Fall 2017 Newsletter

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Fall 2017 Newsletter
7th Residency Announcement

Exciting Residency Announcement!

ACGME approves seventh resident complement; first increase in over 30 years!

Grand Rounds

Grand Rounds and Case Studies

Check out our weekly presentations

OTEP

OTEP

Ophthalmic Technician Education Program

LARGEST STUDY ON CHINESE AMERICANS PUBLISHED

LARGEST STUDY ON CHINESE
AMERICANS PUBLISHED

USC Ophthalmology Researchers Find More
Effective Treatments For Blinding Eye Diseases

EDUCATION

Case Study: Couching Lenses, Hidden Pressure

Sastry Xu
Presenter: Ananth Sastry, MD, PGY-4 Discussant: Benjamin Y. Xu, MD, PhD
 

History

  • 57-year-old male presents following blunt trauma to right eye presents with pain and decreased visual acuity in the right eye five days after trauma
  • Remote past ocular history of intra-orbital foreign body (removed) in the right eye

Exam Findings

  • BCVA OD: HM; OS: 20/30
  • IOP OD: 48; OS: 14
  • Pupils: OD: Mydriatic, nonreactive; OS: Round, reactive, no RAPD
  • SLE OD (Figure 1): 2+ conjunctival injection, diffuse corneal microcystic edema, very deep anterior chamber with 2-3+ flare/haze, mydriatic iris, lens- poor view, cortical changes
  • SLE OS: Within normal limits
  • DFE OD: No view; OS: Within normal limits
  • Gonioscopy OD: No view; OS: Open to CB 360

Figure 1
Figure 1: Slit lamp photo of the right eye showing conjunctival injection, diffuse microcystic corneal edema, a deep anterior chamber with haze and flare and a mydriatic pupil

 

Differential Diagnosis

  • Phacoantigenic uveitis
  • Lens particle glaucoma
  • Angle recession
  • Microhyphema
  • Uveitic glaucoma/trabeculitis
  • Phacolytic glaucoma

Additional Investigations

  • CT scan (Figure 2): Lens notably absent within right globe; intact lens in left globe
  • B-scan ultrasonography (Figure 3): Mobile hyperechoic, ovoid structure within vitreous cavity visible on vertical axial, T3 and T6 views

Figure 1
Figure 2: CT scan of the orbit, axial view. Absent lens material from right globe. Hyperdense foreign object in anterior right orbit is likely residual intraorbital foreign body from prior trauma

 
Figure 2
Figure 3: B-scan ultrasonography of the right eye, vertical axial view. Hyperechoic, ovoid structure in anterior/inferior portion of the vitreous represents posteriorly dislocated lenticular nucleus

 

 

Diagnosis

  • Phacoantigenic uveitis

Pathophysiology

  • The lens capsule is violated by trauma, which exposes a large quantity of lens particles to the anterior chamber.
  • Lens particles are seen as antigens and induce an IgG mediated type III hypersensitivity reaction.
  • An intraocular granulomatous inflammatory reaction ensues, which obstructs the trabecular meshwork and increases the intraocular pressure.

Treatment

  • Topical and oral aqueous suppressants
  • Topical and oral corticosteroids
  • Cataract extraction (In this case, the patient required a pars plana vitrectomy and lensectomy.)

Prognosis and Future Directions

  • Prognosis depends on the extent of damage to uveal tissue secondary to granulomatous inflammation as well as glaucomatous damage to the optic nerve from increased intraocular pressure.

References

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  • Richter C, Epstein DL. Lens-induced open-angle glaucoma. In: Ritch R, Shields MB, Krupin T, eds. The Glaucomas. 2nd ed. St Louis: Mosby; 1996.
  • Kanski J, Brad Bowling. Lens-related glaucoma. In: Kanski J, Brad Bowling, eds. Clinical Ophthalmology: A systematic approach. 7th ed. Elsevier Saunders; 2011.
  • Sowka J. Phacomorphic glaucoma: case and review. Optometry. 2006 Dec;77(12):586–9.
  • Lee JW, Lai JS, Yick DW, Yuen CY. Argon laser peripheral iridoplasty vs systemic intraocular pressure-lowering medications as immediate management for acute phacomorphic angle closure. Clin Ophthalmol. 2013;7:63–9.
  • Lee SJ, Lee CK, Kim WS. Long-term therapeutic efficacy of phacoemulsification with intraocular lens implantation in patients with phacomorphic glaucoma. J Cataract Refract Surg. 2010 May;36(5):783–9
  • Papaconstantinou D, Georgalas I, Kourtis N, Krassas A, Diagourtas A, Koutsandrea C, Georgopoulos G. Lens-induced glaucoma in the elderly. Clin Interv Aging. 2009;4:331–6.
  • Jarrett WH ll. Dislocation of the lens. Arch Ophthalmol. Sep 1967;78(3):289–296.
  • Dureau P. Pathophysiology of zonular diseases. Curr Opin Ophthalmol. 2008 Jan;19(1):27–30.
  • Izquierdo NJ, Traboulsi EI, Enger C, Maumenee IH. Glaucoma in the Marfan syndrome. Trans Am Ophthalmol Soc. 1992;90:111-7; discussion 118–22.
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  • Flocks M, Littwin CS, Zimmerman LE. Phacolytic glaucoma: a clinicopathological study of 138 cases of glaucoma associated with hypermature cataract. Arch Ophthalmol. 1955;54:37–45.
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  • Epstein DL, Jedziniak J, Grant WM. Identification of heavy molecular weight soluble protein in aqueous humor in human phacolytic glaucoma. Invest Ophthalmol Vis Sci. 1978;17:398–402.
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  • Jain SS, Rao P, Nayak P, Kothari K. Posterior capsular dehiscence following blunt injury causing delayed onset lens particle glaucoma. Indian J Ophthalmol. 2004 Dec;52(4):325–7.
  • Kim TH, Kim SJ, Kim E, Chung IY, Park JM, Yoo JM, Song JK, Seo SW. Spontaneous anterior lens capsular dehiscence causing lens particle glaucoma. Yonsei Med J. 2009 Jun 30;50(3):452–4.
  • Marak GE Jr, Font RL, Alepa FP. Experimental lens-induced granulomatous endophthalmitis. Mod Probl Ophthalmol. 1976;16:75–79.
  • Thach AB, Marak GE Jr, McLean IW, Green WR. Phacoanaphylactic endophthalmitis: a clinicopathologic review. Int Ophthalmol. 1991;15:271–279.
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  • Ocular Pathology Atlas. American Academy of Ophthalmology website. https://www.aao.org/resident-course/pathology-atlas. Published 2016. Accessed January 4, 2017.
  • Luna G, Eliassi-Rad B. Lens Induced Glaucomas. http://eyewiki.aao.org/Lens_Induced_Glaucomas

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Produced by: Monica Chavez, John Daniel and Mellissa Linton
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