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this is a case that hasn't had surgery
and having heard from the previous speakers this may actually be a case
from Purgatory rather then the case from Hell
the other ones are definitely making me nervous
let's talk it through it. It's quite a long history
there's quite a lot has been going on and that's the reason that
I chose this as an
an instructive or as a teaching case is i think there are lots and lots of
different issues
particularly medical issues in the choice of medication and i know that
within these forums that most people tend to choose from
quite exciting surgical cases
which don't necessarily apply to everyone here i don't know what the
rates of tube surgery is in the audience but i know that not everyone
does tube surgery
but everyone here prescribes meds
so... that's that's why i've chosen this one.
And also because of that there's something in it for everyone, there's something
in it for everyone
to sit there and think
"what would i have done differently"
and don't worry about saying that because
you won't offend me because
a lot of the case occurred
before i saw them
uh... but also to just
get our minds thinking and questioning about
all the various complexities of
complex medical cases. So this was a lady that when she first... came under the
care of Moorfields
uh... had already had a
diagnosis of primary open angle glaucoma for a decade
She'd been seen and managed elsewhere then moved
By this stage she was already eighty
And i know that some units
really don't like surgical interventions in
the extremes of life... And also
people tend to start thinking "well, what is the life expectancy?
how long are we going to keep them seeing for?
maybe we can moderate or adjust our target pressures accordingly"
and looking into the crystal ball
and this is perhaps a
salutary tale that we have to be careful
She'd already had infective keratitis, she'd been described as having severe blepharitis,
had her lenses out
we had no idea what her maximal pressures are, and she had
polymyalgia rheumatica.
She was being managed on
prostaglandine and
and a not particularly effective beta blocker and she was taking a lot of steroids for her
for her polymyalgia
and she was bit depressed because she had to make some aches and pains of old age
and she had pretty good fields.
so we started off in pretty good base....
open angles
normal HRC
and vision's at 6:9. So she's 80, she's got full fields
her vision's at 6:9
and her pressures are great so
we're all very happy with that and think we can see her
at a nice long follow-up interval
and we're not worried.
So what do you already thinking??
well you're probably thinking
Did she have any systemic steroid effect? was there any
contribution from her
kind physicians who had been
really quite heavily dosing her with oral steroids for her polymyalgia - she's a little
frail thing - she's is about five foot five
or she could be if she could stand up these days
How robust is her original diagnosis, does she really need those steroids?
Can she use the drops? Polymyalgia gives you a proximal limb weakness and ache,
can she actually get the drops in, who's doing them for her?
i think we have all heard about compliance this morning
She's had a poor tear film, could we minimise her preservative load?
Does an 80-year old really need any beta blockers?
Her exercise tolerance is
going to be limited, unfortunately, by her walking.
What might we be doing with those beta blockers? And is this really
glaucoma at all, if she's got full fields and healthy discs,
what are we actually dealing with
and has anyone actually thought about bone prophylaxis? because often
these people get started on oral steroids by ophthalmologists - everyone
diligently carries on prescribing them, and no one necessarily thinks
about all the other
prophylaxis
so...
We switched her onto a better beta blocker and her pressures were even lower.
She still had a blepharitis and she still had a band keratopathy,
and then she came back a few years later and her pressure was 37
She had a series of fields,
she now has definitely got some visual field loss and we can now say
yes she's getting worse, and in that period.
whether this was
non-compliance whether this was an escape from control
she definitely had glaucoma.
Then,
under the hands of my predecessors, she had a Teracheolectomy
because of the multiple treatment she was having she was poorly tolerating
Partly she's got a poor optical surface,
and she had surgery
So, now she's had surgery
and medicine in the other eye,
and topical lubricants and good pressures.
This was the year before last, and she's not doing too well.
But now she's had a diagnosis of
ATRAL fibrillation, Polyarteritis Nodosa, so part of the whole spectrum
of collagen disorders
She's developed an anxiety disorder
This is her drug history. She's now on
she has got some bone prophylaxis
she's got some Cholecalciferol, some Calcium Carbonate, Warfarin, Alendronate weekly,
Digoxin once a day, Diltiazem twice a day, Prednisolone once a day, Methotrexate
Doxepin once a day, Folic Acid three days after the Methotrexate
if she remembers,
plus all her eye drops
so i'm thinking about...
What are you thinking about?
well i would probably be thinking
that's a hell of a drug regime
We hope that she's got somebody to help her out with that
even with a little dosset box
to regularly dish her out the tablets at the right time of day,
on the right day
that's a hell of a thing to be coping with.
And she's got to cope with her drops.
i'm still thinking does she really need those beta blockers? because she's still got
them and can't
we do something about the ocular surface, because we're still poisoning her?
Can she actually still take these drops?
And yes, it was really glaucoma, or at least by the time we've now got
this far
it had become glaucoma.
So she's now eighty-seven
pretty unhappy
she complained of ocular pain as well as pain everywhere else
and she's got a blurred right eye.
Visions dropped a bit
I've managed to measure the corneal thicknesses,
and she's now got pressures that are up in the right eye.
her SHO gave her Diamox, which an 87-year old who's got
multiple systemic pathologies -- I've scratched the surface of some of them --
was a brave thing to do. But he thought of that, so he gave her a low dose.
She's got a pretty poor right cornea,
and her discs are cupping out.
so she may well be having poorer compliance in between visits anyway
and she's obviously doing badly at the moment.
We switched the Diamox to Iopidine, and I switched everything to preservative free.
What else are you now thinking??
Drug interactions, Diamox; do we really want to be giving Diamox to her?
Why we might not want to use Cosopt? we know that she's got
pretty awful corneas.
Why didn't we do a trab? Well, she's got polyarteritis nodosa,
rheumatoid arthritis
and an appalling ocular surface
Just wondering about her antidepressants, just having a little think about
the possibility of trachyphylaxis
crossing the blood-brain barrier in our choices of alphaangulants
I'm also thinking about lid hygiene, she's still got terrible blepharitis, and can't
reach her lids to do any kind of lid hygiene although
everyone's diligently written in the notes that's what we're doing
Yes, she's still on beta blockers and an elderly woman.
Her right eye is holding up pretty well,
and then it crashes to counting fingers.
She's now got, aged 87,
a severe
florid bilateral anterior uveitis, with cmo worse in
the right eye
and i'm told that these are not normal by my retinal colleagues
appalling
corneal surface disease
she is very, very unhappy
not least of which she's wheelchair-bound takes a long time to get into hospital
and funnily enough she's coming back to see us
and the uvitis service
and the corneal guys quite frequently so she's got three different services
managing
what is the remainder of her, what? three years? five years? of life
She's spending most of that time just in ophthalmology let alone the rest of it
and
she's now got
a series of preservative-free drops, which GPs hate because it costs a fortune,
but at least we can write to them and tell them they don't have a choice.
The corneal team give her Hyloforte, which is for ocular surface,
and Doxycycline,
which hopefully is ringing some alarm bells somewhere in the audience.
and she still unhappy
So what else we thinking?
Prizes for
those people who wer
worried about the Doxycycline
because Doxycycline with the Warfarin anticoagulant
is certainly one drug interaction that may well kill her.
Most of what we've done so far isn't likely to kill her rapidly but the Doxycycline
potentiates the action of Warfarin, and therefore may well push her RNR
through the roof
Then she may have a haemorrhagic stroke. There's a significant instance of
with that sort of drug interaction.
I've certainly seen a number of individuals come in with
spontaneous supercorneal hemorrhages...
two intelligible one intelligible injection required for people who
have been given
antibiotics that have potentiated Warfarin.
and then develop an intractable secondary
posterior segment mechanism angle closure glaucoma
(because you wanted me to get angle closure in).
So...
that's the first thing.
Then we stopped the Doxycycline so we didn't embarrass the corneal colleagues.
Can we use systemic steroids?
Why the uveitis?
Well she's got an intermediate uveitis when you look a little more closely.
Now she's got some controlled
pressures
on her medications.
A new infection's coming along, so we reduce the corneal sensation, we give her Levofloxacin,
preservative free
this was not
a case from
the ivory towers
because things still go wrong. She gets
preserved medications the GP hadn't changed her records. She got preserved
Levofloxacin because the pharmacist had that in stock, but not the unpreserved
So what are we now thinking?
Anyone want to do surgery?
What about her compliance? I mentioned the fact that she's seeing three eye teams
alone
She's got multiple different
scripts, repeat medications
communication failures between the three eye teams
the rheumatologist, the GP,
and the psychologist.
She's definitely getting anxious about all of this, and she's spending
most of her remaining days in hospital.
She comes back in
She's now got a pressure
in the originally unoperated eye of 36.
Anyone want to operate?
And she's fed up.
so now she's on
a series of preservative free drops
her pressures back in control, we had a long sit down chat with
with a little bit of help, some hand-holding, and a little bit of hand-holding
with her long suffering carers.
we've got her pressures under control
So the preservative-free worked well, the preservative-free Prostogandene
seemed to be a good thing in this case
the laser trabeculoplasty - well, who knows.
so
it's a non-surgical case
We managed to juggle and juggle and talk her and
her carers into taking her drops.
we finally for the time being get her under control
we've managed to stop our corneal colleagues from killing her
and
the various messages are the old messages. that we always always always
get
and i think apply to all of us
which is, compliance
and I know Dave talked a lot about compliance but that's that such a big deal
that we can't ignore it:
protect the surface
minimize the load if we can
and then also just consider those drug interactions in the whole patient
where we can
they're all things we know and i think that at various different times in our practice
they are things that we forget
That was the reason for choosing her, and I hope that was some help.