Curbside Consultation in Cornea and External Disease 49 Clinical Questions

Are you looking for concise, practical answers to those questions that are often left unanswered by traditional references on cornea and external diseases? Are you seeking brief, evidence-based advice for the daily examination of patients?Curbside Consultation in Cornea and External Disease: 49 Clinical Questionsprovides quick and direct answers to the thorny questions most commonly posed during a "curbside consultation" between experienced clinicians.Dr. Frank Price Jr., joined by associate editors Dr. Marianne Price and Dr. Erik Letko, have designed this unique reference in which cornea and external clinicians offer expert advice, preferences, and opinions on tough clinical questions commonly associated with cornea and external diseases. The unique Q&A format provides quick access to current information related to cornea and external diseases with the simplicity of a conversation between two colleagues. Images, diagrams, and references are included to enhance the text and to illustrate clinical diagnoses and treatment plans.Curbside Consultation in Cornea and External Disease: 49 Clinical Questionsprovides information basic enough for residents while also incorporating expert pearls that even high-volume ophthalmologists and specialists will appreciate. Refractive surgeons, general ophthalmologists, residents alike will benefit from the user-friendly and casual format and the expert advice contained within.Some of the questions that are answered:bull; How do I manage a corneal ulcer? What if it is not responding to treatment? bull; How do I manage post-operative astigmatism after penetrating keratoplasty, before and after suture removal. bull; What is the differential diagnosis and management of peripheral corneal thinning? With 360 degree corneal thinning, how should I manage the cataract? bull; What are the options for closing a small corneal perforation? bull; When do I consider conjunctivochalasis to be clinically significant? How do I decide on conservative or surgical management? bull; When is the right timing for cataract surgery in a patient with Fuch's dystrophy? Does central corneal pachymetry play a role in my decision?

Francis W. Price, Jr., MD, founder and medical director of Price Vision Group in Indianapolis, IN, is an internationally recognized ophthalmic surgeon and recipient of the Senior Achievement Award from the American Academy of Ophthalmology. He has authored over 100 peer-reviewed publications and has been principal investigator on over 80 clinical studies of ophthalmic devices, medications, and surgical techniques. He is also an inventor and holds several patents for ophthalmic devices. Dr. Price is a graduate of Indiana University Medical School and completed a fellowship in cornea and external disease at Tulane University. He has been active in developing and teaching endothelial keratoplasty techniques to hundreds of surgeons from around the world.           
Marianne Price, PhD is executive director of the Cornea Research Foundation of America in Indianapolis, IN. She holds a PhD in Medical and Molecular Genetics from Indiana University School of Medicine. A respected scientist and author, Dr. Price has made presentations to vision care audiences around the world. She is a member of the American Academy of Ophthalmology and serves on the Board of Prevent Blindness Indiana, the Indiana University Kelley School of Business—Women MBA’s Alumni Advisory Board, and the Scientific Programs and Research Committees of the Eye Bank Association of America. She and Dr. Francis Price are recipients of Melvin Jones Fellow Awards from the Lions International Foundation and Vision Awards from the Corneal Dystrophy Foundation.          

Erik Letko, MD dedicates his career to the improvement of treatment and surgical techniques for a spectrum of corneal conditions. He graduated from Charles University 1st School of Medicine in Prague, Czech Republic, where he also completed his ophthalmology residency and cornea fellowship. He received extensive training as a fellow in Cornea, External Eye Diseases, and Ocular Immunology at the Massachusetts Eye and Ear Infirmary, Harvard Medical School. He completed a second residency in ophthalmology at Casey Eye Institute in Portland, OR. Dr. Letko participated in over 30 clinical studies and authored or co-authored over 25 peer reviewed articles and 10 book chapters. He serves as a reviewer for ophthalmology journals and lectures in the United States and abroad.

 

Dedication Acknowledgments About the Editor About the Associate Editors Contributing Authors Preface Section 1         Corneal Degeneration and Dystrophy Question 1          I Have a Patient With Fuchs’ Endothelial Dystrophy. Is There Anything
                               New to Improve Her Vision?                                Mark S. Gorovoy, MD Question 2          I Am Seeing a 64-Year-Old Female for Cataract Evaluation. The Slit
                               Lamp Examination Is Significant for Anterior Basement Membrane
                               Dystrophy Affecting the Visual Axis and 2+ Nuclear Sclerosis of the Lens
                               in Both Eyes. How Should I Manage This Patient?                                Sadeer B. Hannush, MD Question 3          A 62-Year-Old Male With No History of Ocular Surgery Complains of
                               Blurry Vision in One Eye. The Exam Shows Diffuse Corneal Stromal
                               Edema. How Should I Work Up and Treat This Patient?                                Anthony J. Aldave, MD Question 4          A Patient Has Irritation in Her Nonseeing Eye. The Exam Shows Mildly
                               Inflamed Conjunctiva and Diffuse Corneal Epithelial and Stromal Edema
                               With Large Bullae. What Should I Recommend?                                Mark A. Terry, MD Question 5          A Patient With Recurrent Erosion Syndrome Is Complaining of Irritation
                               and Pain in the Right Eye That Typically Wakes Her Up Early in the
                               Morning. What Should I Do?                                Dimitri T. Azar, MD (co-authored with Kristina Thomas, MD) Question 6          A Patient With a Filtering Bleb Complains of Discomfort in the Eye. The
                               Bleb Is Prolapsing Onto the Cornea and an Area of Stromal Thinning
                               and Epithelial Staining With Fluorescein Is Adjacent to the Bleb. What Is
                               the Optimal Management?                                Sonia H. Yoo, MD (co-authored with Mohamed Abou Shousha, MD) Question 7          A 63-Year-Old Male Complaining of Blurry Vision Has 360-Degree
                               Peripheral Corneal Stromal Thinning and Conjunctivalization and
                               Moderate Cataract in Both Eyes. Does He Need Surgery?                                J. Bradley Randleman, MD Question 8          A Patient With Eye Irritation While Wearing Soft Contact Lenses Is Noted
                               to Have White Elevated Nodules at the Limbus. Does She Need
                               Surgery?                                Thomas Kohnen, MD Question 9          A 22-Year-Old Female Complaining of Blurry Vision in One Eye Has Deep
                               Sectoral Corneal Stromal Neovascularization With Stromal Infiltrate and
                               Lipid Deposits in the Center of the Cornea. How Should I Manage This
                               Patient?                                Majid Moshirfar, MD, FACS (co-authored with JoAnn C. Chang, MD) Section II        External Eye Disease and Tumors Question 10        How Should I Treat a Patient With Red Eye and Photophobia if My
                               Exam Reveals Meibomian Gland Dysfunction and Foci of Subepithelial
                               Infiltrates at the Limbus?                                Neal P. Barney, MD Question 11        How Can I Help a 47-Year-Old Female Who Uses Artificial Tears
                               6 Times Daily and Continues to Complain of Dry Eyes?                                Stephen C. Pflugfelder, MD Question 12        A 68-Year-Old Female With Rheumatoid Arthritis Presents With a Red,
                               Painful Eye and Stromal Melt at the Limbus. How Should I
                               Treat Her?                                Virender S. Sangwan, MS Question 13        A 47-Year-Old Hispanic Male Complains of a “Growth” in the Corner of
                               His Right Eye. Does His Pterygium Need to Be Removed?                                William Trattler, MD Question 14        A Patient Diagnosed With Bell’s Palsy 2 Days Ago Presents With
                               Lagophthalmos and Moderate Superficial Punctuate Keratopathy
                               Inferiorly on the Cornea. How Should I Treat Her?                                Natalie A. Afshari, MD, FACS (co-authored with Brad H. Feldman, MD) Question 15        A 43-Year-Old Female Is Complaining of Dry Eyes. The Exam Shows
                               Punctate Keratopathy in the Inferior Third of Her Corneas. What Is the
                               Optimal Management?                                Jeffrey P. Gilbard, MD Question 16        A 42-Year-Old Female With Sectoral Redness in Her Right Eye
                               Complains of Irritation in One Eye, but No Pain. How Should I Treat Her
                               Episcleritis?                                Albert S. Jun, MD, PhD Question 17        A 53-Year-Old Female Came to My Office With Sectoral Redness and Pain
                               in One Eye. How Should I Manage Her Scleritis?                                Sana S. Siddique, MD (co-authored with C. Stephen Foster, MD, FACR, FACS) Question 18        An 18-Year-Old Male Complaining of Severe Itchy Eyes and Redness
                               Has Diffuse Eyelid Erythema With Dry Scaly Skin, Meibomian Gland
                               Dysfunction, 2+ Conjunctival Bulbar and Palpebral Injection, and 3+
                               Papillae. Does He Need Steroid Drops?                                Michael B. Raizman, MD Question 19        A 72-Year-Old Female Has Conjunctival Injection in Both Eyes and
                               Symblepharon and Trichiasis in the Right Eye. The Right Cornea Has
                               Moderate Punctate Staining. Should I Just Pull Out the Lashes or Do a
                               Wedge Resection of the Lower Lid to Tighten It Up?                                David D. Verdier, MD Question 20        A 67-Year-Old Female Complains of Constant Eye Irritation. The Exam
                               Shows Conjunctivochalasis of the Lower Bulbar Conjunctiva. Should I
                               Excise the Redundant Conjunctiva?                                James P. Dunn, MD (co-authored with Aarup A. Kubal, MD) Question 21        A Patient Complaining of Eye Irritation Has Moderate Meibomian
                               Gland Dysfunction and Trace Conjunctival Injection. Could This Be
                               Rosacea?                                Richard E. Braunstein, MD (co-authored with Prathima R. Thumma, MD) Question 22        A 49-Year-Old Male Comes to the Office With a Red Swollen Upper Eyelid.
                               The Symptoms Started Yesterday. Should I Start Treating Him for
                               Chalazion?                                John D. Ng, MD, MS, FACS Question 23        A 13-Year-Old Female Is Complaining of an Enlarging Brown Spot on
                               Her Eye. The Exam Shows a Flat Conjunctival Pigmented Nevus
                               That Is 3 mm in Diameter Surrounded by Mild Conjunctival Injection.
                               Should I Be Worried About Malignancy?                                Frederick (Rick) W. Fraunfelder, MD (co-authored with Michael A. Page, MD) Question 24        A 52-Year-Old Obese Male Comes to the Office Complaining of Pain and
                               Irritation in the Right Eye. The Exam Shows Floppy Eyelids, 3+ Papillae
                               in Upper Tarsal Conjunctiva, and Lash Ptosis. Does He Need Eyelid
                               Surgery?                                Reza Dana, MD, MSc, MPH Question 25        A 72-Year-Old Male Is Complaining of Decreased Vision. The Exam
                               Shows Nuclear Cataract and Cortical Spoking. In the Area Above the
                               Cortical Spokes, There Is a Pigmented Lesion of the Iris and Ectropion
                               Uvea. Should I Arrange for Excision of the Lesion?                                Henry Daniel Perry, MD Question 26        A Young Patient With Recurrent Episodes of Thygeson’s Keratitis Wants
                               Me to Refill a Prescription for Topical Corticosteroids That She Uses
                               Intermittently as Needed for Discomfort. Should I Do It?                                Jayne S. Weiss, MD Section III       Infection Question 27        A Patient Presents With Corneal Ulcer. What Work-Up and Treatment
                               Would You Recommend?                                John W. Cowden, MD; Prashant Garg, MD; and Martin Filipec, MD, PhD Question 28        I Have a General Ophthalmology Practice in a Remote Area. When
                               Should I Consider Doing Corneal Cultures?                                Francis S. Mah, MD Question 29        A Corneal Infiltrate Is Unresponsive to Topical Fluoroquinolones. Could
                               This Be Acanthamoeba?                                Elmer Y. Tu, MD Question 30        A Corneal Infiltrate of a Farmer Hit by a Tree Branch Is Not Clearing on
                               Topical Fluoroquinolone Drops. What Should I Do Next?                                Erik Letko, MD Question 31        I Have a Patient With Shingles Over the Right Side of His Face and
                               Around the Eye Treated With Oral Antivirals for 10 Days. Does This
                               Protect Him From Eye Involvement?                                Terry Kim, MD (co-authored with Tanya Khan, BA) Question 32        I Have a Patient With Herpes Simplex Dendrites. What Is the Best Plan to
                               Minimize Both the Recurrences and Possible Scarring?                                Penny Asbell, MD, FACS, MBA (co-authored with Daniel Brocks, MD) Question 33        After Recently Treated Bacterial Keratitis, a Diabetic Patient Continues
                               to Have Persistent Stromal Ulcer Despite Bandage Contact Lens and
                               Topical Antibiotics. What Are the Options?                                Carlindo Da Reitz Pereira, MD Question 34        A Patient With a History of Recurrent HSV Keratitis Continues to Have
                               Dense Punctate Keratopathy and Visual Acuity of 20/100 Despite Hourly
                               Lubrication With Preservative-Free Artificial Tears. What Else Could Be
                               Done?                                Michael W. Belin, MD Question 35        A Patient With Red, Irritated Eyes, Tearing, and Photophobia That Started
                               Yesterday Has Mild Conjunctival Injection and 2+ Follicles of the
                               Palpebral Conjunctiva. When the Patient Awoke, His Eyelids Were Stuck
                               Closed. Is This Acute Conjunctivitis?                                Marian Macsai, MD Section IV       Contact Lenses Question 36        My Patient Complains of Redness and Photophobia After Sleeping
                               With Contact Lenses. The Exam Shows Diffuse Patchy Epithelial and
                               Anterior Stromal Infiltrates. What Should I Do?                                Stephen C. Kaufman, MD, PhD Question 37        A Young Patient Has Best Spectacle-Corrected Visual Acuity of 20/30 OD
                               and 20/25 OS, and Retinoscopy Shows Scissor Reflex. Is This
                               Keratoconus?                                Yaron S. Rabinowitz, MD Question 38        What Should I Do for a Patient Who Wears Soft Contact Lenses and
                               Complains of Dry and Itchy Eyes?                                Thomas F. Mauger, MD Question 39        How Should I Manage a Patient With Keratoconus Who Cannot Tolerate
                               Hard Gas-Permeable Contact Lenses?                                Donald Tan, FRCSG, FRCSE, FRCOphth, FAMS
                               (co-authored with Jod S. Mehta, BSc, MBBS, MRCOphth, FRCOphth, FRCS(Ed)) Question 40        A Long-Time Soft Contact Lens User Complains of Eye Irritation and Has
                               Superficial Punctate Keratopathy in the Area of Corneal Apex. Is This a
                               Poor Contact Lens Fit?                                Mark J. Mannis, MD, FACS Question 41        A Long-Time Soft Contact Lens User Complains of Eye Irritation and Has
                               Superficial Punctate Keratopathy in the Superior Cornea and Limbus.
                               What Should I Do?                                Kenneth Mark Goins, MD Section V        Trauma Question 42        A Piece of Glass Flew Into My Patient’s Eye. The Exam Shows Central
                               Corneal Perforation <1 mm in Diameter. The Anterior Chamber Is
                               Shallow, but Formed. How Should I Close This Wound?                                Roberto Pineda, MD Question 43        My Patient Was Splashed With Cement in Both Eyes. He Has Red, Irritated
                               Eyes and Blurry Vision. The Exam Shows Debris on the Conjunctiva and
                               Under the Lids, Diffuse SPK in the Right Eye, and Central Corneal
                               Epithelial Defect in the Left Eye. What Should I Watch For?                                Bennie H. Jeng, MD Question 44        A Tire Blew Up in Front of My Patient’s Face. He Complains of Eye
                               Irritation. The Exam Shows Multiple Tiny Foreign Bodies 100 to 200 µm
                               in Diameter Embedded in the Conjunctiva and Cornea. Does He Need
                               Surgery?                                Jose L. Güell, MD (co-authored with Merce Morral, MD) Question 45        A Patient With a Chemical Burn in the Right Eye 6 Months Ago Complains
                               of Blurry Vision and Photophobia. He Has an Area of Corneal
                               Neovascularization and Conjunctivalization Extending 4 mm From the
                               Limbus. Does He Need Limbal Stem Cell Transplantation?                                Scheffer C. G. Tseng, MD, PhD (co-authored with Hosam Sheha, MD, PhD) Section VI       Postoperative Question 46        What Should I Consider for a Patient With a Corneal Transplant Who
                               Presents With a Red Eye and Photophobia?                                David S. Chu, MD Question 47        How Should I Manage an Intraocular Pressure Spike of 43 mm Hg in a
                               Descemet’s Stripping Endothelial Keratoplasty Patient Who Is Taking
                               One Drop of Pred Forte 1% Daily?                                Rudy M. M. A. Nuijts, MD, PhD (co-authored with Muriel Doors, MD;
                               Carroll A. Webers, MD, PhD; and Nienke Visser, MD) Question 48        I Was Asked to Assume Follow-Up of a Patient 5 Months After
                               Penetrating Keratopolasty for HSV-Related Scar. How Should I Manage
                               This Patient?                                Joseph Tauber, MD Question 49        What Should I Do for a Patient Who Presents With 6-D Astigmatism After
                               Undergoing Penetrating Keratoplasty 4 Months Ago?                                Roger F. Steinert, MD Financial Disclosures Index