2.  I do not have any affiliations nor am I paid by any of the companies that are used in this presentation.

3.  Everyday as eye care professionals we see strange and unusual cases that we don’t expect.  With instrumentation and technology we can explain some of these interesting cases.  Today we will review some cases that I have seen over the past year that make you stop and say UMMMMM.

7.  43 y.o. white female presents for her annual comprehensive eye exam.  Patient is new to our office and has no previous records with her today.  Chief complaint – Glasses don’t feel strong enough, needs an updated Rx.  No other complaints noted.

8.  BCVA 20/20 OU  Slit lamp exam was unremarkable OU  IOPs normal OU  Visual Fields unremarkable OU  Fundus photo appears normal OU

13.  Optic Nerve Head Drusen  Calcification of protein-like structures in the optic nerve.  Can be on the surface or buried deep within the nerve.  Frequency about 1% of people.  75% will have some sort of visual field defect.

14.  Treatment – majority of cases we monitor.  IOP is very important.  Neuroprotective agents like Alphagan can be used to protect the nerve as well as reduce IOP.

15.  24 y.o. wf presents for her annual contact lens exam  Chief complaint – out of contacts  Patient is new to the office  No other complaints

16.  Entering VAcc = 20/25 OD and 20/25 OS  Visual Fields were normal  IOP normal  Fundus imaging normal  Refraction BCVA = 20/25 OU  WHY?

17.  Slit lamp exam

21.  Dense persistent pupillary membranes OU  The human iris is closed in early embryonic development.  The pupil doesn’t open until later stages of development.  In some people, the iris doesn’t completely open leaving iris strands.

22.  Treatment – None required  Vision of 20/25 OU would not warrant surgical intervention.  Monitor with yearly exams, caution dilating could cause an iris tear.

23.  54 y.o. wm presents as a walk in to the office.  Chief complaint – he thinks there is something on his contact lens OD. Says he has rinsed it multiple times but the spot won’t go away.  Patient was in a hurry didn’t want to do any testing just wanted a new contact.

24.  With a lot of convincing I was able to get the patient to agree to a couple tests.  Entering VA 20/20 OD  External slit lamp exam was normal contact appeared clean and clear of damages.  Screening visual fields showed superior nasal defect  Patient was dilated (he was very unhappy)

25.  Optos and 20 D BIO performed

28.  Inferior temporal horseshoe tear of the retina  Treatment – refer to retinal specialist for vitrectomy and scleral buckle.  Outcome - 20/20 vision OD after secondary cataract surgery.

30.  42 y.o. wf presents for her annual comprehensive eye exam  Chief complaint – needs more contacts  New patient to our office unremarkable medical and family history  No other complaints

31.  Entering visual acuity 20/20 OU c CL  Visual fields normal OU  Fundus photos normal OU  Initial external slit lamp exam reveals what appears to be a shiny debris on her contact lens.  Had pt remove CLs  Secondary external slit lamp exam revealed

33.  Upon further inquiry of patient history it was discovered that she is a dental assistant who doesn’t wear her contacts when she works and doesn’t wear safety glasses when the dentist is drilling out fillings.

35.  Metallic dental filling material embedded in cornea  Treatment – none required material will sluff off on its own.  Recommended safety glasses at work.  Followed up in 3 months – cornea was almost 100% clear.

36.  40 y.o. wm presents for medical exam  Chief complaint – doesn’t feel like he is seeing well OS  Patient is an airline pilot thinks he may need glasses  New patient to the office however I have know patient for years

37.  Entering visual acuity sc 20/15 OD and 20/30 OS.  Refraction – no improvement  AR showed +0.50 OS  Visual field was normal OU  External slit lamp was unremarkable  Fundus photo at first glance unremarkable.

39.  Without any obvious signs to explain his symptoms I decide to look at the retinal photos a little closer.

41.  Upon further inquiry of patient history it was discovered that he is currently going through recertification for his pilots license and has been under a lot of stress.  Need to do an OCT!

44.  Central Serous Retinopathy OS  Often seen is 40 + men with high stress jobs and type A personalities.  Treatment – none. Generally resolves on its own.  Follow-up 3 months vision returned to 20/15 OS.

45.  34 y.o. wf presents for annual comprehensive eye exam  Chief complaint – “Doctor, my husband thinks I am crazy”  When we go on vacation I lose the ability to read?????????????

46.  Entering visual acuity 20/20 OU  Visual field normal OU  External slit lamp exam normal OU  Fundus photos normal OU  OCT normal OU  NKDA  No medications

47.  Doesn’t matter if they drive or fly  No heart or blood pressure problems  No history of stroke or TIAs  No headaches  No aura  WAIT…….Flash back to 2001…….

48.  In 2001 I went to an IUPHARM convention in San Francisco.  While I was there I went on a wine tour through Napa Valley.  About half way through the tour I could no longer read the wine menus (no I wasn’t drunk…lol)  So I did what any one would do in this situation

49.  Upon further inquiry of patient history it was discovered that the patient wears scopolamine patches for motion sickness when she travels.

53.  Pharmaceutical cycloplegia  Not crazy, just dilated

54.  Treatment – recommended patient talk to PCP about switching her to a different motion sickness medication.  Follow-up yearly.

55.  12 y.o. Asian Female present for annual comprehensive eye exam.  Chief complaint according to mom, every time she looks at knives she gets shooting pains in her eyes.  WHAT?????????????

56.  Entering visual acuity 20/20 OU  Confrontation fields normal OU  PERRL –APD  Fundus photo normal OU  OCT normal  External slit lamp exam revealed lower eye lid turned in OU.

59.  Severe entropion with trichiasis OU  Treatment – refer to oculoplastic surgeon for eye lid retraction  Follow up in 3 months – no more problems looking at knives.