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

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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: What’s Stucc in Your Eye?

ShahMoshfeghi
Presenter: Ravi Shah, MDDiscussant: Andrew Moshfeghi, MD, MBA
 

History

  • 44-year-old Hispanic male who reports three-day history of stucco solution in his left eye while working on construction site. He complained of redness, tearing, and pain with resolving photophobia
  • Six months prior to this presentation, the patient reported that he was hammering porcelain tile when felt something went into his left eye
  • He was examined and treated at that time at an outside hospital with topical antibiotics, corticosteroids, and cycloplegics for two weeks, but then had a lack of follow-up
  • His vision slowly declined gradually over three months and then then remained stable but very poor in the left eye

Exam Findings

  • 20/20 OD, Light perception OS. Pupils reactive OD, and Fixed/dilated and white OS with a 2+ rAPD OS. IOP 13 OD and 0 OS by applanation (4 by Tonopen)
  • pH of the left eye was within normal limits
Figure 1
Figure 1: External photo of the left eye showing 360 degree injection without chemosis and an obvious dense white cataract. Minor Iris atrophy at 6 o’clock and 10 o’clock.
Figure 2
Figure 2: Full thickness stromal scar with posterior transillumination defect.

 

Additional Exam Findings

  • Corneal endothelial pigment, 3+ cell and 1+ flare in the anterior chamber. Seidel negative.
Figure 3
Figure 3: B-scan ultrasound of a Vertical axial section of the left eye showing total retinal detachment with optic nerve tethering.

 

Figure 4
Figure 4: B-scan ultrasound of a Horizontal Axial section of the left eye showing Posterior vitreous detachment, total retinal detachment, retinal thickening and retinoschisis centrally.

 

Differential Diagnosis

  • Given the constellation of findings there is really only one thing that unifies all of them, so a good differential diagnosis was difficult to construct:
    • Chemical alkali injury to the left eye
    • Intraocular foreign body left eye
    • Traumatic cataract left eye
    • Retinal Detachment causing hypotony left eye/li>
    • (much less likely):
      • Open globe
      • Endopthalmitis
      • Anterior uveitis
      • Corneal Ulcer/abrasion

Additional Investigations

Figure 5
Figure 5: Urgent CT maxillofacial axial section of the soft tissue window showing left anterior, inferior and nasal foreign body without scattering artifact indicating absence of metal.

 

Diagnosis

  • External alkali chemical injury from stucco solution (general with a pH of 13)
  • Ceramic intraocular foreign body (IOFB) – chronic in nature

Pathophysiology

  • Patient found to have an occult chronic IOFB with associated traumatic dense white cataract and retinal detachment–likely chronic in nature given the diffuse retinal thickening, chronically poor vision, and history of previous trauma six months prior
  • IOFB was likely self-sealing leaving behind a full thickness stromal scar pigmented by either blood or iris pigment with an associated transillumination defect just posterior to the scar delineating the path of the projectile
  • IOFB and retinal detachment likely caused anterior segment inflammatory reaction observed on slit lamp examination
  • This was confirmed with computed tomography imaging as the foreign body was not found on B-scan ultrasound likely given its small size, anterior location, and the limits of resolution of the standard B-scan ultrasound probe
  • Given the relative lack of vitritis and deep boring pain, foreign body was likely not causing any severe inflammatory/infectious reaction posteriorly. Additionally, per patient report, the composition of the foreign body was porcelain, a material known to be relatively inert (along with glass, rubber, coal, silver, silver, gold)

Treatment

  • For patient’s resolving chemical injury, aggressive lubrication was prescribed after adequate copious irrigation of the surface with normal saline had been performed.
  • Erythromycin ointment was added given the remaining unknown contaminants of the stucco solution
  • For patient’s inflammation, prednisolone acetate QID was prescribed for the left eye
  • After thorough discussion of the situation, surgery for IOFB removal was discussed and a joint decision was made to defer surgery for the time being

Prognosis and Future Directions

  • Data is currently equivocal on incidence of endophthalmitis based on time to IOFB removal
    • Outcomes can be largely variable depending on composition of IOFB (inert materials are less likely to cause inflammatory and oxidative injury compared to materials such as tin, iron, copper, and vegetable matter) and nature of injury (i.e. heat sterilized projectiles having less infectious burden than farm/wood injuries)
  • However, there are often other factors to consider when determining how urgently to take a patient to surgery for primary open globe closure +/- IOFB removal including hemodynamic stability of patient, presence of other life-threatening injuries, presence of active signs of infection in the eye, and availability of appropriate OR personnel and equipment
  • Certain factors have been shown to portend an overall worse prognosis including increased size and mass of IOFB, worse presenting visual acuity, the presence of a relative afferent pupillary defect (RAPD), hammering of metal on metal injury, vitreous hemorrhage, retinal detachment and hyphema
  • Other factors tend to produce better overall outcomes including older patient age, better presenting visual acuity, and normal lens at presentation
  • Prognosis of our patient was poor given that he was younger, already had an RAPD, retinal detachment, and worse presenting visual acuity

References

  • Rao NA, Tso MOM, Rosenthal AR. Chalcosis in the Human Eye: A Clinicopathologic Study. Arch Ophthalmol. 1976;94(8):1379–1384.
  • Bagheri, Nika and Brynn Wajda. The Wills Eye Manual: Office and Emergency Room Diagnosis and Treatment of Eye Disease. Philadelphia: Wolters Kluwer, 2017.
  • S. Yeh et. al. Current trends in the management of intraocular foreign bodies. Curr Opin in Ophthal, 2008,19:225-233.
  • Guevara-Villarreal DA, Rodríguez-Valdés PJ. Posterior Segment Intraocular Foreign Body: Extraction Surgical Techniques, Timing, and Indications for Vitrectomy. Journal of Ophthalmology. 2016.
  • Loporchio, D, Mukkamala, L, Gorukanti, K, et al. Intraocular foreign bodies: A review. Survey of Ophthalmology. 2016;61:582-596.

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Produced by: Monica Chavez, John Daniel, Mellissa Linton and Dr. Vivek Patel
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