Keith Martin (ophthalmologist)

Transcription

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.