Routine cases may be more common, but it is not uncommon for complex cases to present themselves unexpectedly. In a recent interactive, virtual YoungMD Connect workshop, John Kitchens, MD; Kourtney Houser, MD; Leyla Yavuz Saricay, MD; and Amina Malik, MD, presented case-based reviews of difficult ophthalmic scenarios.
Chronic Macular Hole with Retinal Detachment
John Kitchens, MD, discussed a case involving a 46-year-old woman who presented with a long-standing macular hole in her right eye, a history of uveitis, and underwent cataract surgery 20 years ago in her right eye. During the patient’s initial surgery, an internal limiting membrane peel was complicated by a vitreous hemorrhage and an unstable lens, which led to a retinal detachment. A second surgery was required to perform a lens removal, a retinectomy, and a retinal transplant. The patient’s eye was then filled with silicone oil. In summary, the patient received successful anatomic closure of the macular hole, but her visual acuity was only 20/400. Dr. Kitchens summarized a couple of key takeaways from this case: recognizing complex cases can present certain anatomical limitations, and reviewing patients’ imaging beforehand helps to prepare a surgical plan.
Cataract with Posterior Capsule Rupture
Next, Kourtney Houser, MD, presented a referral case involving a woman in her early fifties who was sent for evaluation after retinal surgery due to a suspected hole in the posterior capsule. The surgical approach included several techniques. Trypan blue dye was first used to stain the capsule. During phacoemulsification, the surgical team lowered intraocular pressure, avoided hydrodissection and lens rotation, utilized a cross-chop technique, and performed gentle irrigation/aspiration. Viscoelastic was used to maintain the stability of the intraocular chamber throughout the procedure. Because of the open posterior capsule, a three-piece intraocular lens with optic capture was chosen for optimal stability. The patient’s recovery was successful. Dr. Houser provided key takeaways from the case, including the importance of adjusting phacoemulsification machine settings, anticipating possible complications, and collaborating with other specialists as needed.
Pediatric Corneal Edema: Amantadine Toxicity
Leyla Yavuz Saricay, MD, presented a case of a pediatric patient who was sent for evaluation of a corneal edema in her right eye and fluctuating vision. The only ocular medication the patient used was artificial tears, and her past medical history included multiple psychiatric and health disorders for which she was on several medications. The medical team highlighted systemic medication (amantadine) as a possible cause. Unfortunately, the medication was used for over two years, so the patient’s corneal edema was irreversible. Discontinuation led to mild improvement, but the patient’s cornea had persistent thickening, which required a partial keratoplasty. Pathology confirmed amantadine toxicity, and post-keratoplasty, her uncorrected vision improved to 20/30. Dr. Saricay echoed the importance of inquiring about systemic medications in unexplained corneal edema and advocates for 12-month follow-ups for patients on amantadine.
Thyroid Eye Disease: Refractory Case Management
Finally, Amina Malik, MD, presented a case involving a 55-year-old woman with a long history of Graves’ disease and relapsing symptoms of comorbid thyroid eye disease. Clinical features at presentation included lid retraction, exophthalmos, diplopia, and optic neuropathy risk. Initial management included steroidal treatment, which was discontinued due to psychiatric side effects, followed by teprotumumab, which elicited a positive response. The patient returned with symptom recurrence and was retreated with teprotumumab. Following another clinic return with worsening symptoms, she was treated with orbital radiation, and nine months later, the patient underwent a bilateral orbital decompression and lid repair. Following a two-year treatment course, the patient’s quality of life greatly improved. Dr. Malik emphasized that thyroid eye disease often requires tailored and sometimes repeated therapies, and noted the importance of collaboration with endocrinology and corneal specialists, as well as setting expectations for chronic disease management.
Take-Home Messages
In a concluding discussion with attendees, the expert panel reiterated the importance of thorough preoperative planning, anticipation of complications, and the value of interdisciplinary collaboration and continuous learning in the field when tackling complex cases. Each doctor agreed that, while the journey can be long and require flexibility, patient outcomes are improved when leveraging all available tools and team expertise.
