Patricio Lorenzo Cruz Case Discussion 2

3A

Case 3

This is a 2 year old female who was brought in by her mother because of eye pain
over her right of 4 weeks duration. She noticed that her child keeps on crying most
of the time. There was no fever or loss of conciousness. No visual threat was elicited
over the right eye. Above is the clinical picture at the time of consult.

1. What is your differential diagnosis?
Differential diagnoses include:
Retinopathy of prematurity
Tuberculosis
Anterior uveitis of childhood
Vitreous hemorrhage
Congenital cataract
Exudative retinal detachment
Retinoblastoma

Additional information. There is no family history of eye disease. An orbital CT scan
was done and is shown below


2. What is your diagnosis?
Retinoblastoma is the most likely diagnosis for this patient, based on the
presentation of the child and the CT scan. The history does not lend much
clue into the disease, as most patients who develop retinoblastoma do not
have any positive history of retinoblastoma. The child exhibits leukocoria,
strabismus, and red eye, which are manifestations of retinoblastoma. The
swelling of the upper eyelids is similar to that seen in orbital cellulitis;
however, this does not necessarily indicate that there is already tumor
involvement of the orbit. On the CT scan, a hyperlucent mass can be seen on
the medial aspect of the right eye, which may be the growing mass.

3. Why is the eye red and painful?
The eye is red because of the presence of tortuous dilated blood vessels.
Blood vessel formation is induced by the presence of the tumor, thus giving
the eye the red appearance. The pain is due to the inflammation caused
extraocular extension of the tumor, with the growing retinoblastoma
invading the periocular tissues.

4. What are your plans in the management of this child?
The treatment for the child is photocoagulation and cryotherapy.
Photocoagulation is a possible option in treatment since the mass is still
small, and if the mass is located more posteriorly in the eye. However, there
is a risk in producing defects in the patients visual field post-treatment. If the
mass is located more anteriorly, cryotherapy can be used.

5. What are the histologic features of this disease?
Histologic exam shows apoptotic cells can be seen between viable cells, with
calcifications often present. These calcifications are usually visible in x-ray
films. These can help in diagnosing retinoblastoma.


Figure 1 Retinoblastoma micrograph.

Characteristic of retinoblastoma is the presence of Flexner-Wintersteiner
rosettes, which are composed of oval tumor cells surrounding a central
lumen, with the nuclei of the cells being peripherally displaced and the
cytoplasm occupying the apices (towards the lumen). The presence of these
rosettes signifies neuroectodermal differentiation.


Figure 2 Flexner-Wintersteiner rosette. The central lumen is surrounded by tumor cells. The nuclei of
the tumor cells (dark spots) can be seen in the periphery, while the apices of the cells remain largely
clear.
Case 4



This 20 year old male presented with pain on his right eye and forehead and
blurring of vision for 3 days.

1. What questions would you ask him?
It is important to ask the patient if he has had chicken pox already as a kid.
He should also be asked if he is currently taking any medications, specifically
if he is taking corticosteroids in his regimen, or if he is currently under
chemotherapy for cancer, as these medications will cause
immunosuppression. His sexual history should also be looked into, if there
are any signs of exposure to HIV.

Additional information: He reported presence of fever and malaise for the past few
days but no other symptoms. There was no previous episode of occurrence of the
said lesions and past ocular history of red eye or discomfort. The pain was
characterized as lancinating and burning on the forehead and around the eye with
eye pain and sensitivity to light.

2. What is the diagnosis?
The most likely diagnosis for this patient is Herpes Zoster Ophthalmicus.
Because the lesions are limited specifically to the right orbital region and
right forehead and the characteristic of the lesions as vesicular and
containing serous exudate, the disease is highly suspect. The region of the
lesion coincides with the distribution of the ophthalmic division of the
trigeminal nerve (CN V), and Herpes Zoster is characterized by the
appearance of rashes and blisters along a distribution of a nerve.

Figure 3 Distribution of the branches of the trigeminal nerve. The distribution of the vesicular lesions in
the patient coincides with the distribution of the ophthalmic branch of the trigeminal nerve.

3. What would a lesion at the tip of the nose mean?
The appearance of lesions at the tip of the nose is called the Hutchinson sign.
This indicates that the nasociliary branch of the trigeminal nerve. The
Herpes Zoster has thus already involved the eye, since the nasociliary branch
provides sensory innervation to the globe, and provides sympathetic
innervation to the dilator muscles of the pupil.

4. What anterior segment eye findings would you look for?
Anterior segment findings of Herpes Zoster Ophthalmicus include keratitis,
conjunctivitis, belpharitis, iridocyclitis, iritis, and anterior uveitis. There can
also be atrophy of the iris and secondary glaucoma.




5. How would you treat this patient?
The main treatment for this patient is acyclovir 800 mg orally five times a
day for seven to ten days. It is important that the patient be given the
acyclovir within the day to prevent the occurrence of postherpetic neuralgia.

To address the pain and edema caused by the lesions, 40-60 mg of
prednisolone can also be given. This must be tapered over the ten-day
course.