Sacco Eye Group - Vestal, NY
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Case Presentations
 

We welcome you to our Case Presentation page!  We are excited to share some of the cases in our practice that demonstrate what we do on a daily basis.  Through these cases we aim to share information about your visual system and the many ways it is intertwined with your overall health and well being.

Traditionally a “Case Report” or “Case Presentation” is used by doctors to study disease entities and interesting patient cases.  We use them frequently as we update our knowledge, either in medical journals or by attending conferences.  The only difference is that these case reports will be presented in a “toned down” way so the lay person can understand the concepts and what we’re discussing.  These are actual patients of ours in our practice, and of course, identities are not revealed. 

Please enjoy, come back often, and learn the wonderful world of vision.

To view the case(s), click on the tab(s) below. You may open multiple cases, or click on the case title again to close the case after viewing.

Case 1:   Jack’s Plaque - Reviewed by Dr. Sacco

"Jack, I'm afraid there's a small plaque in the back of your left eye" I said at the conclusion of my exam.

Jack responded, "I have a plaque in my eye?! Who put it there or how did that get there, I'm a bit confusedů"

Jack was a new patient to our office, 58 years old and pleasant as could be, and I could understand the confusion coming from the poor guy. He thought I meant the type of plaque you hang on a wall! I, however, was talking about a plaque from cholesterol or clogged arteries in either his neck or heart, otherwise known as emboli or an embolus. My attempt to make it more easily understood by using the word plaque instead of embolus was a failure.

Jack came to us simply because he needed new reading glasses, and for no other reason. He had no symptoms. He was on no medication, golfed avidly, and enjoyed working on his antique cars. His kids were out of college and he was contemplating retirement. He had a pretty good thing going. His vision was even perfect at distance without eye glasses and he only needed reading glasses.

When we dilated Jack's pupils to examine his retinas however, we found a very tiny bright plaque in one of the arterioles of his retina. This plaque is perhaps 1/100th of a millimeter in size, if that, and the artery it is lodged in is as fine as a human hair. A photo of this plaque is below at the arrow:

Case 1

We immediately feared that Jack had an emboli break off one of his major arteries in his neck .  The immediate concern with a plaque such as this is that it can be a precursor to a stroke or signal clogged arteries from elevated cholesterol or hypertension.  Sometimes they are from heart valve problems as well, so a cardiology consultation was in order.  Many times there are no symptoms, but plaques such as these can cause mini-strokes or transient ischemic attacks (TIA’s).  Jack had no symptoms whatsoever and he was fortunate it didn’t cause a loss of vision (a stroke to the eye).

We photographed the plaque and made sure Jack knew what we were looking at.  We instructed him to go ahead and get his new reading glasses, but we called his family doctor at Lourdes Hospital before we let him go.  He was seen the next day with a battery of tests and we received a report a week later.

Jack had about 50% blockage in his left carotid artery, his blood pressure was a bit high, and his cholesterol was elevated.  His heart was good to go, which was a relief.  During his examination in our office Jack told us he was healthy, but he hadn’t had a physical or seen his doctor in five or six years!

We saw Jack not too long ago; he’s 63 now and doing great.  As is his style, he thanked us again for detecting his problem and possibly prolonging his life.  His plaque is still along for the ride, unchanged, which is typical.  But now Jack is on cholesterol medication, he’s lost weight, his blood pressure is down, and he’s feeling even better than before.  Way to go Jack!

Case 2:   I Have Glaucoma? - Reviewed by Dr. Kirchheimer

“Derek, I think there is a very good chance you are developing glaucoma in your left eye,” I said after I finished my exam.

Derek didn't completely understand, but I started to explain.  “The pressure inside of your left eye is higher than the right eye, and there appears to be some minor damage to your optic nerve in that eye.”  Derek was 63 at the time and had been a patient at our office for many years.  He had been getting yearly eye exams for as long as he could remember.  He is very active and loves to go fishing with his grandsons. 

Derek responded, not completely sure of what I was talking about.  “I feel fine and my vision is great, especially with the new glasses prescription.  How could I have glaucoma when everything is fine?” 

I went on to explain that we have an optic nerve in each eye.  It acts as the cable that connects the eye to the brain, and I can look at the end of it.  The diameter of an optic nerve is usually less than two millimeters, and so our microscopes are necessary to see the detail needed to pick up damage characteristic of glaucoma.  I also described how the eye is basically a ball filled with fluid.  When the pressure of this fluid gets too high, the optic nerve gets damaged. 

Still, Derek was unsure because his vision seemed fine.  As I continued, I described that in early glaucoma, the vision loss is not noticeable in every day life, but that we can see it on a test called a visual field.  This test measures the side (peripheral) vision, and helps us to know how much damage there is, and if it is getting worse.  Although glaucoma can be a very slow progressing disease, by the time it causes the symptoms of vision loss, it is often very advanced, and sometimes too late. 

Over the next few months, we ran more tests.  I was able to measure the thickness of the front of the eye (the cornea) with an ultrasound, which has been shown to affect glaucoma.  We then took digital, high resolution, three dimensional photographs of the optic nerves to have on file.  We also used a computerized imaging tool called an HRT to measure the thickness of the nerve fibers around the optic nerve.  All of this testing was easy for Derek, not invasive, and helped us make a good decision for treatment.  Below are pictures of a normal optic nerve on the left and an optic nerve with glaucoma on the right.

The good news for Derek was that we can treat glaucoma pretty easily with drops to lower eye pressure.  In many cases, we prescribe a drop that is used one time in the evening, and works well enough to reduce eye pressure for the entire day.  Derek felt incredibly lucky that his glaucoma was caught early because of the fact that it is not reversible.  We can only keep it from getting worse with drops, but we can't make it better.  Derek is still doing well, is feeling as good as ever and still loves to fish with his grandsons.  We intend to help keep it that way.

Case 3:   Just Glasses? - Reviewed by Dr. Kirchheimer

“Jessica, these glasses will make studying easier for you and you should finish your homework without getting so tired,” I said towards the end of her exam.

Jessica was a new patient to our office; a healthy 12 year old who’s grades were fair and who didn’t like reading very much.  Her mother brought Jessica in simply because she was eligible for an examination with the family’s vision insurance.  She had never had an eye examination, and she always tested 20/20 at the pediatrician and the school nurses office.

When I asked how school was going, Jessica and her mother looked at each other.  Jessica replied, “OK.”  As I asked more questions, I found out that Jessica had been getting a lot of “C's” and some “B's”, which was a decline from the year before.  She felt homework was taking longer for her than for her friends, and she seemed to get bored quickly with her assignments or became very sleepy.  She hadn’t told her mother that sometimes she had headaches after studying.  The worst part was that Jessica and her mother both felt that she wasn't performing up to her potential, but they blamed different things.  Jessica felt her work was too boring.  Her mother felt she just didn’t apply herself and do her best.  It was obvious to me that Jessica was a very sharp kid.

When I started to refract (test her eyeglass prescription) it became obvious that Jessica was slightly hyperopic, or farsighted.  She could see 20/20, but had to work a bit at it.  We looked very closely at how Jessica’s eyes were working together as a team, first measuring stereo acuity, or the ability to see in 3-D.  Then we measured how well Jessica could focus, also called accommodation.  We then checked to make sure Jessica's eyes were lined up properly with each other to rule out an eye turn, or strabismus.  Finally we worked together to determine if she had enough stamina to focus from near to far repeatedly for a prolonged period of time (this is called accommodative facility).  All of these tests were normal and I was a bit perplexed. Then we used painless cycloplegic drops to relax her focusing muscles (and temporarily “paralyze” her accommodation and dilate her pupils).  After only thirty minutes, the results were telling. 

Jessica measured almost twice as much farsightedness after the drops were administered.  This was surely the cause for her fatigue.  We call this latent or “hidden” hyperopia.  Her condition is analogous to a slight cramping of the inner eye muscles that reduces efficient focus.  The only way to diagnose it is to use the cycloplegic/dilating eye drops.  Since most focusing takes place at near and shifts to far and the blackboard, the symptoms are more likely to get worse as the day wears on.  Like so many youngsters her age with hyperopia, the symptoms of blur just didn’t exist.  We can draw an analogy to working on your feet all day.  You may not be aware that you’re standing and getting tired, but at the end of the day all you want to do is sit down. 
   
When Jessica and her mother heard that I thought she needed glasses, they were skeptical because she was already seeing 20/20.  I explained that many students see perfect 20/20 vision but struggle from fatigue.  It masquerades as boredom, inattention or just plain lack of effort.  In reality, the degree of effort needed to get through the school day wears a young student down until they just don’t feel like studying when they get home.  I prescribed glasses with the recommendation that she wear them for at school and for studying.  She could remove them for gym class and other physical activities. 

Three months later we saw Jessica for a progress visit.  Jessica enjoyed reading again and her grades were working their way back up.  We recommended that Jessica have an eye examination every year to monitor for a change and make sure her eyes stayed healthy.  We couldn't be happier with the changes she has made, and neither can her mother!

 
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