I’ve been meaning to post about an interesting case that I had this week. The problem is that I’ve had several interesting cases and I couldn’t decide which one to share with you all. FINALLY, after much debate, I decided to share with you the tale of the man with a painful right lower lid.
Wednesdays are great at the Salem VA eye clinic. The morning is spent in rotations, journal club, lectures, or- as the case was today- administration time. I had a nice chunk of time to catch up on some much needed work like looking over part of the lecture I have to give with Dr. Tara next week, reading up on my case that I’m putting together for the Academy meeting in November, and reviewing all the carotid ultrasounds that I have ordered. We all see patients in the afternoons on Wednesday; my schedule was not overbooked, which was a nice relief! Glancing ahead at what was to come, I noticed that I had two full eye exams, one dilation, one pressure check, and a walk-in for a “painful lower lid”. I hit the jackpot! One full exam and the one pressure check thought that they didn’t need their eyes checked, so they decided not to show up for their appointments. The other full exam was quite easy. The dilation was no big deal. It was the hordeolum that threw me off my game this afternoon.
Don’t get me wrong, I can handle a painful nodule with no problem, it was his history of glaucoma and his pressures of 19 and 47, right eye/left eye, that had my brain turning. My attending, Dr. Musick, walked in my exam room just as I was beginning to take his pressure reading on his left eye. My slow head turn, big eyes, and scrunched up eyebrows tipped her off that something was definitely not normal. I check the pressure twice after that… same thing. Obviously I requested that she quadruple check my readings. She measured a 48, big difference, I know.
Cue grand exit from the exam room to find glaucoma drops. Iopidine at 1432 (military time–> 2:32pm), timolol at 1441, dorzolamide at 1458, Travatan Z at 1508. Rechecked his pressure at 1532: 47. My thought: “you’ve got to be kidding me.”
Luckily, the Salem VA has an exceptional glaucoma specialist as the chief of ophthalmology, Dr. Li, who consulted with Dr. Musick and me and the best way to approach the patient’s care. In my head I was thinking we should give him some oral acetazolamide (2-250mg tablets), and that’s what Dr. Li suggested. At this point I’m also thinking, “how late are we going to have to keep this guy if his pressures don’t go down?” Oh yeah, and, “did I put the right order in for Keflex for his stye?”
Two acetazolamide tablets and a trip to the pharmacy to pick up his Keflex later his pressure was 37, so a reduction of 10mmHg 30 minutes after his dose.
Pressure lowered, go us. The tale is not over (it never is with me, is it?). The type of glaucoma that this patient was diagnosed with was pseudoexfoliative glaucoma… pseudoexfoliation seems to be following me lately. The patient had previously been on maximal medical therapy for glaucoma, then had a combination cataract surgery/endoscopic cyclophotocoagulation (ECP) in 2008 to reduced his aqueous production to HOPEFULLY keep his IOP low. Sometime around this time period he had 360 degrees of ALT to try to increase the drainage of the aqueous to HOPEFULLY keep his IOP low. Obviously neither of these procedures worked very well.
Differentials for unilateral increased IOP? Dr. Musick was thinking something inflammatory was going on, like a trabeculitis. I was thinking something more pseudoexfoliative-related, like pseudoexfoliative material in the angle. Gonioscopy showed some material on the inferior peripheral edges of the iris, but the angle was wide open and not overtly clogged up. Mr. Patient was definitely mister patient because he sat there with a gonioscopy lens on his eyeball for about 4 minutes while I messed around with my camera to get a picture of his angle and the white material hanging out on his iris. I did get a picture, but it’s on my camera, not uploaded yet, and it’s a bit blurry. But I was on 25 magnification and was using my digital camera, don’t knock my attempt. :) I might post it if I can enhance it a little. I know you are just dying to see it.
Anyway, we (Dr. Li, Dr. Musick, and me) sent him on his merry way with a prescription for acetazolamide (2-250mg po, because the VA does not have 1-500mg po on its formulary). He is to come back within two weeks to return to the care of his usual ophthalmologist, Dr. Eliason, who is absolutely phenomenal in his patient care. Not that I was bad or anything…
So my hordeolum patient left 2 hours later, still happy as could be. Except for the painful bump that was the reason he came in the first place, but we’re working on that.
-Dr. Meg