Grand Rounds Scleromalacia Amir R. Hajrasouliha, M.D. University of Louisville Department of Ophthalmology and Visual Sciences Friday, January 17, 2014.

Slides:



Advertisements
Similar presentations
Grand Rounds Peripheral Exudative Hemorrhagic Chorioretinopathy
Advertisements

Ocular Pathology Case Presentation Jeffrey Healey, M.D. Leela Raju, M.D. March 2011.
Scleral Disease China Medical University NO.4 Affiliated hospital Ophthalmology; Ophthalmology hospital of China Medical University.
Grand Rounds Brooke LW Nesmith, M.D., J.D.
Grand Rounds Amir R. Hajrasouliha, M.D. University of Louisville Department of Ophthalmology and Visual Sciences Friday, August 15th, 2014.
Grand Rounds Best Disease Mark Sherman MD University of Louisville Department of Ophthalmology and Visual Sciences 04/04/2014.
Grand Rounds Ethambutol Toxicity Mark Sherman MD University of Louisville Department of Ophthalmology and Visual Sciences 11/21/2014.
Clinical Rounds Taylor Strange, D.O. University of Louisville School of Medicine Department of Ophthalmology and Visual Sciences Friday, June 6th 2014.
Treatment of Arthritis.  Arthritis is a form of joint disorder that involves inflammation of one or more joints. inflammation  There are over 100 different.
Grand Rounds Brooke LW Nesmith, M.D. University of Louisville School of Medicine Department of Ophthalmology & Visual Sciences 1/16/2015.
WEGENER’S GRANULOMATOSIS
Immunoglobulin A Nephropathy as a Systemic Underlying Cause of Bilateral Anterior Scleritis Aruoriwo Oboh-Weilke, MD Florian A. Weilke, MD InnovisHealthFargo,ND.
NYU Medical Grand Rounds Clinical Vignette Monalyn R. Labitigan, M.D. PGY-3 November 17, 2010 U NITED S TATES D EPARTMENT OF V ETERANS A FFAIRS.
Grand Rounds Conference Eric Downing MD University of Louisville Department of Ophthalmology and Visual Sciences.
The Child With Joint Pain Diagnostic Clues Abraham Gedalia, M.D. Professor of Pediatrics Head, Division of Rheumatology Departments of Pediatrics, Louisiana.
Painless Necrotizing Scleritis with Inflammation in Wegener’s Granulomatosis Divya Mutyala, M.D. Robert S. Feder, M.D. Feinberg School of Medicine Northwestern.
Grand Rounds Nanophthalmos Mark Sherman MD University of Louisville Department of Ophthalmology and Visual Sciences 2/20/2015.
Non-Infective Inflammatory disease Dr. Mohammad Shehadeh
Case #13 Ellen Marie de los Reyes March 15, 2007.
Grand Rounds Vitamin A Deficiency Amir R. Hajrasouliha, M.D. University of Louisville Department of Ophthalmology and Visual Sciences Friday, March 7th,
NYU Medical Grand Rounds Clinical Vignette Joseph Shin, MD Tuesday, April 3, 2012 U NITED S TATES D EPARTMENT OF V ETERANS A FFAIRS.
Josephine-Liezl Cueto, M.D.* Kendall R. Dobbins, M.D.* Geisinger Medical Center, Department of Ophthalmology Danville, PA *No financial interest.
NYU Medicine Grand Rounds Clinical Vignette Julia Manasson, PGY2 November 20 th, 2013 U NITED S TATES D EPARTMENT OF V ETERANS A FFAIRS.
Eye Disease ~ Scleritis By Michael Dawes. Description Scleritis is a serious inflammatory disease that affects the white Outer bit of the eye, known as.
OFTALMOS® -SC-BRAZIL Triple Procedure for Bilateral Perforated Mooren's Ulcer G. S. Lima; P. Ferreira; A.
NYU Medical Grand Rounds Clinical Vignette Sruthi Reddy, MD PGY-2 10/9/12 U NITED S TATES D EPARTMENT OF V ETERANS A FFAIRS.
Case Discussion Dr. Raid Jastania. What is the outcome of inflammation?
Post Keratoplasty Atopic Sclerokeratitis (PKAS) after Deep Anterior Lamellar Keratoplasty (DALK). Sharmina R Khan William H Ayliffe Mayday University Hospital,
Grand Rounds Amir R. Hajrasouliha, M.D. University of Louisville Department of Ophthalmology and Visual Sciences Thursday, December 5 th, 2014.
Pathology Case Presentation
Grand Rounds Conference Reema Syed, MBBS University of Louisville Department of Ophthalmology and Visual Sciences August 7, 2015.
Rheumatoid Arthritis Dr Chandini Rao Consultant Rheumatologist.
Department of Ophthalmology Medical University of Warsaw, Poland Expanded Polytetrafluoroethylene Patches to Treat Ocular Surface Disorders Dorota Kopacz.
Behcet's Disease in an Indian Patient
Consultant, Uveitis Service
Assist. Lecturer of Ophthalmology
Cat Scratch Disease Rupesh Agrawal, Carlos Pavesio
Debra Goldstein, MD Northwestern University Chicago, IL
Posner-Schlossman Syndrome Bianka Sobolewska, MD Manfred Zierhut, MD Centre of Ophthalmology University of Tuebingen, Germany.
Diffuse infiltrating retinoblastoma > >. Ocular and General History  5 years old boy  Unremarkable birth history (BBW: 2800g, full-term)  No preceding.
A Case of ?????? ????? MD Associate Prefessor Labbafinejad Medical Center Shahid beheshti University of Medical Sciences Feb 2014.
Lens induced Uveitis Dr. Rathinam Sivakumar HOD - Uveitis Services Dr. Radhika. T Consultant, Uveitis Service Dr. Vedhanayaki Rajesh Dr. Vedhanayaki Rajesh.
MULTI-NODULAR POSTERIOR SCLERITIS Dr Nilutpal Borah, M.S. Guwahati Eye Institute and Research Center Assam, India.
Tubulointerstitial Nephritis and Uveitis (TINU) Syndrome Sana Khochtali Imen Ksiaa Anis Mahmoud Bechir Jelliti Department of Ophthalmology Fattouma Bourguiba.
Central serous chorioretinopathy and uveitis Central serous chorioretinopathy and uveitis Rim Kahloun, MD Sonia Zaouali, MD Moncef Khairallah, MD Moncef.
Behçet´s Disease Christoph Deuter Centre for Ophthalmology, University Hospital, Tuebingen, Germany.
Posterior Scleritis associated with Orbital Pseudotumor Nikolas London, MD Retina Consultants San Diego.
Manfred Zierhut Manfred Zierhut Centre of Ophthalmology University of Tuebingen, Germany Masquerade Syndrome.
Relapsing Polychondritis Rupesh Agrawal, Carlos Pavesio Moorfields Eye Hospital, NHS Foundation Trust, London, United Kingdom.
A CASE OF INFECTIOUS AND AUTOIMMUNE DISEASE COEXISTENCE Elisabetta Miserocchi MD Department of Ophthalmology and Visual Sciences University Hospital San.
Choroidal Tuberculoma Rupesh Agrawal, Carlos Pavesio Moorfields Eye Hospital, NHS Foundation Trust, London, United Kingdom.
SCLERA Dr.Sucharitha.
A Case of Beauveria Bassiana Keratitis Confirmed by Gene Sequencing Sung-Dong Chang, M.D., Jong-Hwa Jun, M.D. Department of Ophthalmology, School of Medicine,
Primary Inflammatory Choriocapillaropathy Rupesh Agrawal, Carlos Pavesio Moorfields Eye Hospital, NHS Foundation Trust, London, United Kingdom.
Uveitis CTP Egla Rabinovich, Sheila Angeles-Han, Drew Lasky and Mindy Lo For the CARRA Uveitis working Group.
Identifying Early Inflammatory Arthritis
Grand Rounds Conference
Fedorko L. MD PhD, Linden R. MD, Jones W. RN,
EPISCLERITIS AND SCLERITIS
Christine Martinez, MD COS 40th Annual Meeting August 19, 2016
To Treat Or Not To Treat…
Diagnosing Rheumatoid Arthritis Early
Wrap-Up and Post Course Self Assessment
Clinical Updates in RA: New Developments and Insights From Washington
Management of Immune Reconstitution Inflammatory Syndrome (IRIS)
Grand Rounds “Triple Procedure Via Open-Sky Approach”
Unusual Uveitic CME Amir Hadayer, MD Ophthalmology & Visual Sciences
Retina Case: “External Pallor”
The Sclera.
Presentation transcript:

Grand Rounds Scleromalacia Amir R. Hajrasouliha, M.D. University of Louisville Department of Ophthalmology and Visual Sciences Friday, January 17, 2014

Patient Presentation HPI: 79 y/o white male present for annual work up. He has a h/o dry AMD with no new complaint. He has no pain or discomfort. HPI: 79 y/o white male present for annual work up. He has a h/o dry AMD with no new complaint. He has no pain or discomfort.

Patient Presentation POH: POH: AMD dry AMD dry PMH: PMH: Rheumatoid arthritis Rheumatoid arthritis H/o bladder cancer H/o bladder cancer Meds: Meds: AREDS AREDS Plaquenil 400mg for 16 years (2,304g total) Plaquenil 400mg for 16 years (2,304g total) Allergies: Allergies: NKDA NKDA SH: SH: No tobacco, no ETOH No tobacco, no ETOH ROS: ROS: Negative (No joint pain and swelling now) Negative (No joint pain and swelling now)

Exam VA cc P T TP VA cc P T TP EOM: Full OU CVF: FULL OU 20/40 3  2mm (-) RAPD OU 20/25

ODOS Extwnlwnl L/Lwnlwnl Conjsup and tempwnl scleral thinning scleral thinning Kclearclear ACformedformed Iriswnlwnl Lens2+ NS2+NS Anterior exam

Photos

Assessment 79 year old male with rheumatoid arthritis and scleral thinning without inflammation OD 79 year old male with rheumatoid arthritis and scleral thinning without inflammation OD Differential Diagnosis Differential Diagnosis scleromalacia scleromalacia Plan Referral to rheumatologist Referral to rheumatologist

Scleromalacia Also known as necrotizing scleritis without inflammation. Also known as necrotizing scleritis without inflammation. It is clinically distinct from other forms of anterior scleritis in which typical signs (redness, edema) and symptoms (pain) of inflammation are not apparent. It is clinically distinct from other forms of anterior scleritis in which typical signs (redness, edema) and symptoms (pain) of inflammation are not apparent.

Scleromalacia Typically occurs in patient with long standing rheumatoid arthritis. Typically occurs in patient with long standing rheumatoid arthritis. It has been also reported to have association with Wegener's granulomatosis, SLE, JRA, PAN, Relapsing Polychondritis, psoriasis, gout, TB, syphilis, HSV, HZV. It has been also reported to have association with Wegener's granulomatosis, SLE, JRA, PAN, Relapsing Polychondritis, psoriasis, gout, TB, syphilis, HSV, HZV.

Scleromalacia A bulging staphyloma develops if intraocular pressure is elevated; A bulging staphyloma develops if intraocular pressure is elevated; Spontaneous perforation Spontaneous perforation is rare, although these eye is rare, although these eye may rupture with minimal Trauma.

Case report A clinical case of scleromalacia perforans in a 56-year-old woman with 20 years of seropositive rheumatoid arthritis. She developed rapidly progressed to scleromalacia perforans OS and became perforated. It was surgically enucleated, and the patient was maintained with steroidal therapy. A clinical case of scleromalacia perforans in a 56-year-old woman with 20 years of seropositive rheumatoid arthritis. She developed rapidly progressed to scleromalacia perforans OS and became perforated. It was surgically enucleated, and the patient was maintained with steroidal therapy. 2 months later she developed new-onset scleromalacia OD. She was first evaluated by a rheumatologist and treated with 200 mg/dose of infliximab, which was administered monthly for the following four months. The biological treatment was accompanied by methotrexate and prednisone. With this therapy, the ocular lesion dramatically improved, and complete remission of rheumatoid arthritis and scleritis was archived four months later. In conclusion, tumur necrosis factor (TNF) blockers are effective therapeutic agents in ocular complications of rheumatoid arthritis. 2 months later she developed new-onset scleromalacia OD. She was first evaluated by a rheumatologist and treated with 200 mg/dose of infliximab, which was administered monthly for the following four months. The biological treatment was accompanied by methotrexate and prednisone. With this therapy, the ocular lesion dramatically improved, and complete remission of rheumatoid arthritis and scleritis was archived four months later. In conclusion, tumur necrosis factor (TNF) blockers are effective therapeutic agents in ocular complications of rheumatoid arthritis. Reumatismo Jul-Sep;61(3):212-5.Infliximab treatment in a case of rheumatoid scleromalacia perforans.

MEDICAL TREATMENT In patients with simple diffuse or nodular scleritis systemic non-steroidal anti- inflammatory drug therapy is almost invariably effective In patients with simple diffuse or nodular scleritis systemic non-steroidal anti- inflammatory drug therapy is almost invariably effective For unresponsive cases and posterior scleritis, the mainstay of treatment is systemic steroids in a dose of 1 mg/kg/day. As soon as the patient responds, the dose should be tapered once 20 mg/day is reached, alternate day therapy can be started. Topical steroids can be applied for symptom relief. For unresponsive cases and posterior scleritis, the mainstay of treatment is systemic steroids in a dose of 1 mg/kg/day. As soon as the patient responds, the dose should be tapered once 20 mg/day is reached, alternate day therapy can be started. Topical steroids can be applied for symptom relief. Immunosuppressive therapy is mandatory for definitively diagnosed systemic vasculitic disease and/or progressive destructive ocular lesions. If the necrotizing scleritis is not severe, not rapidly progressing, the first choice of therapy is methotrexate 7.5 mg once a week as a starting dose Immunosuppressive therapy is mandatory for definitively diagnosed systemic vasculitic disease and/or progressive destructive ocular lesions. If the necrotizing scleritis is not severe, not rapidly progressing, the first choice of therapy is methotrexate 7.5 mg once a week as a starting dose

Scleromalacia Extreme corneal thinning or perforation requires reinforcement. Donor sclera, fascia lata, Extreme corneal thinning or perforation requires reinforcement. Donor sclera, fascia lata, periosteum or artificial materials can be used. To maintain its integrity the material must be covered by conjunctiva. periosteum or artificial materials can be used. To maintain its integrity the material must be covered by conjunctiva.

Thank You