My Favorite Practice Altering Therapeutic Cases. Retinal Specialist Results. Case #1 History. Referred to LHEA (my office)

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1 My Favorite Practice Altering Therapeutic Cases Case #1 A complicated case made easy Case #1 History Patient referred from Dallas by brother in law Saw OD first with report of blurry vision OD occurring over several months Dx: : Early NS, possible macular degeration Best corrected vision OD.20/100, OS.20/25 Patient referred to Retinal Group for further evaluation Retinal Specialist Results OD Early NS, clear vitreous, flat disc, normal arterioles, blunted foveal reflex, normal periphery OS unremarkable Dx: : Decreased visual acuity, right eye, questionable macular pathology Fluorescein angiogram normal Retinal Specialist Recommendations Optical coherence tonography Results normal Neuroimaging. Results normal Refer to neuro-ophthalmology ophthalmology Unable to find cause of decreased acuity although confirmed macular blunted reflex Referred to LHEA (my office) Patient FG sits in chair I set phoropter in front of him as I plan to do full workup I look through phoropter with retinoscope I sit back and tell him I found his problem He looks perplexed as it took me 20 seconds to find his problem 1

2 Retinoscopy Not just for refractive error I personally can t t do a complete exam without retinoscopy I don t t usually use it for refractive error I use it to center pupils, measure pupil size (allowing consistent lighting for measurement), and to evaluate the red reflex Red reflex Very easy way to see NS, cortical spoking, psc, scissors reflex If the OD has a slightly dimmer reflex than the OS, I may not be as concerned if the best acuity is less in the OD Cataract support group: used ophthalmoscope to screen for cataracts I showed them how much better the retinoscope was for this Patient FG Oil drop cataract seen easily with retinoscope 2

3 Patient FG Referred to local retinal group for evaluation of macula as I saw no retinal problems Local retinal group found no retinal problems They also couldn t t find a cataract even with my coaching them over the phone, but they were using the slitlamp Patient FG I told him to try using a retinoscope He saw it immediately I referred FG to my co-managing cataract surgeon for cataract consultation/removal He called me to congratulate me for finding an oil drop cataract, and asked me how I found it Retinoscopy I told him.. Retinoscopy He told me that his past professor would not let him finish an exam without writing down the retinal reflex as seen by retinoscopy I have found posterior lenticonus among other diagnosis that were very tough to see with the slit lamp Patient FG Cataract surgery performed on FG s OD 20/20 a a patient for life Case # 2 A strange case of dyslexia?? Case # 2 History A 10 year old girl presents to the clinic for a vision examination She is 20/20 OD,OS,OU and has no apparent problems 6 months later she returns for a complaint of blurry vision occurring over the last two to three months 3

4 Case # 2 Patient SG Exam Refraction showed low amount of cylinder OD x /100 OS x /100 I find no obvious pathology I refer to Pediatric Ophthalmologist for further evaluation Pediatric Ophthalmologist Report Dyslexia.. No pathology seen Patient couldn t t see big difference with large lens changes and occasionally reversed letters Patient SG Pediatric Ophthalmologist Report Returns to my office for follow up Mother and I discuss case..don..don t t feel comfortable with diagnosis of dyslexia Refer to the other pediatric ophthalmologist in town for further evaluation Dx: : Dyslexia, possible malingering Patient SG Returns to clinic for follow up Best corrected vision 20/200 OD, OS, OU I tell mother I m m not leaving this room until I figure this out Although K s were normal they were a little steep 46/47 I decide to try an RGP on the OD to see if there is a corneal issue Patient SG With RGP on.20/20!! Mother and young girl can t t believe it Note: this was before the Eyesys came out Then mother drops a bombshell when she says you know, her twin sister has been complaining of poor vision lately 4

5 Patients SG and EG Sister (EG) is 20/100 OD, OS, OU with no improvement with an Rx Both are 20/20 with RGP wear SG wears RGP 14+ hours a day EG wears RGP 8+ hours a day They return in 2 months for a follow up Patient SG and EG After 2 months of wear I check their refraction SG is correctable to 20/20 OD, OS, OU with spectacles EG is correctable to 20/25 OD, OS, 20/20 OU with spectacles I see a pattern over time..if they D/C RGP s, their best corrected VA drops As long as they wear CL s s regularly they are correctable to 20/20 Family Ties Mother tells me her brother has 2 children in Pennsylvania that are dyslexic I write a letter for her to send to her brother explaining what may be a similar case Her brother shows the letter to his childrens MD The MD says that I am trying to sell contact lenses AARRGGGHHHH!!!! I write another letter saying that no matter what they may think of me or my profession they can certainly prove me wrong by trying an RGP on and overrefracting the children They do not respond to me and the brother reminds the mother that his doctor is an MD SG and EG Follow Up Care RGP s are worn for over 10 years SG comes in for follow up She says she lost her RGPs several months ago She is still correctable to 20/20 Hmmmm..She wants to know if she can wear SCL s I try it for several weeks Patient SG She remains correctable to 20/20 (over time she has become a 3D myope) Note: Topography never showed a problem because her corneas were molded before the eyesys was available Her sister is out of state (marriage) but returns for an eye exam while in town 5

6 Patient EG She has been out of RGP s for about 1 year Her best corrected vision with glasses is 20/30 OD 20/40 OS She wore the RGP lenses much less than her sister She also desired SCL s and was correctable to approximately the same vision as glasses Patterns.. I year after seeing the twins I see another patient with a diagnosis of dyslexia I am working with a multidisciplinary group, but am in a very small town The patient presents for a vision exam with broken glasses His mother says he will only see 20/40, as he is dyslexic Patient LB I ask how she knows he is dyslexic She becomes very hostile and tells me that he has seen Dr Whatever I m m sure you ve heard of him she reports the diagnosis of dyslexia was also given to him by his psychologist, another world famous doctor OK Let s s be sneaky 20/40..dyslexic..dyslexic.huh?.huh? I can t t help myself.after instilling fluorescein,, I put an RGP in his OD (note: I did this without K s..a BC) He easily corrects to 20/20 His mother can t t believe it I say he s s not dyslexic, he has irregular astigmatism Follow up I have reported these cases in lectures for years and have had many reports of similar cases I I got one The pattern seems to occur around 10 years of age The twins were the only cases that I ve I been able to follow for years, but I feel that their molding over that period of their life gave them a permanent reduction in irregular astigmatism Case # 3 Lasik gone awry 6

7 Case # 3 History During Lasik on the OS the microkeratome malfunctions from human error and the patient is left without most of his iris and lens, and has his cornea transversed Patient RW His remaining lens is removed through phacoemulsification and an implant is placed in the remaining bag His iris is purse-stringed stringed by running a suture through the remaining iris root and pulling, creating a daisy-shaped shaped pupil Patient RW What is his vision?... Drumroll.. 7

8 Patient RW Patient RW Treatment 20/25 OS uncorrected Is he OK??? NO..glare Take pictures of good eye as well as both eyes together Send pictures to lab for narcissus lens I used Adventures in Color Patient RW Lens Dispense Lens arrives Looks a little different in changing lighting conditions 8

9 Follow Up Care of RW Vision 20/20, with no complaint of glare Glare reduced by black backing Brown eyes much easier to fix Cosmetic Lenses Case # 4 With brown eyes, use WJ Freshlook with black backing..with or without open pupil Prices vary for this Post-op op RK corneal molding with RGP s 9

10 Post-Op RK Corneal Molding 36 y/o male, 2 weeks post-op op RK is hyperopic A molding RGP lens is worn for 2 ½ months on a daily wear basis which eliminated the overcorrection Patient TW OS 2 weeks post-op op x 85 OD -.25 sphere Pre-op OS cyclo: x 17 Pre-op OS K s: : / 77 If K is patient should be plano Experience shows a slight loss of molding benefits after RGP discontinuation, usually about 1.25 to 1.75 diopters Patient TW RGP ordered: BC: ( should temporarily give patient refraction) Power: Secondary curve: Diameter: Oz: 7.4 Patient TW Follow ups for 2+ months Cyclo hovered around -.50 After cl discontinuation. Plano refract (stayed over time) Review of Optometry ( 1/15/96) 10

11 Lesson Learned THE END Haven t t found a better way to fit them! May get some temporary ortho K (reverse) Most post-op op RK patients are hyperopic If myopic, fit flatter 11

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