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Case Presentation

Case Presentation

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Published by Kshitij Shukul

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Published by: Kshitij Shukul on Aug 15, 2011
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MODERATOR: DR ZIYA SIDDIQUI PRESENTER: DR KSHITIJ SHUKUL 11/8/2011

PATIENT DETAILS
y NAME: ANWAR AHMED y AGE/SEX: 60ys/M y R/O TURKMAN GATE,ALIGARH

COMPLAINTS
y DIMINUTION OF VISION(LE) SINCE 4 MONTHS y FLOATERS(LE) 4 MONTHS BACK y PAIN, REDNESS(LE) SINCE 7 DAYS

History of Present Illness
y According to the pt.

Apparently well 4 months back c/o sudden onset, painless, progressive DOV(LE) near & distance assoc with floaters(LE) progressed,but floaters resolved partially over time not assoc with Redness,watering --flashes of light, --distortion of shape/size --coloured haloes,glare -- curtain like effect

severe painful diminution of vision(LE) --progressive. coloured haloes --Only a little bit relieved with oral pain killers --Continued next 3 days . photophobia. watering.Assoc with headache.History of Present Illness(contd. in afternoon --Developed sudden onset..) y Six days back. dim light conditions -. for distance and near --More during evening.

weakness.Hospital.) y Consulted doctors at M. episodes of unconsciousness ..Aligarh y Prescribed Prednisolone acetate and Ofloxacin y y y y comination eye drops × Qid Also took Tab.History of Present Illness(contd.S. Prednisolone 20mg × od over the counter from a chemist Got relief But complaints reappeared after 1 day He left medications the same day as some reddish rashes appeared all over his body and face not assoc with any breathlesness. vertigo.

PAST HISTORY y No similar episodes in past y Gradual onset . painless .HTN.progressive diminution in RE for past 10 years y For which operated upon 8 months back y No history suggestive of DM. hospitalization .Systemic illness y No history of any long term medication.

Diminution of vision(LE) y Evaluated . Prescribed: --Inj. admitted.Redness. watering.Treatment History y Underwent Cataract surgery in RE 8 months back at Tibbya College without any Lens implantation y Prescibed Glasses after surgery y Presented JNMCH OPD on 8/8/2011 with C/O pain.Mannitol 20% 300ml IVI over 25 min --Tab Acetazolamide 250mg qid PO --Syp Potklor 1 tsp tid PO --Tim e/d BD LE .

REGULAR y ADDICTION NIL y APETITE .REDUCED y BOWEL/BLADDER.PERSONAL HISTORY y SLEEP.REDUCED .

FAMILY HISTORY y N o h/o similar episodes in other family members y No h/o suggestive of DM/HTN/Chronic illnesses .

20/min y afebrile .R.VITALS y PULSE 88/min y B. 130/90 mm Hg y R.P.

Systemic Examination y CNS y CVS y RESP y ABD WNL .

superiorly 3mm from sup limbus. well covered by conjunctiva .0 DC 180 HM PR ++ + + .-+ MILD DIFFUSE SWELLING OF BOTH UPPER AND LOWER EYELID SEVERE CILLIARY CONGESTION WITH MARKEDLY DIFFUSE SUPERFICIAL CONGESTION ± EYELIDS NORMAL CONJUNCTIVA NORMAL --surgical scar healthy.0 DS +3.OCUL R EX MI RIGHT EYE UCVA 6/60 TION LEFT EYE HM BCVA 6/12 with +10.

.

OCULAR E AMINATION RIGHT EYE Cornea --Central Clear --Scar +nt sup temp quad near 2mm from limbus AC -.Deep --Quiet Iris --PI at 10 o & 1 o Clock --Patches of iris atrophy near pupillary border and other multiple places in middle part .

Jet black colour --normal size --normal reaction to light -.No RAPD --Tremulousness of pupillary border Lens --APHAKIA DT --NORMAL .OCULAR E AMINATION RIGHT EYE Pupil -.

4mm from inf limbus AC --Normal depth --Quiet Iris --Pattern normal --Thin vessels seen all around the pupillary border and also criss crossing on the iris surface at multiple meridians (NVI) .neb cor opacity at 5 o clock.OCULAR EXAMINATION LEFT EYE Cornea diffusely hazy due to mild to moderate epithelial and stromal edema --3×3mm.oval.

LEFT EYE PUPIL --VERTICALLY OVAL --MID DILATED --NON REACTING TO LIGHT --No RAPD LENS --NS GR 2 --PSC GR 2 DT --MARKEDLY HIGH .

6 mmHg y IOP(APPLANATION): RE 14 mmHg (9/8/11) LE 42 mmHg .7 mmHg LE 50.y IOP(SCHIOTZ)(8/8/11): RE 12.

FUNDUS(INDIRECT OPHTHAL.4 NRR WNL BLOOD VESSELS AT DISC WNL BLOOD VESSELS WNL MACULA HEALTHY FR +NT .) y RIGHT EYE C/D : 0.

FUNDUS(INDIRECT OPHTHAL.)(LE) .

.

GONIOSCOPY y RIGHT EYE CBB SS TM SS y LEFT EYE New vessels TM New Vessels SL CBB New vessels New vessels SS .

.

.

INVESTIGATIONS y B.SUGAR(FASTING & PP) y RFT y LIPID PROFILE y HAEMOGRAM WITH GBP y ECHO y ECG y COLOR DOPPLER OF OPHTHALMIC ARTERY .

PROVISIONAL CLINICAL DIAGNOSIS y APHAKIA(RE) with PI (RE) with OLD CRVO(LE) with NEOVASCULAR GLAUCOMA(LE) with IMSC(LE) .

DIFFERENTIAL DIAGNOSIS y CRVO with Neovascular Glaucoma y PDR with NVI y UVEITIC GLAUCOMA y CHRONIC ANGLE CLOSURE GLAUCOMA y FUCH S HETEROCHROMIC IRIDOCYCLITIS y ICE SYNDROME .

.

Steroids --Atropine .TREATMENT Control IOP --Aqueous suppressants --Avoid miotics & prostaglandines -.

then we are left with an uncomplicated angleclosure problem which should be amenable to classical drainage surgery.´If the neovascular element can be removed and further neovascularisation prevented.µ Flanagan D.W. & Blach R.526-8 .67.K. Br J. Ophtamol 1983.

Pan retinal photocoagulation .

g. y IVB may be administered in conjunction with PRP in an attempt to achieve rapid regression of neovascularization thereby preventing permanent angle synechiae and more quickly achieving pressure control . media opacities) ‡ In cases of severe pressure elevation despite maximal medical therapy.y Intravitreal bevacizumab is useful ‡ Patients unable to undergo PRP ‡ bridge therapy until PRP can be performed (e..

03) and there was a significantly higher rate and speed of neovascular regression in the combination group than in the PRP-only group (100% in 12 days vs 17% in 127 days). Set al Retina. The combination group had a significant reduction in IOP compared with the PRP-only group (²11 vs 0 mm Hg. Ehlers JP. p = 0. Spirn MJ.28(5):696²702 . 2008. Lam A. consecutive case-control study compared 11 patients receiving same-day combination therapy with IVB and PRP versus 12 patients who received PRP alone as treatment of NVG. Combination intravitreal bevacizumab/panretinal photocoagulation versus panretinal photocoagulation alone in the treatment of neovascular glaucoma.INTRAVITREAL AVASTIN y Retrospective.

SURGERY Pre operative preparation y Adequate PRP to reduce vaso-proliferative stimulus/ Avastin y Atropine and steroids are indicated to decrease inflammation y anti-glaucoma medication to decrease IOP y Wait approximately 3-4 weeks to allow the eye to quiet down .

TRABECULECTOMY y Site away from NVA y Success 67 100% in 3 studies y Mitomycin > 5 FU y Mitomycin(200 micro /3min) y Diode Laser application to the trab bed .

Intravitreal bevacizumab (avastin) injection for neovascular glaucoma. 2007. Pakravan M.16(5):437 439 .Filtering surgery Adjunctive IVB at the time of trabeculectomy and valve implant surgery for neovascular glaucoma has been reported. All surgeries were reported to be successful without adverse events. Yazdani S. J Glaucoma. Hendi K.

more complication like hypotony and blocked tube y Molteno y AGV y Valved implants better than non valved .AQUEOUS DRAINAGE DEVICES y Next modality when trab fails y In nvg can be done as primary procedure also y Complication same as trab .

CYCL DES 1. Direct to ciliary processes Transpupillary cyclophoto coagulation Endo cyclophoto coagulation . Cyclo cryo therapy CTI E ROCED RES 2. Trans-scleral Contact diode laser Non contact Yag laser B.Cyclo-photocoagulation A.

NEWER MODALITIES y PHOTODYNAMIC THERAPY WITH NANOPARTICLE SENSITIZATION .

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