Guest Post:
Age/Race/Gender: 57 Hispanic Male
CC: 57 yo male presents for f/u recurrent HSK OD.
HPI: 1 active presentation OD, 1 recurrence w/in 1 year OD. Patient denies redness, photophobia, or change in vision. NO flashes, floaters, or ocular pain. Complains of itching after instillation of glc meds.
POHx:
1. Recurrent HSV keratitis OD
2. h/o occludable angles OU, s/p LPI OU(revision OD 12/15/10, revision OS 7/17/10)
3. Cataracts OU, non-visually significant
4. glaucoma suspect OU
-Gonioscopy 7/2010:
OD: anterior TM inferiorly, narrow occludable
OS: pigmented TM inferiorly, mildly narrow
-HVF 24-2 OU 4/2010:
OD: unreliable, no real deficits seen
OS: unreliable, some small central defects noted
-RNFL 8/30/2010:
OD: superior and inferior thinning
OS: green 360, no thinning
Ocular Medications:
Brimonidine 1 gtt TID OU
trusopt 1 gtt BID OU, using qd OU
Prednisolone qd od
Acyclovir 400mg BID PO, taking 200mg BID
PMHx:
1. non-DM 07/13/2010 A1C GLYCOHEMOGLOBIN 5.70
Entering Visual Acuity cc
OD: +1.25 +0.75 x015 20/25-1
OS: +2.25 +0.75 x170 20/20
MRx:
OD: +1.75 +0.50 x005 20/25-1
OS: +2.00 +0.75 x170 20/20
pupils: 2.5 mmL, 3.5 mmD, round and equally reactive 1+, no APD OU
Ocular Tension - TAP
R 16
L 18
slit lamp:
lids: clear OU
conj: clear OU
cornea: OD: diffuse stromal haze c band forming temporally, no active inflammation or dendrite
OS: clear
A/C: deep and quiet OU
iris:
OD: LPI patent 9 o'clock
OS: LPI NOT patent at 3 o'clock
lens: 1+ NS OU
ant. vit: syneresis OU
DFE: 1 gtt 2.5% phenylephrine, 1 gtt 1.0% tropicamide OU; AUG 01, 2011 12:50
vitreous: syneresis OU
C/D:
OD: 0.55/035
OS: 0.4/0.4
nerve: pink, distinct margins OU
macula: clear, flat OU
vessels: healthy, 2/3 OU
periphery: no breaks, holes, tears 360 OU
*photos below of previously active lesion*
Impression/Plan:
ReplyDelete1. Recurrent HSV keratitis OD
- continue Acyclovir 200 BID po, PF qd OD
- rtc 6 mos or sooner if decrease in vision or increase redness/photophobia
2. h/o occludable angles OU, s/p LPI OU c revisions OU
- LPI OS not patent
- IOP today: 16/18 (last 14/14)
- continue with glc clinic 6 mos for VF; 1 yr for DFE, OCT, photos
3. Cataracts OU: NVS currently, observe
f/u 6 mos cornea/uveitis, 6 mos glaucoma
Per glaucoma specialist chart same day: no change in ONH appearance or VF. RTC 1-2 weeks for revision LPI OS. No apparent steroid response OD.
OU cornea/uveitis specialist prefers oral acyclovir and trifluridine ung (vs gtts due to toxicity) for active epithelial keratitis.
Most will resolve without recurrence.
For actively recurring/chronic stromal disease, keep on low maintenance dose of acyclovir po until quiet, then f/u every 6 mos.
Have had good success with RoseK2IC (irregular cornea) GP for post-herpetic corneas.