kranias diagnostic challenges in retinal diseases 06 20 14
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DIAGNOSTIC CHALLENGES IN DIAGNOSTIC CHALLENGES IN
RETINAL DISEASESRETINAL DISEASES
GEORGE KRANIAS, M.D.GEORGE KRANIAS, M.D.
Vitreoretinal Summer SchoolVitreoretinal Summer School
June 21, 2014June 21, 2014
OCULAR MANIFESTATIONS AS AN OCULAR MANIFESTATIONS AS AN
INITIAL SIGN OF SYSTEMIC DISEASEINITIAL SIGN OF SYSTEMIC DISEASE
BRIEF OVERVIEW OF 5 CASE HISTORIESBRIEF OVERVIEW OF 5 CASE HISTORIES
PATIENT HISTORYPATIENT HISTORY
PH: 43 yo WF c/o sudden onset of blurred PH: 43 yo WF c/o sudden onset of blurred vision OS x1 day.vision OS x1 day.
PMH: Arthritis and multiple allergiesPMH: Arthritis and multiple allergiesEXAM: VA OD 20/30EXAM: VA OD 20/30
OS 20/400 OS 20/400 IOP OD 18 mm HgIOP OD 18 mm Hg
OS 18 mm HgOS 18 mm Hg BP 138/76 mm HgBP 138/76 mm Hg
LABORATORY FINDINGSLABORATORY FINDINGS
HGB: 6.5 LOWHGB: 6.5 LOW
HCT: 19.0 LOWHCT: 19.0 LOW
ANA: (+)ANA: (+)
SLE antibodiesSLE antibodies
NL 12.0-15.0NL 12.0-15.0
NL 35-42%NL 35-42%
TREATMENT COURSETREATMENT COURSE
BLOOD TRANSFUSIONBLOOD TRANSFUSION
PLAQUENIL RXPLAQUENIL RX
SYSTEMIC LUPUS ERYTHEMATOSUSSYSTEMIC LUPUS ERYTHEMATOSUS
Autoimmune inflammatory diseaseAutoimmune inflammatory diseaseMultiple organ involvementMultiple organ involvementPolyarthritisPolyarthritisSkin lesionsSkin lesionsRenal diseaseRenal diseasePericarditisPericarditisHepatosplenomegalyHepatosplenomegalyAnemiaAnemiaNeurological disorderNeurological disorder
SYSTEMIC LUPUS ERYTHEMATOSUSSYSTEMIC LUPUS ERYTHEMATOSUS
OCULAR FINDINGSOCULAR FINDINGS::
Sjogren’s syndromeSjogren’s syndrome
ScleritisScleritis
RetinopathyRetinopathy
a. Retinal hemorrhagesa. Retinal hemorrhages
b. Cotton wool spotsb. Cotton wool spots
c. Retinal artery occlusionc. Retinal artery occlusion
d. Retinal vein occlusiond. Retinal vein occlusion
PATIENT HISTORYPATIENT HISTORY
PH: 69yr. W/M c/o increased difficulty PH: 69yr. W/M c/o increased difficulty reading X1 moreading X1 mo
PMH: type II DM X12 yr, hypertension, PMH: type II DM X12 yr, hypertension, prostate and testicular CAprostate and testicular CA
EXAM: VA OD 20/200 phniEXAM: VA OD 20/200 phni
VA OS 20/200 phniVA OS 20/200 phni
BP 130/70 mm HgBP 130/70 mm Hg
LABORATORYLABORATORY
INCREASED SERUM INCREASED SERUM VISCOSITY 11.1VISCOSITY 11.1
HEMATOCRIT 15HEMATOCRIT 15
IgM PROTEIN 11,000IgM PROTEIN 11,000
NORMAL=2.0NORMAL=2.0
NORMAL=38-45NORMAL=38-45
TREATMENT COURSETREATMENT COURSE
CHEMOTHERAPY AGENTSCHEMOTHERAPY AGENTS
WALDENSTROM’S MACROGLOBULINEMIAWALDENSTROM’S MACROGLOBULINEMIA
LYMPHOPROLIFERATIVE DISORDER LYMPHOPROLIFERATIVE DISORDER
HIGH INTRAVASCULAR CONCENTRATION OF HIGH INTRAVASCULAR CONCENTRATION OF ABNORMAL MONOCLONAL IgM PROTEINABNORMAL MONOCLONAL IgM PROTEIN
INCREASED BLOOD VISCOSITYINCREASED BLOOD VISCOSITY
INCREASED INTRAVASCULAR VOLUMEINCREASED INTRAVASCULAR VOLUME
RETINOPATHY IN 50% OF CASESRETINOPATHY IN 50% OF CASES
PATIENT HISTORYPATIENT HISTORY
CC: 27 yo WF c/o decreased VA x1 CC: 27 yo WF c/o decreased VA x1 week, fatigue and not feeling well. week, fatigue and not feeling well.
PMH: Unremarkable.PMH: Unremarkable.
EXAM: VA OD CF @ 5 ft.EXAM: VA OD CF @ 5 ft.
OS 20/60OS 20/60
LABORATORY FINDINGSLABORATORY FINDINGS
WBC: 19.8 HIGHWBC: 19.8 HIGH
RBC: 1.13 LOWRBC: 1.13 LOW
HGB: 4.4 CRITICALHGB: 4.4 CRITICAL
HCT: 12.8 CRITICALHCT: 12.8 CRITICAL
PLT: 14.0 CRITICALPLT: 14.0 CRITICAL
NL 5.0-10.0 (X1000)NL 5.0-10.0 (X1000)
NL 4.2-5.4 (X10^6)NL 4.2-5.4 (X10^6)
NL 12.0-16.0NL 12.0-16.0
NL 36-46%NL 36-46%
NL 150-450 (X1000)NL 150-450 (X1000)
TREATMENT COURSETREATMENT COURSE
CHEMOTHERAPY AGENTSCHEMOTHERAPY AGENTS
PATIENT HISTORY
CC: 25 yo WF c/o “brown spot” CC: 25 yo WF c/o “brown spot” centrally x2 weeks. Had similar centrally x2 weeks. Had similar episode 2 mo ago, attributed to episode 2 mo ago, attributed to
optic neuritisoptic neuritis
PMH: UnremarkablePMH: Unremarkable
EXAM: VA OD CF @ 5 ft.EXAM: VA OD CF @ 5 ft.
OS 20/100OS 20/100
LABORATORY FINDINGSLABORATORY FINDINGS
WBC: 14.2WBC: 14.2
RBC: 2.72RBC: 2.72
HGB: 9.1HGB: 9.1
HCT: 26.5HCT: 26.5
BLASTS 81BLASTS 81
PATIENT HISTORYPATIENT HISTORY
CC: CC: 54 yo dermatologist developed 54 yo dermatologist developed scotoma OS while flying at 33,000 scotoma OS while flying at 33,000 feet. feet.
PMH: Unremarkable.PMH: Unremarkable.
EXAM: VA OD 20/60EXAM: VA OD 20/60
OS 20/80OS 20/80
LABORATORY FINDINGSLABORATORY FINDINGS
WBC: 19.8WBC: 19.8
RBC: 1.13RBC: 1.13
HGB: 4.4HGB: 4.4
HCT: 12.8HCT: 12.8
PLT: 14.0PLT: 14.0
BLASTS: 80BLASTS: 80
LEUKEMIALEUKEMIA
Group of blood disorders with abnormal, Group of blood disorders with abnormal, unregulated proliferation of WBC.unregulated proliferation of WBC.
Acute (80% children) or chronicAcute (80% children) or chronic
Lymphoid: B-cell and T-cellLymphoid: B-cell and T-cell
MyeloidMyeloid
Accounts for 3.7% of cancer deaths Accounts for 3.7% of cancer deaths
LEUKEMIALEUKEMIA
OCULAR MANIFESTATIONSOCULAR MANIFESTATIONS::
50-80% ocular involvement50-80% ocular involvement
Leukemic infiltratesLeukemic infiltrates
Secondary complications related to: Secondary complications related to:
-anemia-anemia
-thrombocytopenia-thrombocytopenia
-hyperviscosity-hyperviscosity
Opportunistic infectionsOpportunistic infections
RETINOPATHY AS AN INITIAL SIGN OF SYSTEMIC DISEASE
SYSTEMIC LUPUS ERYTHEMATOSUSSYSTEMIC LUPUS ERYTHEMATOSUS
WALDENSTROM’S MACROGLOBULINEMIAWALDENSTROM’S MACROGLOBULINEMIA
LEUKEMIALEUKEMIA
PATIENT HISTORYPATIENT HISTORY
60 yo WF60 yo WF
Loss of vision ODLoss of vision OD
Eyeball achinessEyeball achiness
Red and puffy ODRed and puffy OD
PMH: Hysterectomy, hernia, hypertension, PMH: Hysterectomy, hernia, hypertension, skin Ca skin Ca
PATIENT HISTORY PATIENT HISTORY contcont..
EXAMINATIONEXAMINATION
OD: 20/60, OS: 20/20OD: 20/60, OS: 20/20
Massive sclerochoroidal swelling with Massive sclerochoroidal swelling with localized localized orbital pseudotumor OD.orbital pseudotumor OD.
Proptosis OD.Proptosis OD.
Prominent, elevated Prominent, elevated mass at the mass at the sclerochoroidal levelsclerochoroidal levelAcoustically solid Acoustically solid Shallow retrobulbar Shallow retrobulbar echolucent spaceecholucent space
A-scan: high internal A-scan: high internal reflectivityreflectivity
Pathology ReportPathology Report
Scleral tissue: mild to Scleral tissue: mild to moderately infiltrated moderately infiltrated with chronic with chronic inflammatory cells.inflammatory cells.
Evidence of scleral Evidence of scleral necrosis.necrosis.
No evidence of No evidence of tumor.tumor.
5 years later5 years later
GIANT NODULAR POSTERIOR GIANT NODULAR POSTERIOR
SCLERITIS SIMULATING SCLERITIS SIMULATING
CHOROIDAL MELANOMACHOROIDAL MELANOMA
Review of 400 patients with lesions Review of 400 patients with lesions clinically simulating choroidal clinically simulating choroidal
melanomamelanoma
Suspicious choroidal nevus 27%Suspicious choroidal nevus 27%Age-related macular degeneration 13%Age-related macular degeneration 13%Age-related extramacular degen. 11%Age-related extramacular degen. 11%Congenital hypertrophy of RPE 10%Congenital hypertrophy of RPE 10%Choroidal hemangioma 8%Choroidal hemangioma 8%Nodular scleritisNodular scleritis 1.5%1.5%
Shields JA, Augsburger JJ, Brown GC, Shields JA, Augsburger JJ, Brown GC, Stephens RF: The differential diagnosis of Stephens RF: The differential diagnosis of posterior uveal malanoma. Ophthalmology, posterior uveal malanoma. Ophthalmology, 1980; 87: 518-5221980; 87: 518-522
NODULAR POSTERIOR SCLERITISNODULAR POSTERIOR SCLERITIS
Inflammatory sclerochoroidal massInflammatory sclerochoroidal mass
Systemic disease in 10% of patientsSystemic disease in 10% of patients
UnilateralUnilateral
AdultsAdults
Blurred vision with pain and red eyeBlurred vision with pain and red eye
Exudative retinal detachmentExudative retinal detachment
A/B scan, CT, MRI helpfulA/B scan, CT, MRI helpful
Systemic corticosteroid therapySystemic corticosteroid therapy
PATIENT HISTORYPATIENT HISTORY
27 yo, HEALTHY WM27 yo, HEALTHY WM
CC: BLURRED VA OD X6 WEEKSCC: BLURRED VA OD X6 WEEKS
PMH: BELL’S PALSYPMH: BELL’S PALSY
VA: OD 20/80, OS 20/40. VA: OD 20/80, OS 20/40.
LABORATORY FINDINGSLABORATORY FINDINGS
CBC: NLCBC: NLESR: 2ESR: 2ACE: NLACE: NLLYSOZYME: NLLYSOZYME: NLLYME TITER: NLLYME TITER: NL
ANA: SL. POSITIVE ANA: SL. POSITIVE (1:80)(1:80)HEPATITIS A,B,C: NEGHEPATITIS A,B,C: NEGANTICARDIOLIPIN: ANTICARDIOLIPIN: NEGNEGC-ANCA, P-ANCA: NEGC-ANCA, P-ANCA: NEGSEROLOGY: NEGSEROLOGY: NEG
FOLLOW-UP (6 MONTHS)FOLLOW-UP (6 MONTHS)
CC: PROGRESSIVE LOSS OF VISIONCC: PROGRESSIVE LOSS OF VISION
VA: OD 20/400, OS 20/80VA: OD 20/400, OS 20/80
FUNDUS: SEVERE ONH EDEMAFUNDUS: SEVERE ONH EDEMA
PROGRESSIVE EXUDATIONPROGRESSIVE EXUDATION
DX: R/O OPTIC NEURITIS, MENINGIOMADX: R/O OPTIC NEURITIS, MENINGIOMA
RX: SYSTEMIC STEROIDSRX: SYSTEMIC STEROIDS
FOLLOW-UP (1 YEAR)FOLLOW-UP (1 YEAR)
VA: OD NLP, OS 20/40VA: OD NLP, OS 20/40
SLE: SEVERE RUBEOSIS IRIDIS ODSLE: SEVERE RUBEOSIS IRIDIS OD
FUNDUS: ONH EDEMA, EXUDATIONFUNDUS: ONH EDEMA, EXUDATION
RX: LASER PHOTOCOAGULATIONRX: LASER PHOTOCOAGULATION
NEURORADIOGRAPHIC FINDINGSNEURORADIOGRAPHIC FINDINGS
CHEST X-RAY: CHEST X-RAY: NEGNEG
MRI: ENLARGED MRI: ENLARGED RIGHT OPTIC RIGHT OPTIC NERVENERVE
May 2001 May 2001 August 2002August 2002
OPTIC NERVE BIOPSYOPTIC NERVE BIOPSY
Dense collagenous stroma with inflammatory infiltrates of Dense collagenous stroma with inflammatory infiltrates of plasma cells, lymphocytes, histiocytes and neutrophilsplasma cells, lymphocytes, histiocytes and neutrophils
IDIOPATHIC SCLEROSING IDIOPATHIC SCLEROSING INFLAMMATION OF THE ORBITINFLAMMATION OF THE ORBIT
Autoimmune diseaseAutoimmune disease
Progressive infiltrative fibrosisProgressive infiltrative fibrosis
Chronic courseChronic course
Visually disableVisually disable
Treatment unsatisfactoryTreatment unsatisfactory
PATIENT HISTORYPATIENT HISTORY
50 y/o healthy, W/F50 y/o healthy, W/F
C/O: blurred and distorted VA OD x 2-3 yrs.C/O: blurred and distorted VA OD x 2-3 yrs.
VA :VA :
OD: 20/80OD: 20/80
OS: 20/20 OS: 20/20
CHOROIDAL OSTEOMACHOROIDAL OSTEOMA
Mostly womenMostly women
Mature boneMature bone
Well defined round or ovalWell defined round or oval
Orange, white or white-yellowOrange, white or white-yellow
Juxtapapillary and macular areaJuxtapapillary and macular area
Bilateral 20%, most often young womenBilateral 20%, most often young women
Ultrasonography: calcificationUltrasonography: calcification
Patient HistoryPatient History
14 y/o w/f, mother noticed that pupil was 14 y/o w/f, mother noticed that pupil was turning white over the past few months.turning white over the past few months.
PMH : unremarkablePMH : unremarkableVA : OD CF VA : OD CF
OS 20/20OS 20/20
COATS’ DISEASECOATS’ DISEASE
Retinal telangiectasis with exudative RDRetinal telangiectasis with exudative RDUnilateral, male to female 3 to 1Unilateral, male to female 3 to 1Young children under age 16Young children under age 16Poor vision, strabismus or leukocoriaPoor vision, strabismus or leukocoriaSubretinal yellowish to greenish exudationSubretinal yellowish to greenish exudationRetinal telangiectasisRetinal telangiectasisManagement: photocoagulation, Management: photocoagulation, cryotherapy, vitrectomycryotherapy, vitrectomy
PATIENT HISTORYPATIENT HISTORY
PH: 19 WM college student who reports decreased PH: 19 WM college student who reports decreased vision OU x 3 wks. Recent cold/flu-like vision OU x 3 wks. Recent cold/flu-like symptoms.symptoms.
PMH: UnremarkablePMH: Unremarkable
Exam:Exam: ODOD 20/200 phni20/200 phni IOPIOP 1313OSOS 20/200 phni20/200 phni 1313
BPBP 132/78132/78
2 Week F/U at Univ. of Kentucky 2 Week F/U at Univ. of Kentucky Medical CenterMedical Center
Complains of headachesComplains of headaches
Blood pressure 240/150 on multiple Blood pressure 240/150 on multiple checkschecks
Positive ANAPositive ANA
SED rate 55SED rate 55
MRI (head and orbits) NormalMRI (head and orbits) Normal
Hypertensive RetinopathyHypertensive Retinopathy
ESSENTIAL HYPERTENSIONESSENTIAL HYPERTENSION
(no known cause)(no known cause)
SECONDARY HYPERTENSIONSECONDARY HYPERTENSION
Preeclampsia/eclampsiaPreeclampsia/eclampsia
kidney diseasekidney disease
adrenal diseaseadrenal disease
coarctation of the aortacoarctation of the aorta
PATIENT HISTORYPATIENT HISTORY
PH: 12 yr. WM c/o decreased vision OD x 5 PH: 12 yr. WM c/o decreased vision OD x 5 days. Flu-like symptoms 1 week prior.days. Flu-like symptoms 1 week prior.
PMH: HealthyPMH: Healthy
EXAM:EXAM: ODOD CF @ 4 ft. CF @ 4 ft. IOPIOP 1212
OSOS 20/2020/20 1212
Serologic Work UpSerologic Work Up
HLA B27HLA B27 NEGATIVENEGATIVEFTA-ABSFTA-ABS NON-REACTIVENON-REACTIVEANAANA NEGATIVENEGATIVERA quant.RA quant. NORMALNORMALRPRRPR NON-REACTIVENON-REACTIVEHIVHIV NEGATIVENEGATIVEACEACE NORMALNORMALCAT SCRATCH AB-RCAT SCRATCH AB-R POSITIVEPOSITIVESED RATESED RATE 6161CXRCXR NORMALNORMAL
Acute Neuroretinitis Secondary to Acute Neuroretinitis Secondary to Cat Scratch DiseaseCat Scratch Disease
Bartonella henselaeBartonella henselae is the causative is the causative organismorganismVA loss may be mild or severeVA loss may be mild or severe33% of cases may be bilateral33% of cases may be bilateral> 90% improve to 20/40 within 8 weeks > 90% improve to 20/40 within 8 weeks and 20/20 within 6 monthsand 20/20 within 6 monthsSmall subgroup left with severe visual loss Small subgroup left with severe visual loss and associated optic atrophyand associated optic atrophy
TreatmentTreatment
No proven treatmentNo proven treatment
Periocular and systemic corticosteriodsPeriocular and systemic corticosteriods
Antibiotic therapy Antibiotic therapy
No difference in treated vs. untreated No difference in treated vs. untreated patientspatients
PATIENT HISTORYPATIENT HISTORY
PH: 50yr. WF who reports distortion and PH: 50yr. WF who reports distortion and occasional blurred vision OU x 6 yrs.occasional blurred vision OU x 6 yrs.
PMH: Breast lumpectomy (benign), trauma PMH: Breast lumpectomy (benign), trauma (auto accident) and Bell’s palsy.(auto accident) and Bell’s palsy.
POH: Glaucoma OU.POH: Glaucoma OU.
EXAM:EXAM: 20/40 phni20/40 phni IOPIOP 1717
20/60 phni20/60 phni 1717
BPBP 140/78140/78
Geographic Helicoid Peripapillary Geographic Helicoid Peripapillary Choroiditis Choroiditis
(Serpiginous choroiditis)(Serpiginous choroiditis)
• CHRONIC RECURRING CHOROIDITISCHRONIC RECURRING CHOROIDITIS• MULTIFOCALMULTIFOCAL• INNER CHOROID & RPEINNER CHOROID & RPE• INFLAMMATION vs. SRNVINFLAMMATION vs. SRNV
TreatmentTreatment
Steroids (oral or periocular injection)Steroids (oral or periocular injection)
Photocoagulation for SRNVMPhotocoagulation for SRNVM
Anti - VEGFAnti - VEGF
PATIENT HISTORYPATIENT HISTORY
25 y/o , w/f was seen for the 125 y/o , w/f was seen for the 1stst time on Feb. time on Feb. 1616thth 2010 2010
c/o intermittent blurring of central vision c/o intermittent blurring of central vision which started 2 mo ago and last about 4-5 which started 2 mo ago and last about 4-5 hours. hours.
Her visual symptoms increased recently Her visual symptoms increased recently and last longer.and last longer.
PMH: unremarkable.PMH: unremarkable.
Case 4
ExaminationExamination
Visual acuityVisual acuity– OD 20/60OD 20/60 OD 16 mm HgOD 16 mm Hg– OS 20/40OS 20/40 OS 14 mm HgOS 14 mm Hg
SLE: SLE: a few vitreous cells.a few vitreous cells.Fundus:Fundus:
Hyperemic optic nerves, OUHyperemic optic nerves, OUCystoid macular edema, OUCystoid macular edema, OU
FANG: FANG: CME with ON leakage, OUCME with ON leakage, OUOCT: Thickened neuroepithelium with large OCT: Thickened neuroepithelium with large
cystic cystic changes, OU changes, OU
Feb. 16Feb. 16thth 2010 2010
Feb. 16Feb. 16thth 2010 2010
OD
OS
Laboratory Work-upLaboratory Work-up
CBCCBC NormalNormal
ESRESR NormalNormal
CRPCRP NormalNormal
RFRF NormalNormal
ANAANA NormalNormal
ACEACE NormalNormal
RPRRPR Non-reactiveNon-reactive
FTA-AbsFTA-Abs Non-reactiveNon-reactive
CXRCXR NormalNormal
MRIMRI NormalNormal
Feb 23Feb 23rdrd 2010 2010
No visual complaintsNo visual complaints
VAVA– ODOD 20/2020/20– OSOS 20/2020/20
Fundus:Fundus:– Macula and optic nerve flat OUMacula and optic nerve flat OU
OCT: OCT: NormalNormal
Feb. 23Feb. 23rdrd 2010 2010
OD
OS
March 16March 16thth 2010 2010
C/O blurred vision since March 3C/O blurred vision since March 3rdrd OU OU
On further questioning, she reported that all On further questioning, she reported that all episodes of blurred vision would start with each episodes of blurred vision would start with each menstrual period (21 days), last the first half of menstrual period (21 days), last the first half of each cycle, and resolve at the end of each cycle, and resolve at the end of menstruation. No oral contraceptionmenstruation. No oral contraception
VA: 20/80 OUVA: 20/80 OUFundus: CME with congested ON, OU.Fundus: CME with congested ON, OU.OCT: CMEOCT: CME
BibliographyBibliography
Cyclic Presentation of CME: A. Assi, J. Hickman Casey, Cyclic Presentation of CME: A. Assi, J. Hickman Casey, et al.: Acta Ophthalmol. Scand. 1998: 76: 245-246et al.: Acta Ophthalmol. Scand. 1998: 76: 245-246
– Presented the case of a 28 y/o lady with unilateral pars planitis Presented the case of a 28 y/o lady with unilateral pars planitis and associated CME in whom visual symptoms fluctuated and associated CME in whom visual symptoms fluctuated regularly during menstrual cycles.regularly during menstrual cycles.
Cyclical central serous chorloretinopathy associated Cyclical central serous chorloretinopathy associated with cystoid macular oedema. with cystoid macular oedema. Birchall W, Charles SJ, Birchall W, Charles SJ, Buckler HM. BJO 2001 Jun;85(6):756-8.Buckler HM. BJO 2001 Jun;85(6):756-8.
– CME resolved on oral contraceptives.CME resolved on oral contraceptives.
Consultations and Work-upConsultations and Work-up
GynecologicalGynecological NormalNormal
EndocrineEndocrine NormalNormal
ImmunologicalImmunological NormalNormal
Clotting Clotting APC, R 0.6APC, R 0.6
TreatmentTreatment
August 20August 20thth, 2010., 2010.– Oral contraceptive pill Yasminelle.Oral contraceptive pill Yasminelle.– Her cycle from 21 days changed to 28 days Her cycle from 21 days changed to 28 days
with initial improvement of her visual with initial improvement of her visual symptoms for 2-3 months.symptoms for 2-3 months.
November 11November 11thth, 2010, 2010– Started on stronger contraceptive pill, Yasmin, Started on stronger contraceptive pill, Yasmin,
with subjective visual improvement. with subjective visual improvement.
Dec 20Dec 20thth 2010 2010
Reports visual improvementReports visual improvement
On oral contraceptives for 4 monthsOn oral contraceptives for 4 months
VA VA – OD 20/60OD 20/60– OS 20/40OS 20/40
Dec 20Dec 20thth 2010 2010
OD
OS
Beginning of Jan. 2011 developed progressive Beginning of Jan. 2011 developed progressive painful ophthalmoplegia OD which was attributed to painful ophthalmoplegia OD which was attributed to a large brain mass. It was not present at her initial a large brain mass. It was not present at her initial
evaluation by MRI.evaluation by MRI.
Biopsy revealed inflammatory compounds.Biopsy revealed inflammatory compounds.
Was treated with IV antibiotics with complete Was treated with IV antibiotics with complete
regression of her ophthalmoplegiaregression of her ophthalmoplegia..
10/02/201127/05/2013
26/04/2011
Happy EndingHappy Ending
Patient got married and is expecting Patient got married and is expecting
a baby soon.a baby soon.
She is on no medications.She is on no medications.
No visual complaints.No visual complaints.
VA: 20/20 OU.VA: 20/20 OU.
QuestionsQuestions
Etiology of Cyclic Presentation of CME.Etiology of Cyclic Presentation of CME.
Treatment?Treatment?
If anyone in the audience has come If anyone in the audience has come across with a similar case, please shareacross with a similar case, please share..
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