Eyeworld

JUN 2014

EyeWorld is the official news magazine of the American Society of Cataract & Refractive Surgery.

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EW RESIDENTS 54 June 2014 considered equally as serious. A recent paper in Annals of Neurology highlights the potential seriousness of these symptoms." 2 "Essentially, a retinal TIA should be treated like a cerebral TIA, and patients should have neuro-imaging within 24 hours of onset (an MRI of the brain but with special attention to DWI images). They also need an MRA of the head and neck, which can be done concurrently with the MRI. If the DWI images show an infarct, the patient needs to be admitted to the stroke neurology service. Patients also need an EKG looking for arrhythmias and is- chemia. Echocardiogram (TEE is more sensitive then TTE) should also be performed, especially if a vascular cause has not been found." Dr. Mammen commented: "In this patient with positional monocular blurred vision and with- out knowledge about his hyphema, one might consider two broad diagnostic categories: cardiovascular and refractive etiologies. In regard to cardiovascular etiology, this patient denied symptoms such as lightheadedness, dizziness, headache, or nausea that might suggest cardiovascular compromise or orthostatic hypotension. In fact, his symptoms actually improve with standing. He has a history of atrial fibrillation, but his symptoms are in- consistent with an embolic event." "With regard to refractive etiolo- gies, given his history of a retinal detachment, shifting subretinal fluid is possible but unlikely, especially in light of his excellent vision when sitting/standing upright. A shifting IOL is certainly possible, especially if located in the sulcus. A malposi- tioned IOL causing a UGH syndrome could certainly explain the patient's hyphema and should be picked up using UBM, and especially if UBM is done with the patient in the kneel- ing position. It is interesting to note the localized peripheral anterior synechiae superiorly in the right eye. This could be secondary to the narrow angle and/or more likely the scleral tunnel. The iris atrophy supe- riorly suggests previous mechanical trauma during the cataract surgery or recent recurrent mechanical trauma, from an IOL haptic perhaps." Case outcome UBM demonstrated adhesion of the superior iris to the sclera (Figure 3). The remainder of the angle was open without apparent abnormality in IOL position. The patient was diagnosed with intermittent positional hyphema deemed to be caused by deep superior scleral sutures catching the iris with chafing and bleeding in the head-down position. The decision was made with the patient to remove the superior scleral sutures in the operating room. The sutures were removed uneventfully, and the patient's symptoms have not returned for nearly 4 years. EW References 1. Ahuja Y, Malihi M, Sit AJ. Delayed-onset symptomatic hyphema after ab interno tra- beculotomy surgery. American Journal of Oph- thalmology. Sep 2012;154(3):476–480 e472. 2. Helenius J, Arsava EM, Goldstein JN, et al. Concurrent acute brain infarcts in patients with monocular visual loss. Annals of Neurology. Aug 2012;72(2):286–293. Contact information Knickelbein: knickelbeinje@upmc.edu Waxman: waxmane@upmc.edu Not your garden-variety continued from page 53 ous or Berger's space (would suggest more strongly the UGH diagnosis)?" Dr. Mitchell commented: "From the neuro-ophthalmology perspec- tive, this patient with a cardiac history and a history of monocular transient blurred/decreased vision is highly suspicious for a TIA. Unfortunately, many in the medical community regard TIA as inconse- quential but a stroke as something serious; however, they should be CATz, our latest innovation in Laser Vision Correction, enables surgeons to treat myopic astigmatism with corneal irregularities. CONTACT NIDEK TO ELIMINATE YOUR USER FEES TODAY! 130%6$54t4&37*$&4t5&$)/0-0(*&4 1 0 5 9 7 N i d e k C at tz z T h i r rd 1 10597 Nidek Catz Third 1 3 8:43 AM /2 8:43 AM /2 8:43 AM 0 0/ 1 4 8:43 AM : 4 3/20/14 8:43 AM 4 43 AM AM 43 AM Figure 3. UBM demonstrated adhesion of the superior iris to the sclera. The remainder of the angle was open without apparent abnormality in IOL position. Source (all): UPMC Eye Center 51-54 Residents_EW June 2014-DL_Layout 1 6/3/14 12:39 PM Page 54

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