and he underwent a PK.

Izumi Yamamoto, MD -- 38-year-old male presented after a self-sealed corneal penetrating injury by powered steel brushes. Small intraocular foreign body was found in the AC angle by careful gonioscopy. Management of anterior chamber intraocular foreign body and metallosis are discussed. Key Words: Intraocular foreign body, Anterior chamber foreign body, Anterior chamber Angle foreign body, Metallosis, Post-traumatic endophthalmitis, Corneal penetrating injury, ERG, Ruptured globe.

David Rhee, MD -- 68 y/o male with one month history of decreased vision OD

December 9, 2004

Linda Semela MD -- Hydroxychloroquine Toxicity -- rare but severe. Early detection to prevent and minimize toxicity is essential. Screening for retinal toxicity is still subject of debate. The focus of this GR is to present the current recommendations for screening and toxicity management published by the AAO and to talk about the role of mfERG as an objective screening tool in asymptomatic patients. Key Words: Hydroxychloroquine, rheumatoid arthritis, retinal toxicity, screening recommendations, risk status, management, mfERG

Shazia Ahmed, MD -- Diagnosis and management of acute posterior multifocal placoid pigment epitheliopathy -- Acute posterior multifocal placoid pigment epitheliopathy is a chorioretinal inflammatory condition first described by Dr. Gass in 1968. Classically the disease process affects young adults and tends to be bilateral. It can present with decreased visual acuity, scotomas, or metamorphopsias. One third of the patients present with a flu-like syndrome. On fundus examination, the retina is known to have multiple subretinal placoid yellow-white lesions mostly located in the posterior pole that are approximately 1 disc diameter or less in size. The condition is self limited and full recovery may require 6 months. While many physicians do not treat APMPPE, some advocate the use of prednisone for an associated systemic vasculitis or macular involvement. Key Words: acute posterior multifocal placoid pigment epitheliopathy, inflammatory disease, chorioretinopathy

Steven N. Truong MD -- 9-year-old boy who failed vision screening at school. Referred to evaluation after seeing several optometrists and ophthalmologists without improvement of vision. Upon examination and ancillary testing, he was found to have Stargardt’s disease. Key Words: School vision screening;  Stargardt’s disease;  Fundus flavimaculatus

November 8, 2004

Cornea Cases -- Johanna Choremis, MD

November 4, 2004

Cristiana Pieroni, MD

Johanna Choremis, MD

Ioannis P. Glavas, MD