OOMC News

Authored by: Danielle Strauss, MD

CC: A 62 year-old man presented to me urgently with a sudden decrease in vision in his “good eye.” He described significant floaters in the right eye for 3 days. 

He had gone to a local ER where a CT head was performed which was normal. He was told to follow up with an ophthalmologist.

PMHX: none

Past ocular history: Ruptured globe injury to the left eye when he was 3 years-old. He was poked with a stick in the left eye. Patient reports poor vision since the injury. CE/IOL OS years ago.

BCVA cc: 20/60 OD, HM OS 

IOP: 10 OD, 12 OS

SLE:

OD: 3+ ns cataract

OS: peripheral corneal scar, traumatic iris loss, decentered IOL

DFE: see imaging below

Imaging:

Widefield color fundus photo of the right eye was hazy due to media (cataract). It showed a hemorrhagic pvd and inferior retinal demarcation line. A demarcation line is retinal hyper-pigmentation due to RPE hypertrophy. It is often seen surrounding chronic retinal detachments or tears.

Widefield photo of the left eye showed diffuse chorioretinal scarring which involved the macula.

SD-OCT of the macula in the right eye was flat but with hemorrhage in the vitreous

SD-OCT of the macula in the left eye showed diffuse thinning and atrophy

Fluorescein angiogram was performed to rule out any neovascular etiology for the vitreous hemorrhage, but it was unremarkable

Ultrasound of the right eye showed vitreous hemorrhage and was also concerning for possible inferior retinal detachment

Assessment and plan:

63 yo essentially monocular man 

1. Hemorrhagic pvd od with suspected chronic retinal detachment with inferior demarcation line. No new tears noted on the exam. 
2. Poor vision os following trauma with ruptured globe, status post repair. Diffuse secondary retinal scarring with limited vision.
3. 1. 1. Plan laser barricade posterior to the suspected retinal detachment OD now
      2. Follow up in 4 days to re-evaluate
      3. Head of bed elevated

Follow-up

The patient returned 4 days later. He did not have any complaints, and reported the floaters had improved. He denied a scotoma. 

Exam and color widefield photo of the right eye revealed the following:

Within days, the patient developed a macula-on supero-nasal retinal detachment due to a new supero-nasal tear. Given the patient is monocular, this was an especially urgent case. 

The patient also had a significant cataract in the right eye with combined nuclear and cortical changes which impeded the view to the retina. 

I called my colleague, Dr. Elana Rosenberg (Cataract/Glaucoma surgeon) and we arranged an emergent combined cataract extraction with IOL, pars plana vitrectomy/retinal detachment surgery. 

Dr. Rosenberg and I would work as a team in a 2 surgeon case to save this patient from blindness. 

That day, the patient had cataract extraction with IOL, pars plana vitrectomy, endolaser, silicone oil.

On post-operative day 1, the patient’s vision was 20/80 through the silicone oil, with the retina reattached. 

Widefield color photo showing reattached retina under silicone oil fill.

Now, several weeks post-op the continues to do well, with no evidence of redetachment or PVR (proliferative vitreoretinopathy) formation. I plan to remove the silicone oil from the eye in the next few months.

This case is a great example of how at OMNI/Phillips Eye, surgeons of various subspecialities are able to work together as a team to provide the best care for patients. Together, we can provide 360 degree complete care for patients with even the most complex ophthalmic problems.