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    Irritation in a bottle: Glaucoma and OSD

    Case highlights need for proper topical therapeutic management

    Editor’s Note: Ophthalmology Times is pleased to announce Lekha Mukkamala, MD, and Albert S. Khouri, MD, of Rutgers-New Jersey Medical School, Newark, NJ, as the third-place winners of the 2016 Resident Writer’s Award Program, sponsored by Allergan.
    The Ophthalmology Times Resident Writer’s Award Program is a unique recognition opportunity designed to promote excellence in ocular surface disease education. It was created to acknowledge outstanding case identification and written presentation skills in ophthalmology residents.
    Sophia Wang, MD, and Shahzad Mian, MD, of the University of Michigan Kellogg Eye Center, Ann Arbor, are the first-place winners of this year’s Resident Writer’s Award Program. Their submission—“10 tips for OSD-associated toxic epidermal necrolysis (TEN)”—can be seen at OphthalmologyTimes.com/10TipsforTEN. Alexander Nguyen, MD, and Jessica Chow, MD, of Yale University School of Medicine, New Haven, CT, are this year’s second-place winners. Their submission—“Cyclosporine for dry eye associated with anti-PD-1 therapy”—can be seen at OphthalmologyTimes.com/CyclosporineAntiPD1.


     

    History

    Our patient is a 72-year-old African American male with a history of hypertension, well-controlled diabetes and 9 years of POAG in both eyes, with the left worse than the right. Baseline vision was 20/30 and 20/40. The patient was on maximal topical therapy in both eyes with the following regimen: brimonidine TID, dorzolamide/timolol BID, and latanoprost QHS.

    He previously had questionable adherence with his medications, but now reported more regular administration, as his daughter was frequently assisting. The patient presented for follow-up with a chief complaint of increasingly blurry vision and foreign body sensation in both eyes over the past 2 months.

    Examination

    Visual acuity was 20/50, pinhole to 20/40 OD and 20/60, pinhole to 20/50 OS. IOP was 13 and 24 mm Hg OD and OS, respectively. Anterior segment exam was significant for 2+ diffuse punctate epithelial erosions (PEE) bilaterally, and pseudophakia bilaterally. Fundus examination revealed C/D of 0.6 OD and 0.8 OS, with mild nonproliferative diabetic retinopathy bilaterally.

    Visual field results showed a dense superior arcuate defect in the left eye that was reproduced from the last field 3 months ago, when progression of the defect had been noted and compliance with medication had been stressed.

    After extensive discussion with the patient and family regarding the recommendation of surgery to prevent further visual field loss in the left eye and given the persistently high IOP for goal on maximal medial therapy, the patient agreed to proceed with trabeculectomy with mitomycin C (MMC) OS.

    Course

    The patient underwent trabeculectomy with MMC without complication OS. The postoperative course was uneventful with a low, diffuse avascular bleb maintaining pressures in the low- to mid-teens on no topical medications.

    Upon follow-up 3 months after the surgery, the patient felt that foreign body sensation persisted in the right eye but was markedly improved in the left. The patient’s vision was 20/60 with no improvement with pinhole OD, and 20/25 OS. There was 2-3+ diffuse PEE OD, while OS showed a diffuse filtering bleb with trace PEE inferiorly on the cornea. IOP was 13 mm Hg in both eyes.

    Fluorescein and lissamine green staining were obtained and illustrated the compromise of the corneal epithelial surface OD. The improvement in vision in the left eye was thought to be due to the resolution of OSD with elimination of the burden of topical medications. The persistent decline in right eye acuity was attributed to worsening keratopathy that occurred with continued administration, given that visual field and IOP were stable.

    Therefore, in the right eye, the patient was started on cyclosporine 0.05% BID and preservative-free artificial tears QID, with brimonidine being decreased to BID.
    The ocular surface healed nicely with only trace PEE inferiorly in the right eye 4 months later. The patient’s vision improved to 20/25 with complete resolution of symptoms.

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