• Second Opinions
• A Visually Impaired Eye M.D.
• Trypan Blue for Filtration Site Localization
The following are in response to “The Case of the Stressed-Out Patient” (July/August, Morning Rounds).
As I look at the pair of fundus photographs, not only did the intraretinal hemorrhages disappear, but the retinal veins were definitely narrower on the follow-up photo. This suggests that a transient, partial, central retinal vein occlusion (CRVO), alluded to by Dr. Gray, might have been the culprit, despite the rapid artery-vein transit time.
Richard L. Sogg, MD
Los Gatos, Calif
I would have to say that the case looks like a mild nonischemic CRVO where flow was already back to normal at the time of the fluorescein angiogram. The diagnosis of “idiopathic hemorrhagic retinopathy” seems unlikely given that none of the hemorrhages look deep.
Chris Blodi MD
Des Moines, Iowa
The patient had a classical mild nonischemic CRVO. I have found that starting these patients on aspirin is not a good idea because that can aggravate the retinal hemorrhages and make the situation worse.
Sohan Singh Hayreh, MD, PhD
Iowa City, Iowa
The following is Andrea V. Gray, MD’s response to Drs. Sogg, Blodi and Hayreh.
Thank you for your keen observations and good comments. Transient, partial, central retinal vein occlusion was certainly at the top of the list of differential diagnoses. In fact, this patient was treated as if she had this as a cause for the hemorrhages. Stress reduction, good hydration, and low-dose aspirin therapy was advised.
Andrea V. Gray, MD
A Visually Impaired Eye M.D.
As a colleague who has, with you, fought against many vision-depriving conditions, I would like to offer some insight and advice from my own experience with macular degeneration.
I am now a visually impaired patient, as well as a visual rehabilitation specialist.
As physicians, when our medical and surgical skills can no longer help our patients, we often feel a sense of honest candor and state, “There is nothing else that can be done.”
Through my own experience, I can tell you that such a declaration not only is an unnecessary blow to the patient and his or her family but also is not true.
Vision rehabilitation can literally change the lives of your “acuity unimprovable” patients and their caretakers.
So please pass on the message of vision rehabilitation to your patients whose acuity you can’t improve.
Yale Solomon, MDEd: The Academy offers vision rehabilitation information and resources through its SmartSight initiative. For more information, visit www.aao.org/smartsight.
Trypan Blue for Filtration Site Localization
I recently performed cataract surgery on a 36-year-old male who previously had a trabeculectomy on that eye. The trabeculectomy had been done at a superior location four years prior in France, and he subsequently developed a hypermature cataract with hand-motion vision in that eye.
I used trypan blue in order to assist visualization of the capsule and noticed, after introducing the trypan, the bleb and filtration site took up the dye very distinctly. This was very helpful in avoiding the filtration site when fashioning the phacoemulsification wound.
The trypan blue delineates the precise architecture of the filtration path and bleb.
I believe that this is a useful technique in this setting, when an alternative site is not desired, and it may be useful in other situations when filtration site architecture needs to be visualized.
Bernie Spier, MD
South Orange, N.J.
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