CASE OF THE MONTH

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Patient Profile
AGE

18 years old

Gender

Male

Last
Eye Exam

Two months ago

Current
Rx

Not provided

Medical
History

Personal ocular history was unremarkable.

Chief
Complaint

Broken glasses

Uncorrected
Visual Distance

20/25 in each eye

EXAM PROTOCOL

His refraction resulted in best-corrected visual acuities of 20/25 in each eye. Fundus photography revealed unremarkable findings OD and superior vessel engorgement with hemorrhaging OS. It was suspected to be a branch retinal vein occlusion.

CONCLUSION

The patients exam was halted, and he was immediately referred for further evaluation by a retinal specialist.

PHOTOS

Blood Vessel Engorgement and Hemorrhage (Suspected Branch retinal vein occlusion)

EXAM EQUIPMENT
  • Topcon NW 400 Non-Mydriatic Retinal Camera
  • Oculus Easyfield C
  • Marco Ion Anterior Segment Slit Lamp Camera
  • Topcon SL-D2 Slit Lamp
  • 2020Now Eyelogic X2 Refraction System
  • Canon Tx-20 Auto tonometer
  • Topcon KR-1 Auto Tonometer and AutoKeratometer.
Patient Profile
AGE

62 years old

Gender

Female

Last
Eye Exam

Two years ago

Current
Rx

Not provided

Medical
History

Hypertension controlled by atenolol

Chief
Complaint

Would like a check up for an updated Rx

Uncorrected
Visual Distance

Not provided

EXAM PROTOCOL

Refraction revealed similar Rx to entering Rx, with hyperopia and presbyopia OU and astigmatism OD. BCVA was 20/20 OD, OS. Ocular examination revealed extensive hemorrhaging, exudates, and cotton wool spots in the superior arcades of the right eye consistent with a branch retinal vein occlusion. An inferior visual field defect was consistent with the retinal findings OD. Pingueculae were present OU as well as moderate nuclear sclerosis OU.

CONCLUSION

Due to extensive branch retinal vein occlusion in the right eye with associated visual field defect, the patient was urgently referred to an ophthalmologist for treatment.

PHOTOS

Branch retinal vein occlusion OD

EXAM EQUIPMENT
  • Topcon NW 400 Non-Mydriatic Retinal Camera
  • Oculus Easyfield C
  • Marco Ion Anterior Segment Slit Lamp Camera
  • Topcon SL-D2 Slit Lamp
  • 2020Now Eyelogic X2 Refraction System
  • Canon Tx-20 Auto tonometer
  • Topcon KR-1 Auto Tonometer and AutoKeratometer.
Patient Profile
AGE

46 years old

Gender

Female

Last
Eye Exam

Five months ago

Current
Rx

Not provided

Medical
History

Significant for thyroid disease and sleep apnea

Chief
Complaint

Not provided

Uncorrected
Visual Distance

Not provided

EXAM PROTOCOL

Best-corrected visual acuities were 20/20 in each eye. Fundus photography revealed unremarkable findings OD and a dense, hyper pigmented, round lesion located superior temporal to the macula. It was approximately 3/4-disc diameter in size with overlying orange pigment and possible sub retinal fluid.

CONCLUSION

The patient was immediately referred to a retinal specialist for suspected choroidal melanoma.

PHOTOS

Suspected Choroidal Melanoma

EXAM EQUIPMENT
  • Topcon NW 400 Non-Mydriatic Retinal Camera
  • Oculus Easyfield C
  • Marco Ion Anterior Segment Slit Lamp Camera
  • Topcon SL-D2 Slit Lamp
  • 2020Now Eyelogic X2 Refraction System
  • Canon Tx-20 Auto tonometer
  • Topcon KR-1 Auto Tonometer and AutoKeratometer.
Patient Profile
AGE

57 years old

Gender

Female

Last
Eye Exam

Not provided

Current
Rx

20/25 OD and 20/40 OS

Medical
History

Dry, irritated eyes and headaches

Chief
Complaint

20/25 OD and 20/40 OS

Uncorrected
Visual Distance

20/25 OD and 20/40 OS

EXAM PROTOCOL

Best-corrected visual acuities were 20/25 OD and 20/40 OS. Fundus photography revealed some scattered drusen OD and a flame hemorrhage with white center (Roth Spot) in the inferior arcades OS.

CONCLUSION

The exam was halted and the patient was immediately referred for further evaluation and comprehensive dilated examination by an ophthalmologist.

PHOTOS

Roth Spot, Flame Hemorrhage

EXAM EQUIPMENT
  • Topcon NW 400 Non-Mydriatic Retinal Camera
  • Oculus Easyfield C
  • Marco Ion Anterior Segment Slit Lamp Camera
  • Topcon SL-D2 Slit Lamp
  • 2020Now Eyelogic X2 Refraction System
  • Canon Tx-20 Auto tonometer
  • Topcon KR-1 Auto Tonometer and AutoKeratometer.
Patient Profile
AGE

33 years old

Gender

Female

Last
Eye Exam

One year ago

Current
Rx

20/40 OD

Medical
History

Unremarkable

Chief
Complaint

Blurry vision distance

Uncorrected
Visual Distance

Diagnosis: Keratoconus suspect OU Findings: OD: Significant distortion of corneal mires on auto- keratometry OS: Significant distortion of corneal mires on auto-keratometry. - 20/40 OD

EXAM PROTOCOL

Comprehensive exam

CONCLUSION

Patient in for routine eye exam and update of spectacles and did not report any history of ocular disease. We were able to determine corneal abnormalities and refer the patient for comprehensive evaluation and treatment.

PHOTOS

AutoKeratometry- Distorted Corneal Mires (Placido Rings)

EXAM EQUIPMENT
  • Topcon NW 400 Non-Mydriatic Retinal Camera
Patient Profile
AGE

53 years old

Gender

Female

Last
Eye Exam

Two years ago

Current
Rx

OD 20/30+1 OS 20/30

Medical
History

Unremarkable

Chief
Complaint

Blurry vision distance

Uncorrected
Visual Distance

20/20 OU

EXAM PROTOCOL

Comprehensive exam

CONCLUSION

Patient in for routine eye exam and update of spectacles and did not report any history of ocular or systemic disease. In our screening we discovered a retinal hemorrhage in the right eye and referred the patient for further evaluation and treatment.

PHOTOS

Hemorrhage between macula and ONH with associated ischemic blood vessel.

EXAM EQUIPMENT
  • Topcon NW 400 Non-Mydriatic Retinal Camera
  • Oculus Easyfield C
  • Marco Ion Anterior Segment Slit Lamp Camera
  • Topcon SL-D2 Slit Lamp
  • 2020Now Eyelogic X2 Refraction System
  • Canon Tx-20 Auto tonometer
  • Topcon KR-1 Auto Tonometer and AutoKeratometer.
Patient Profile
AGE

11

Gender

Male

Last
Eye Exam

2 years ago

Current
Rx

OU 20/20

Medical
History

Unremarkable

Chief
Complaint

Blurry vision, mild discomfort around the eye and occasional sensitivity upon touch

Uncorrected
Visual Distance

OD Count fingers, OS Count fingers

EXAM PROTOCOL

Clinical evaluation through ocular telemedicine revealed borderline elevated IOP. Further testing including non-dialated fundus images revealed OU Papilledema with a hemorrhage in OS

Conclusion

The patient was immediately admitted into the hospital and scheduled for surgery to resolve the condition.

PHOTOS

Papilledema – OD Papilledema – OS

EXAM EQUIPMENT
  • Topcon NW 400 Non-Mydriatic Retinal Camera
  • Oculus Easyfield C Visual Field
  • Marco ION Anterior Segment Slit Lamp Camera
  • Topcon SL-D2 Slit Lamp
  • 2020Now Eyelogic X2 Refraction System
  • Canon TX-20 NCT
  • Topcon KR-1 Auto Refractor/Keratometer
Patient Profile
AGE

54 year old

Gender

Female

Last
Eye Exam

2 years ago

Current
Rx

OU 20/20

Medical
History

Unremarkable

Chief
Complaint

Routine Eye Exam For Failed DMV Exam

Uncorrected
Visual Distance

N/A

EXAM PROTOCOL

Clinical examination, slit lamp images showed that the OU anterior chamber was quiet and deep, nasal and temporal angles were 1-2 and iris was flat with clear lens. Her IOP OD was 17mmHg and OS was 21mmHg at 6:30pm. OD visual field analysis showed inferior nasal defect while OS was normal. The defects in the OD visual field were repeatable on subsequent tests. The optic nerve analysis reported OD 0.85 C/D ratio with superior thinning and RNFL wedge defect at 11:00, while OS had 0.75 C/D ratio with possible inferior thinning and notching. As the diurnal curve of IOP for a patient could be very different at a different time of day, as a final impression patient was diagnosed as a glaucoma suspect, with a higher potential of Normal Tension Glaucoma (OD >> OS). The RNFL wedge defect OD was consistent with the visual field defect in OD. Large cupping was observed in both optic nerves with rim thinning. The OS notch and rim thinning may result in damage to the visual field OS if left untreated.

Conclusion

The final diagnosis was explained to the patient and she was referred to a glaucoma specialist for evaluation and treatment to prevent further damage. Currently, more than 3 million Americans are diagnosed with glaucoma. The overall glaucoma national rate is estimated to be 1.9% for the U.S. population with age 40 and higher. Majority of them are diagnosed after about 40% of irreversible peripheral visual loss. With an expected surge in the prevalence of glaucoma to be 4 million by 2030 in the USA, early glaucoma screening and diagnosing plays a crucial role to provide treatment in a timely manner. Comprehensive exams via telemedicine helps to improve access for medically underserved and high-risk patients. Providing cost effective screening, referring and educating patients regarding the risk of glaucoma and need for regular follow-up also contributes towards patient awareness.

PHOTOS

OD Retinal images with optic nerve cupping and RNFL Wedge defect – Images 1 & 2

Markup of the wedge defect corresponding to the visual field defect – Images 3 & 4

OS Retinal images with optic nerve cupping and possible inferior  notching – Images 5 & 6

 

 

 

EXAM EQUIPMENT
  • Topcon NW400 Non Myd Camera
  • Medview FireFly Slit Lamp & Capture System
  • 2020NOW Eyelogic X2 Refraction System
  • I-Care Tonometer
  • Topcon KR-1 Auto Tonometer and Auto Keratometer
Patient Profile
AGE

58 year old

Gender

Female

Last
Eye Exam

2 years ago

Current
Rx

OD +1.75/-0.75*129 20/25
OS +1.50 20/25
Add +2.50

Medical
History

No Medical or Ocular History

Chief
Complaint

Blurred Vision

Uncorrected
Visual Distance

OD 20/80
OS 20/50

EXAM PROTOCOL

This is a case presentation of a 58-year-old female diagnosed with anatomical “Narrow Angles” and a potential risk of angle-closure glaucoma during a comprehensive telemedicine eye exam. Glaucoma is a group of disease that can damage the optic nerve resulting in irreversible vision loss. This irreversible damage can be managed or better prevented if diagnosed and treated in a timely manner. While open-angle glaucoma is known to progress gradually with subtle or sometimes no initial symptoms, angle-closure glaucoma on the contrary is known to be a true eye care emergency causing acute rise in the intra-ocular pressures leading to complete loss of vision. This acute attack of angle-closure glaucoma can be avoided if diagnosed and treated using preventive measures. The following case study highlights how a comprehensive eye exam performed via telemedicine, detected and provided referral in a timely manner to execute preventive measures.
58-year-old female with no medical or ocular history presented for a routine eye exam. Patient denied history of any ocular or systemic abnormalities, surgeries, pain or trauma. Her glasses were 2 years old and she faced difficulties in her vision for distance and reading with them. The patient was hyperopic with best-corrected visual acuities of OU 20/20 for distance and near. On further clinical examination, digital slit lamp images showed - OU anterior chamber, cornea, iris and lens were within the normal limits but both her nasal and temporal angles OU were Grade 1. Non-contact intraocular pressure results were 16/17mmHg OD and 15/11mmHg OS. Patient’s visual field test and fundus images were within the normal limits. Patient was referred to an eye care professional for further dilated evaluation due to narrow angles and for possible preventative treatment. Patient was additionally educated regarding the signs of angle closure glaucoma and was advised to seek immediate medical care ASAP if they occur.

CONCLUSION

Though angle-closure glaucoma is not as common as open-angle glaucoma, it does present more severe symptoms and can cause rapid loss of vision. There are two forms of angle-closure glaucoma, acute and chronic.  Acute angle-closure glaucoma occurs when there is a sudden block in the normal flow of aqueous humor between the iris and the lens. It may include severe symptoms like pain, vomiting, blurred vision, nausea, and a rainbow halo appearing around lights. It is a medical emergency that must be treated immediately, or it can result in blindness within one or two days. While chronic angle-closure glaucoma progresses gradually and can cause damage without severe symptoms, like open-angle glaucoma. As early detection and preventative treatments are very crucial in any glaucoma cases. Access to care via ocular telemedicine plays a significant role in reaching those potential patients that would not routinely have comprehensive eye exams. It not only serves as a bridge between in-person doctors and patients, but it also contributes in patient education and awareness.

PHOTOS

OD Narrow Angles – Image 1
OS Narrow Angles – Images 2 & 3

EXAM EQUIPMENT
  • Topcon NW400 Non Myd Camera
  • Mediview FireFly Digital Slit Lamp & Capture System
  • 2020NOW Eyelogic X2 Refraction System
  • I-Care Tonometer
  • Topcon KR-1 Auto Tonometer and Auto Keratometer
Patient Profile
Age

51 year old

Gender

Female

Last
Eye Exam

3 years ago

Current
Rx

OD -1.00/-1.25*101 20/20
OS -1.00/-1.00 *91 20/20
Add +2.00 20/20

Medical
History

HTN and elevated cholesterol for 2 months. Patient on medication for the same.

Chief
Complaint

Blurry vision at all distances as her current glasses are damaged

Uncorrected
Visual Distance

The patient was hyperopic with best-corrected visual acuities of OU 20/20 for distance and near.

EXAM PROTOCOL

The refraction performed revealed Myopia, Astigmatism, and Presbyopia OU with best corrected visual acuity of 20/20 OD and 20/20 OS. Upon ocular examination, various hemorrhages were found in the inferior retina of left eye while the right eye retina was within the normal limits. No abnormal changes were observed in the anterior segment. Visual field testing were within the normal limits.  The patient’s intraocular pressures were slightly elevated at approximately 21/22 OU at 4:50pm.

CONCLUSION

Due to uncontrolled systemic hypertension, high cholesterol levels and inferior retinal vein occlusion in the left eye, the patient was referred for an urgent comprehensive dilated evaluation by a retinal 
ophthalmologist.  The patient was able to visit a retinal MD and is currently being treated for the retinal vein occlusion.

PHOTOS

OD

OD

OS Inferior Retinal Vein Occlusion

OS Inferior Retinal Vein Occlusion

EXAM EQUIPMENT
  • Topcon NW 400 Non-Mydriatic Retinal Camera
  • Oculus Easyfield C
  • Marco Ion Anterior Segment Slit Lamp Camera
  • Topcon SL-D2 Slit Lamp
  • 2020Now Eyelogic X2 Refraction System
  • Canon Tx-20 Autotonometer
  • Topcon KR-1 Autotonometer and AutoKeratometer
Patient Profile
Age

61 year old

Gender

Male

Last
Eye Exam

2018

Current
Rx

OD +0.75 -0.75 x 100 +2.25
OS +0.75 -1.25 x 075 +2.25"

Medical
History

Hypertension, Hypercholesteremia

Chief
Complaint

Lost Glasses

Uncorrected
Visual Distance

OD 20/40
OS 20/50

Exam Protocol

Initially upon intake, the patient reported dry, itching, burning eyes and no other symptoms. During the review, he reported seeing a dark spot most of the time in his superior vision (eye unknown). He had mentioned it to a relative who is a paramedic, who rated it of low concern; therefore, he’s ignored it since. He was correctable to 20/20 OD, OS, and OU with minor hyperopic, astigmatic, and presbyopic correction. His extraocular muscles, confrontations, color vision, and stereopsis testing was all within normal limits. Anterior segment evaluation performed with Eyefficient Firefly S390L revealed scalloped lid margins OU, aligning with his symptoms on intake. Also, he was noted to have early 1+ NS cataracts OU. All other anterior segment findings were determined to be within normal limits. IOP is usually determined by NCT, but was deferred during this examination due to COVID-19 guidelines. The patient performed a visual field test on the OCULUS Easyfield C. His right eye was significant for high false positives; however, there is a notable superior defect, aligning with the dark spot in his vision. The visual field in his left eye was also unreliable, but overall unremarkable. His posterior segment was examined with a photo from Centervue DRS. His nerves were pink and healthy with a 0.25 cup-to-disc ratio in both eyes. His right eye was significant for a 1.5DD CHRPE in the superior temporal arcade. There was also an area from 4:30 to 8:00 of retinal whitening, indicating poor perfusion.

Conclusion

The patient’s symptoms, visual field, and posterior pole all aligned suggesting a problem. The patient was diagnosed with a branch retinal artery occlusion of the right eye. He was referred out to an OMD for confirmation and evaluation of possible treatment options. He was also referred to his PCP for a stroke evaluation and work-up. No follow-up has been received.

PHOTOS

Exam Equipment
  • Centervue DRS
  • Oculus Easyfield C
  • Eyefficient Firefly S390L
  • 2020Now Eyelogic X2 Refraction System
  • Topcon CV.5000Phoropter
  • Visionix VX120
Patient Profile
AGE

84 year old

Gender

Male

Last
Eye Exam

January 2020

Current
Rx

OD: plano-0.75 x 065 +2.50
OS: -0.75-1.00 x 070 +2.50

Medical
History

Brain Cancer 2014
Lasik Vision Correction 2000
Cataracts Removed in Both Eyes

Chief
Complaint

Unhappy with near vision

Uncorrected
Visual Distance

OD 20/40
OS 20/50

EXAM PROTOCOL

While reviewing the refraction, we discussed the benefits of contrast in relationship to both near vision and golfing. Specifically, we discussed the benefits of good lighting when reading paper and high contrast when working on screens. With golfing, a bright neon golf ball would improve contrast making it easier to follow. Regarding his ocular health, chair side testing revealed testing within normal limits for his extraocular muscles, confrontations, and color vision. Stereopsis testing was slightly reduced, which aligns with the reduced visual acuity. Anterior segment evaluation performed with Eyefficient Firefly S390L digital slit lamp. The visual fields were performed OCULUS Easyfield C. His visual field was significant for a right congruous homonymous hemianopia. Although the reliability of his visual fields is questionable, a repeat was not warranted due to age, poor mobility, and poor acuity. Furthermore, the findings aligned with a history of brain surgery. The anterior ocular evaluation on the Eyefficient Firefly S390L digital slit lamp was significant for dermatochalasis OU and IOL placement OU. Otherwise, all other anterior segments were unremarkable and within normal limits. IOP by NCT was deferred at the time of examination secondary to COVID-19. Posterior segment photos were attempted, but due to poor patient compliance interpretation was limited. While educating the patient on today’s examination findings, he was aware of his visual field defect from everyday experiences; however, it was unclear if it was ever made a formal clinical finding or diagnosis. A further ocular health examination was also recommended to account for his overall reduced visual acuity and ensure good posterior segment health. During that evaluation, the right homonymous hemianopsia should also be confirmed with a Humphrey 24-2.

CONCLUSION

The patient was diagnosed with a right homonymous defect. There were no other afferent findings, which makes sense because the lesion would be behind the Lateral Geniculate Nucleus. Due to its high congruity, it most likely is in the region of the optic tract. The second most likely area would be the left occipital lobe both above and below the calcarine fissure. This information is imperative to pass on to his neurologist, because if this does not match with his medical and surgical history, then it would be warranted to resume a narrowed search for the recurrence of his brain cancer. The appropriate paperwork was provided to the patient, but no follow-up has been received.

PHOTOS

EXAM EQUIPMENT
  • Centervue DRS
  • Oculus Easyfield C
  • Eyefficient Firefly S390L
  • 2020Now Eyelogic X2 Refraction System
  • Topcon CV.5000Phoropter
  • Visionix VX120