Case I: 77 year old Caucasian male with complaint of decreased VA OD
I. Differential diagnoses:
A. Exudative or rhegmatogenous retinal detachment
B. Amelanotic primary choroidal melanoma
C. Choroidal hemangioma
D. Choroidal metastasis
E. Choroidal detachment
II. Underlying systemic disorder:
A. Incidence of choroidal metastasis varies from 9-37% of cancer patients
B. Most common primary site of tumor in men (Lung, GI tract)
C. Most common primary site of tumor in women (Breast, Lung, GI tract)
D. Approximately 30% of patients have no knowledge of systemic cancer at
presentation
E. As high as 50% will find no systemic cancer at initial work-up after ocular diagnosis
F. Mean survival time after ocular diagnosis: 8-9 months
III. Ocular work-up:
A. Careful fundus examination
B. Ultrasound:
1. A-Scan: medium to high internal reflectivity
2. B-Scan: acoustic solidity
C. Fluorescein Angiography
IV. Systemic work-up:
A. Full body evaluation by oncologist (special attention to lungs, breast and GI tract)
B. MRI to rule-out brain metastasis
V. Treatment:
A. Systemic chemotherapy
B. External beam radiation
C. Plaque brachytherapy
D. Hormone therapy
E. Local resection
F. Observation
G. Management depends on many factors most importantly the patient’s life
expectancy and the threat to vision in remaining life
Case II: 47 year old white female, 64 in. and 320 lbs. with headaches and decreased VA
I. Differential diagnosis:
A. Anterior ischemic optic neuropathy
B. Optic neuritis
C. Optic disc drusen
D. Papilledema
II. Systemic work-up:
A. MRI of the brain
B. Lumbar puncture with CSF analysis
C. Idiopathic Intracranial Hypertension “Pseudotumor cerebri” = signs and
symptoms of elevated intracranial pressure with no localizing neurologic signs
(except CN VI paresis), normal neuroimaging, ICP>250 with normal CSF
composition
III. Ocular manifestations:
A. Vision loss/dysfunction
1. Can have normal visual acuities while at the same time be going blind from
visual field loss
B. Diplopia – secondary to CN VI paresis
C. Transient visual obscurations (TVOs)
III. Systemic manifestations:
A. Headaches
B. Pulsatile tinnitus
IV. Treatment:
A. Observation with Visual Fields
B. CAI’s / Diuretics
C. Weight Loss
D. ONSF
E. Lumboperitoneal shunt (LPS) / Ventriculoartrial (VA) shunt
Case III: 77-year-old African American Male with sudden loss of vision OD
I. Differential diagnoses:
A. Retinal macroaneuryism
1. Saccular
2. Fusiform
B. Choroidal neovascular membrane
C. Valsalva retinopathy
D. Coats disease
E. Cavernous hemangioma
II. Underlying systemic disorders:
A. Hypertension
B. Anemia
1. Severe anemia (HgB <8 g/dl) has a 70% retinopathy incidence
III. Ocular work-up:
A. Careful fundus examination
B. Fluorescein angiography
C. Indocyanine green angiography
IV. Systemic work-up:
A. Blood pressure and pulse
B. Blood work
1. CBC with differential and platelets, lipid profile, fasting blood sugar,
Sickledex test, HgB, HIV
C. Complete cardiovascular and systemic work-up
D. Carotid ultrasound
V. Treatment:
A. Observation
B. Pan-retinal photocoagulation
C. Pre-retinal hemorrhage
1. Vitrectomy
2. Membranotomy
3. Others
Case IV: 54 year old asymptomatic male
I. Differential diagnoses:
A. Diabetic retinopathy
B. Hypertensive retinopathy
C. Anemic retinopathy
D. Interferon retinopathy
II. Underlying systemic disorder:
A. Hepatitis C
1. Infects an estimated 3.5 million Americans, World wide 170 million afflicted
2. Common cause of liver transplantation with increased risk of cirrhosis,
decompensated liver disease, and hepatocellular carcinoma
B. Inter feron is commonly prescribed medication for variety of diseases
III. FDA approved indications for interferons include:
A. Hepatitis B and C (INF-alpha)
B. Cancer (Melanoma, lymphoma, leukemia, Kaposi’s sarcoma)
C. Macular degeneration (not favorable results)
D. Multiple sclerosis (IFN-β)
E. Chronic granulomatous disease and osteoporosis (IFN-γ)
F. Doses of interferon vary with disease indication (Cancers = higher doses)
IV. Systemic complications of interferon therapy:
A. Flu-like syndrome (Fatigue, fever, nausea, diarrhea, weight loss)
B. Blood dyscrasia (Leukopenia, thrombocytopenia)
C. Neurologic (numbness, depression)
F. Altered liver function
IV. Ocular complications of interferon therapy:
A. Minor vascular occlusive disease (common)
1. Intraretinal hemorrhage
2. Cotton wool spots
B. More severe occlusive disease (rare)
1. Branch retinal vein occlusion
2. Anterior ischemic optic neuropathy
3. Cranial nerve palsies
4. Neovascularization with secondary tractional retinal detachment
V. Treatment:
A. Stopping treatment (Usually reversible)
B. Appropriate management of more severe sequella
Case V: 49 year old asymptomatic black male
I. Differential diagnosis:
A. HTN retinopathy
B. HIV retinopathy
C. Systemic lupus erythematosus
D. Retinal arteriole occlusion
II. Underlying systemic disorder:
A. 859,000 cases of AIDS in the United States through 2002
B. 199,759 cases of HIV in the United States through 2002 – 35,147 new cases in
2002
C. AIDS = CD4+ T-cell count < 200 cells/mm3 and/or presence of an opportunistic
infection known as an AIDS defining illness
III. Systemic work-up:
A. Diagnosis/detection
1. ELISA (Enzyme-Linked ImmunoSorbent Assay) – most common screening
test
2. Western Blot – most common confirmatory test
B. Monitoring
1. CD4+ cell count (cells/ml) – state of the immune system
2. Viral load – HIV-RNA in blood
IV. Ocular associations:
A. Anterior segment: dry eye syndrome, herpetic eye disease, kaposis sarcoma
B. Posterior segment: microangiopathy, cytomegalovirus retinitis (CMV), retinal
necrosis
V. Associated findings:
A. Systemic: anemia, thrombocytopenia, adrenal, testicular, and pancreatic
dysfunction, GI infection, periodontal disease
B. Concomitant infections: syphilis, hepatitis, tuberculosis, toxoplasmosis
C. Neurologic manifestations: lymphoma, CNS toxoplasmosis, meningitis
VI. Treatment:
A. Highly active antiretroviral therapy (HAART)
1. Combination of drug regimens aimed to synergistically control the HIV
infection and thereby preserve immune function
2. Targeted prophylaxis for opportunistic infections
Case VI: 35 year old Caucasian female asymptomatic
I. Differential diagnoses:
A. Butterfly pattern macular dystrophy
B. Macular degeneration
C. Choroidal neovascular membrane
D. Atypical idiopathic central serous chorioretinopathy
II. Underlying systemic disorder:
A. Inhaled or systemic steroid
B. Stress
C. Sarcoidosis
D. Organ transplantation
E. Pregnancy
F. Lupus
III. Ocular work-up:
A. Vision
B. Amsler grid
C. Photostress test
D. Fluorescein angiography
IV. Treatment:
A. Observation
B. Photocoagulation
1. Indications