Optometry & Vision Science

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Optometry & Vision Science:
doi: 10.1097/OPX.0b013e3182718b8f
Clinical Communications

Clinical Communications

Free Access

This month OVS introduces Clinical Cases and Commentary papers as part of a new section “Clinical Communications”. On line we have the opportunity to expand the color image content and allow Supplementary Digital Content (SDC) such as video clips. All with no cost to the authors.

Each paper in this new section will be followed by a clinical comment by our Clinical Editor, emphasizing the clinical “Take Home” message. As noted in my Editorial, the clinical comment will be found in the hard copy of the Journal, following the papers title, authors and Abstract. The full text and illustrations will be found on line with the colored images and video clips.

I am grateful to Larry Alexander, OD, FAAO, an OVS Editorial Board member, for accepting the responsibility as Clinical Editor for this new feature of OVS. He provides all of the clinical comment (“Clinical Pearls”) on each article in Clinical Communications. This is all part of our plan to enrich the clinical content of OVS and make it very accessible, in color and motion, to clinicians, readers, and authors alike.

Tony Adams, OD, PhD, FAAO

Editor in Chief

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Clinical Cases

Severe and Recurrent Interface Hemorrhage after Endothelial Keratoplasty

Alvin L. Young, Vishal Jhanji, Alex H. Fan, Patrick M. K. Tam, Lulu L. Cheng and Srinivas K. Rao

Purpose. To report the occurrence and management of recurrent hemorrhage after Descemet Stripping Endothelial Keratoplasty (DSEK) in a patient with pseudophakic bullous keratopathy.

Methods. An 84-year-old Chinese female on two oral antiplatelet drugs, underwent DSEK in her left eye. Preoperative best-corrected visual acuity (BCVA) was 20/30 OD and 14/200 OS. Intraoperative bleeding was noted from the iris root. Surgery was completed uneventfully and interface was thoroughly irrigated in the end. Slit lamp examination on the first postoperative day showed a dense interface hemorrhage and an intraocular pressure of 24 mm Hg. Repeat interface irrigation was carried out on postoperative day 4, but the hemorrhage appeared again on the following day. Donor lenticule was well-apposed to the corneal stroma and visual acuity was hand motions in the operated eye. No further surgical interventions were performed. Corticosteroid eye drops were continued four times a day in the operated eye and patient was advised weekly follow-up.

Results. Over the next four weeks the interface blood gradually started to clear from the central cornea. At the end of 4 months postoperatively, the interface hemorrhage disappeared completely. A final BCVA of 20/80 was achieved. Specular microscopy revealed an endothelial cell density of 1375 cells/mm2.

Conclusions. Interface hemorrhage is a known complication after DSEK surgery. Recurrent hemorrhage may be expected in patients on oral antiplatelet treatment. In cases without associated graft dislocation, conservative management can still result in good visual outcome.

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Clinical Pearls - Larry Alexander, OD, FAAO

* Blood thinners increase the risk of complications in DSEK

DSEK is becoming a more common procedure for management of corneal endotheliopathy. The likelihood of co-managing DSEK will increase. In this patient, taking oral antiplatelet medication, there is the report of recurrent interface hemorrhage. This case illustrates that even with this complication, proper management can still result in reasonable outcomes.

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Beware of “Old” Horner's Syndrome

Ivan Adamec, Vesna Matijeviæ, Goran Pavliša,Ivana Zadro and Mario Habek

Purpose. Chronic Horner's syndrome is a rare clinical condition, the etiology of which often remains undiscovered.A patient is presented with an 8 year history of Horner's syndrome who was diagnosed with multiple cervical artery dissections.

Case report. A 42-year-old female presented to our emergency department with a severe occipital headache that woke her up from sleep three days earlier. She had a history of headaches and recalled one in particular dating back to 2003. At that time she sought medical attention at general practitioner's office because of the terrible headache and a noticible disparity of her pupils. She was told that she had miosis of the right pupil. The examination conducted in 2011 revealed Horner's syndrome with right miosis and ptosis. A four-vessel cerebral angiography revealed an occlusion of the right internal carotid artery (ICA). The morphology of stenosis and pseudoaneurysm of C1 segment of left ICA, as well as a pseudoaneurysm of V3/V4 junction of left vertebral artery indicated a probable dissective etiology.

Conclusions. This case illustrates that Horner's syndrome with a chronic presentation can be as potentially dangerous as its acute counterpart and should be judiciously investigated.

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Clinical Pearls - Larry Alexander, OD, FAAO

* Chronic Horner's Syndrome may be associated with neurovascular disease

As clinicians, we are at times ineffective in pupillary analysis and this case illustrates how this inadequacy could result in a significant clinical “miss.” In this presentation the clinician is alerted to yet another “association” with the presentation of chronic Horner's. There is “new” technology available that can help us with more effective pupillary analysis.

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Imatinib Mesylate (Gleevec) Induced Unilateral Optic Disc Edema

Crystal DeLuca, Nancy Shenouda-Awad, Charles Haskes and Stephen Wrzesinski

Purpose. Imatinib Mesylate (Gleevec) is a chemotherapy medication developed to treat chronic myelogenous leukemia as well as gastrointestinal stromal tumors (GISTS).1 Ocular side effects are commonly reported with the use of imatinib mesylate such as periorbital edema and epiphora. More serious ocular side effects such as optic disc edema are rarely reported.

Case Report. This case is of a patient who presented with monocular painless loss of vision in the left eye from a previously documented 20/20 to 20/70 shortly after starting treatment with imatinib mesylate.

Results. Every aspect of the ocular presentation and clinical history were addressed to unveil the cause of the disc edema. After ruling out all other causes, the patient was later diagnosed with unilateral optic disc edema as a related side effect of the toxicity from imatinib mesylate.

Conclusions. The properties of imatinib mesylate and the possible etiology of secondary optic disc edema are discussed. This study aims to highlight the importance of systemic medications review for possible etiology of ocular disease as well as the multidisciplinary approach to managing oncology patients with ocular side effects.

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Clinical Pearls - Larry Alexander, OD, FAAO

* Chemotherapy has potential side effects

As practitioners in the primary care arena we must be constantly vigilant regarding ocular side effects of systemic medications. While we concentrate heavily on the physical diagnostic aspects of eye disease, we just have to remember that virtually every “pharmaceutical” advertised on television has a litany of side effects. An increase in the “chemotherapy” of so many conditions that affect the immunological system should keep us on the alert to investigate these ocular side effects.

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Medical Decision Making Capacity and Cataract Surgery

Mark W. Swanson

Background: Medical decision making has evolved from a paternalistic, “doctor knows best system” to one of shared decision making between health care providers and patients. Shared decision making involves informed consent related to the proposed health care options and medical decision making capacity by patients. Adults aged 90 and older are the fastest growing segment of the US population. Dementia prevalence increases dramatically among this group. Dementia may affect the ability of patients to participate in shared decision making.

Case Report. The case of a 91 year old female rehabilitation inpatient with mild cognitive impairment, cataracts and macular degeneration is presented. The case highlights key issues of informed decision making and medical decision making capacity related to cataract surgery. Video examples of the assessment of cognitive and medical decision making capacity are presented.

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Clinical Pearls - Larry Alexander, OD, FAAO

* Assessment of the effects of cognitive impairment of elderly patients is critical in making medical decisions involving intervention

As our population ages, we can expect more issues that both compromise vision and are potentially amendable by intervention. It is critical that health care providers take a logical approach to the assessment of the decision-making capacity of patients regarding these interventions. This paper with accompanying videos offers a simple in-office approach to the assessing the patient for the informed medical decision making process.

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Clinical Commentary

It's Time to Stop Using 20/20 in the Clinic

Mark Rosenfield

Visual acuity is inherently a measure of a visual angle [the minimum angle of resolution (MAR)] but historically is expressed as a fraction whose numerator identifies the test distance while the denominator expresses the distance at which the letter subtends 5 min arc. Unfortunately the fraction is frequently misused in a way that does not reflect the actual test distance. Here a call is made to drop the erroneous use of the Snellen fraction and adopt an angular measure (e.g. logMAR or MAR) or the decimal system (the reciprocal of the decimal equivalent).

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Clinical Pearls - Larry Alexander, OD, FAAO

* Stop abusing Snellen notation!

We clinicians are not always conscious of the way we misuse the Snellen fraction. This author issues a plea for us to have optometry take the lead in what he sees as a more rational approach. In an invited perspective from Ian Bailey, in the September OVS “Low Vision” issue, made similar points to clinician researchers for publishing visual acuity results.

© 2012 American Academy of Optometry


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