August 3, 2013 | POSTED BY | Articles, Clinical Optometry, Retina
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Age/Sex/Race

35 year old Caucasian male

Chief Complaint

“Just here for an eye exam. I also got a Welder’s burn yesterday in both eyes.” He described having foreign body sensation in both eyes and pain of 8 out of 10. He reported that he is a welder so this occurs very often. He stated that he normally uses potatoes to take the moisture out of the eyes.

Medical History

Hypertension

Ocular History

He had a surgery in his right eye about 12 years ago for “some kind of infection that was growing and affecting his vision.”

No history of glasses

Medications

Metoloprol

Allergic to Codiene

Family History

Negative

Diagnosis and initial plan of action

I was thinking about thermal keratitis because of welder’s burn and refractive error. I forgot about surgery when I started entrance testing.

Applicable Testing & Results of Testing

Distance visual acuity (uncorrected)

OD: 20/20-

OS: 20/25-

Cover test: Ortho at distance and near

Confrontation fields: FTFC OU

Extraocular muscles: Full OU

Pupils: PERRLA, (-) APD OU

Slit lamp examination:

Normal lids

Conunctiva: Grade 3+ chemosis OU

Cornea: Grade 2+ superficial punctate keratitis OD and grade 3+ superficial punctate keratitis OS

Courtesy of http://www.wikidoc.org/index.php/Keratitis

No anterior chamber reaction

IOP: 15 OU

Dilated Fundus Exam

OD – punched out yellowish-white lesions with pigment in the center surrounded by hypopigmentation in the inferior retina

–        Chorioretinal scar about 1.5DD in size adjacent to the macula

–        Cup-to-disc ratio 0.2/0.2

Courtesy of http://www.myvisiontest.com/newsarchive.php?action=tag&id=152. My patient had the big macular scar but it was adjacent to the macula. Thus, his vision was unaffected. Punched out lesions were smaller and further out in the periphery with little less pigment in the center.

OS – punched out lesion superior temporal

–        Cup-to-disc ratio 0.1/0.1

Here is another picture with subretinal fluid:

Courtesy of http://webeye.ophth.uiowa.edu/eyeforum/cases/83-presumed-ocular-histoplasmosis-pohs.htm

Assessment and Plan

We diagnosed the patient with presumed ocular histoplasmosis (POHS). It is a triad of punched out chorioretinal lesions (“histo spots”), peripapillary atrophy or pigmentation and macular compromise from choroidal neovascularization (CNV). We assumed patient picked up the fungal bacteria, Histoplasma capsulatum, at a farm since he owned a farm. POHS is commonly seen in people who lived or visited Ohio and Mississippi river valleys or history of exposure to pigeons, chickens and blackbirds. For POHS, we decided to monitor the patient since there were no signs of active infection. A literature review stated that if a patient has a scar in one eye, there is 30% chance that the other eye will develop CNVM. We educated patient that if he saw any type of change in his vision, he needs to return to clinic ASAP. For thermal keratitis, we gave the patient Erythromycin (usage – four times a day) and educated that he can use that whenever he gets Welder’s burns again.

References:

Kanski, Jack J. Clinical Ophthalmology: A Systemic Approach. Philadelphia 2007: pages 484-485

Presumed Ocular Histoplasmosis Syndrome. Handbook of Ocular Disease Management. http://cms.revoptom.com/handbook/sect5o.htm

Presumed Ocular Histoplasmosis Syndrome. Eyewiki.