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Cruz, P. - Ophthalmology Case Discussion 2

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Cruz, P. - Ophthalmology Case Discussion 2
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  Patricio Lorenzo Cruz Case Discussion 2 3A Case 3 This is a 2 year old female who was brought in by her mother because of eye pain over her right of 4 weeks duration. She noticed that her child keeps on crying most of the time. There was no fever or loss of conciousness. No visual threat was elicited over the right eye. Above is the clinical picture at the time of consult. 1.   What is your differential diagnosis? Differential diagnoses include:    Retinopathy of prematurity    Tuberculosis    Anterior uveitis of childhood    Vitreous hemorrhage    Congenital cataract    Exudative retinal detachment    Retinoblastoma Additional information. There is no family history of eye disease. An orbital CT scan was done and is shown below    2.   What is your diagnosis? Retinoblastoma is the most likely diagnosis for this patient, based on the presentation of the child and the CT scan. The history does not lend much clue into the disease, as most patients who develop retinoblastoma do not have any positive history of retinoblastoma. The child exhibits leukocoria, strabismus, and red eye, which are manifestations of retinoblastoma. The swelling of the upper eyelids is similar to that seen in orbital cellulitis; however, this does not necessarily indicate that there is already tumor involvement of the orbit. On the CT scan, a hyperlucent mass can be seen on the medial aspect of the right eye, which may be the growing mass. 3.   Why is the eye red and painful? The eye is red because of the presence of tortuous dilated blood vessels. Blood vessel formation is induced by the presence of the tumor, thus giving the eye the red appearance. The pain is due to the inflammation caused extraocular extension of the tumor, with the growing retinoblastoma invading the periocular tissues. 4.   What are your plans in the management of this child? The treatment for the child is photocoagulation and cryotherapy. Photocoagulation is a possible option in treatment since the mass is still small, and if the mass is located more posteriorly in the eye. However, there is a risk in producing defects in the patient’s visual field post  -treatment. If the mass is located more anteriorly, cryotherapy can be used. 5.   What are the histologic features of this disease? Histologic exam shows apoptotic cells can be seen between viable cells, with calcifications often present. These calcifications are usually visible in x-ray films. These can help in diagnosing retinoblastoma. Figure 1 Retinoblastoma micrograph.   Characteristic of retinoblastoma is the presence of Flexner-Wintersteiner rosettes, which are composed of oval tumor cells surrounding a central lumen, with the nuclei of the cells being peripherally displaced and the cytoplasm occupying the apices (towards the lumen). The presence of these rosettes signifies neuroectodermal differentiation. Figure 2 Flexner-Wintersteiner rosette. The central lumen is surrounded by tumor cells. The nuclei of the tumor cells (dark spots) can be seen in the periphery, while the apices of the cells remain largely clear. Case 4 This 20 year old male presented with pain on his right eye and forehead and blurring of vision for 3 days. 1.   What questions would you ask him? It is important to ask the patient if he has had chicken pox already as a kid. He should also be asked if he is currently taking any medications, specifically if he is taking corticosteroids in his regimen, or if he is currently under chemotherapy for cancer, as these medications will cause  immunosuppression. His sexual history should also be looked into, if there are any signs of exposure to HIV. Additional information: He reported presence of fever and malaise for the past few days but no other symptoms. There was no previous episode of occurrence of the said lesions and past ocular history of red eye or discomfort. The pain was characterized as lancinating and burning on the forehead and around the eye with eye pain and sensitivity to light. 2.   What is the diagnosis? The most likely diagnosis for this patient is Herpes Zoster Ophthalmicus. Because the lesions are limited specifically to the right orbital region and right forehead and the characteristic of the lesions as vesicular and containing serous exudate, the disease is highly suspect. The region of the lesion coincides with the distribution of the ophthalmic division of the trigeminal nerve (CN V), and Herpes Zoster is characterized by the appearance of rashes and blisters along a distribution of a nerve. Figure 3 Distribution of the branches of the trigeminal nerve. The distribution of the vesicular lesions in the patient coincides with the distribution of the ophthalmic branch of the trigeminal nerve. 3.   What would a lesion at the tip of the nose mean? The appearance of lesions at the tip of the nose is called the Hutchinson sign. This indicates that the nasociliary branch of the trigeminal nerve. The Herpes Zoster has thus already involved the eye, since the nasociliary branch provides sensory innervation to the globe, and provides sympathetic innervation to the dilator muscles of the pupil. 4.   What anterior segment eye findings would you look for? Anterior segment findings of Herpes Zoster Ophthalmicus include keratitis, conjunctivitis, belpharitis, iridocyclitis, iritis, and anterior uveitis. There can also be atrophy of the iris and secondary glaucoma.
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