April 2018 — Case of the Month:Yellow Spots...— History60-year-old female, Caucasian Presents with blurred vision in the left eye for a few weeks. No pain. — Examination VA: R 6/7.5, L 6/24 (ph NI) — Imaging UWFHazy view from vitritis. Peripheral yellow choroidal lesions. Similar findings on the right but less pronounced. OCTCystoid macular oedema and vitritis. — Differential Diagnosis1. Infective: TB, syphilis, Lyme, endogenous endophthalmitis — InvestigationsTB (QFG): negative — DiagnosisMultifocal choroiditis and panuveitis— DiscussionMultifocal choroiditis and panuveitis is an idiopathic inflammatory condition. Other conditions like tuberculosis, syphilis, sarcoidosis, birdshot chorioretinopathy as well as malignancies need to be ruled out. It is typically bilateral with a female predilection and a median age of around 30. The choroidal lesions vary in size from 50 to 350 µm. They can be located centrally or in the peripheral fundus. Other associated inflammatory signs include disc swelling, macular edema, vascular sheathing and neurosensory retinal detachment. This condition can be recurrent, or chronic and indolent, and some older lesions may appear pigmented. The prognosis for multifocal choroiditis is variable based on the location of the inflammatory lesions and presence of sequelae such as secondary cystoid macular edema, subretinal fibrosis or choroidal neovascular membrane. Treatment is with immunosuppression which includes oral or periocular steroid as well as other immunosuppressive agents as required. In this particular case our patient had a history of non-Hodgkin’s lymphoma and the concern upon presentation was whether she may have had a recurrence of her neoplastic disease. The features that would not support a recurrence of non-Hodgkin’s lymphoma in this case include the small and peripheral location of the choroidal lesions. Often systemic lymphoma that spreads to the eye will deposit in the most vascular region of the eye, the posterior pole. In addition, some of the lesions have pigmentation suggesting chronicity, or a relapsing, recurring course, like with multifocal choroiditis. Blood workup and chest x-ray did not indicate a recurrence of lymphoma. I offered periocular steroid to treat the macular oedema in the left eye. Minimal improvement was noted initially after two weeks and an intravitreal steroid depot, Ozurdex, is planned in the coming weeks if oedema persists. hello@blink.clinic www.blink.clinic April 2018 — Newsletter:— "No Gap" emergency vitreoretinal surgery Dr Richard Barry is now offering NO GAP vitreoretinal surgery for emergency cases. This offer is for any insured patient who wishes to have a timely and efficient, specialist private service for an acute vitreoretinal presentation. Most commonly this will be for retinal detachment, acute macular hole or vitreous haemorrhage, but also for ocular trauma involving the posterior segment. Dr Barry has access to three private hospital facilities and will be able to provide emergent surgery as needed from Monday to Friday. Once referred, the patient will have immediate access to Dr Barry at Blink Eye Clinic, a prompt surgical booking process, reliable surgical timing, as well as ongoing personalized, specialist care peri-operatively. For more information call the team at Blink Eye Clinic on 02 51040929 or email hello@blink.clinic — The cost of ongoing anti-VEGF injections: a little clarity to help you and your patients More and more people are requiring ongoing anti-VEFG injections for macular disease and the burden on the public hospital system is extreme. To venture into the private sector seems unaffordable for many people, especially as the treatment burden is so variable in frequency and longevity. Most anti-VEGF injections are for the treatment of "wet" macular degeneration and many patients are pensioners. Fortunately, there is a Medicare Safety Net to significantly reduce the financial burden on patients with chronic diseases needing regular treatment. I will give you an example... (the figures are not an exact representation of Blink fees, just a guide). Mary is 80 and a pensioner. She has a few other active medical issues requiring specialist visits throughout the year. She develops wet macular degeneration in her right eye. She is referred to a specialist eye doctor. Initial consultation and injection: out-of-pocket cost = $400 Next visit at 1 month: out-of-pocket-costs = $300 Mary is now on the Safety Net...(many patients are already on the safety net from treatment of other co-morbidities) All subsequent visits for injections for the remainder of the calendar year: out-of-pocket-costs = $50 Average number of injections in first year = 7 to 8, often less for subsequent years. Average overall 12 month out-of-pocket cost in first year = approx. $1000 For more information call the team at Blink Eye Clinic on 02 51040929 or email hello@blink.clinic |