General Practitioners

• Arthritis
• Cryotherapy
  On examination, the patient’s best corrected Snellen visual acuity measured 20/80 in the right eye (OD) and 20/63 in the left eye (OS). Intraocular pressure was normal in both eyes. Anterior segment exam of the right and left eyes revealed posterior chamber intraocular lenses in both eyes, a temporal iridectomy in the right eye and corneal edema in the right eye. No anterior chamber or vitreous cells were noted. Posterior segment exam of the right eye was significant for a small area of retinal whitening and edema superotemporal to the fovea (Figure 1A). The left fundus was notable for an epiretinal membrane, a pigmented demarcation line through the macular from prior retinal detachment and a retinal break with surrounding cryotherapy scars in the superotemporal periphery (Figure 1B). Optical coherence tomography (OCT) of the right eye showed cystoid macular edema (Figure 2A and C). OCT angiography showed no vascular occlusion (Figure 2B). OCT of the left eye showed an epiretinal membrane. Fluorescein angiography (FA) of the right eye showed a focal area of perivenous hyperfluorescence consistent with vascular leakage (Figure 3). The left eye FA was unremarkable.
• Medical Weight Loss
  At initial presentation, the patient stated he had been diabetic for only 1-2 years and that his blood glucose was well-controlled (last A1C 6.4). He also reported excellent control of his blood pressure. Review of systems was positive for fatigue, weight loss, and bilateral leg pain. He was sent to an internist for further evaluation and workup.
• Pediatric Care
• Primary Care
  Upon further questioning, the patient reported a history of HIV diagnosed 6 years prior and having unprotected sexual contact with other men. He denied any previous history of syphilis but had contracted other STI’s in the past which were successfully treated. He denied having any current rashes or neurological symptoms. Based on his presentation and imaging results, the following labs and testing were obtained: ESR, CRP, CBC, CMP, RPR, QuantiFERON-TB gold, CXR, and CD4 count. These results showed an elevated ESR of 66 (0-20 mm/hr), reactive RPR, and reactive FTA-ABS, consistent with a diagnosis of syphilis. His absolute CD4 count was within normal limits at 837 (490-1740 cmm). The patient’s primary care provider was contacted, and treatment was immediately initiated with intravenous penicillin G for a planned 14 day course. The patient returned in one week and his symptoms had nearly resolved, with improvement of his visual acuity to 20/40 OD and 20/20 OS (previously 20/250 and 20/32). The patient was seen again in 2 weeks, with further improvement in the right eye acuity to 20/32. The patient’s OCT showed substantial improvement of the outer retina architecture in the right eye (Figures 5A and B). Fundus autofluorescence showed a reduction in the areas of hyperautofluorescence (Figures 6A and B).
• Emergency Care
  Review of outside records indicated that she had developed left sided periorbital erythema and edema associated with inability to open the left eyelids three-and-a-half weeks prior, and had been treated with a four day course of oral corticosteroids by her local urgent care provider. However, she noted no symptomatic improvement after one week, and consulted with a community ophthalmologist who noted the presence of left-sided scattered periorbital lesions, diffuse conjunctival injection, inferior chemosis, inferior corneal subepithelial infiltrates, and mild anterior chamber cell. Examination of the right eye was unremarkable. The patient was prescribed a 10-day course of acyclovir and topical corticosteroid eyedrops to treat suspected herpetic uveitis on the left. She was lost to follow up for two weeks, only to return when she noted decreased vision in her right eye. Her ophthalmologist referred to our clinic for evaluation of new-onset inflammation of the right eye. The patient’s best-corrected visual acuity measured as 20/60 on the right and 20/20 on the left. Her intraocular pressures were normal, and assessment of her extraocular motility and confrontational visual fields was unremarkable. Examination of her anterior segments was remarkable for keratic precipitates with severe anterior chamber reaction on the right, and temporal scleritis with a quiet anterior chamber on the left eye (Fig. 1). Ophthalmoscopic examination identified moderate vitritis and peripheral, multifocal necrotizing retinitis on the right (Fig. 2), but was unremarkable on the left. Fluorescein angiography of the right eye showed areas of retinitis and vasculitis (Figs 3A and 3B).
• Infectious Diseases
  Shah GK, Krachmer JK: Infectious diseases: Corneal manifestations. In Krachmer JH, Mannis MJ, and Holland EJ, editors, Cornea, 3rd Edition St. Louis, 2004. Mosby, In print
• Electrocardiogram
  Ciuffo, AA, Cunningham ET Jr, Traille TA. Familial pulmonary valve stenosis, atrial septal defect, and unique electrocardiogram abnormalities. J Med Gent 1985; 22:311-313.
• Diarrhea
• Immunizations

Ophthalmologists

• Glaucoma
  What is a Central Retinal Vein Occlusion? A central retinal vein occlusion or CRVO is a blockage of the main vein that drains blood from the retina. The blockage in this vein causes a back up in blood flow, and increased pressure in the small capillaries.These capillaries then begin to ooze blood and serum. Serum is the clear sticky part of blood. This oozing of fluid into the retina is called retinal edema. Retinal edema and blood in the retina cause the retina to work poorly. The vision becomes blurred and distorted and may have splotches in it. Some blockages are relatively mild and the vision is affected only a little, while others are more severe and the vision is affected much more. Sometimes a CRVO can be so severe, that blood supply to the retina is inadequate and the eye tries to compensate with new blood vessel formation termed neovascularization. Neovascularization can cause bleeding into the eye and an abrupt loss of more vision. Neovascularization can also grow in the front portion of the eye and block the structure that helps to regulate eye pressure. This can cause very high eye pressure and severe pain. This condition is called neovascular glaucoma. A CRVO most often occurs in patients with diabetes, hypertension, and atherosclerosis.
• Ophthalmology
  California Pacific Medical Center is a participant in the The San Francisco Ophthalmology Fellowship Match, Program #4125. To register for a Match certificate, contact SF Match at www.sfmatch.org.
• Macular Degeneration
  Age-related Macular Degeneration (AMD ) typically occurs in people over the age of 60. Most people who have the early stages of AMD may notice little if any changes in their vision. This condition is caused by the accumulation of metabolic waste deposits under the retina, called drusen. AMD only affects the central vision, the macula (see How The Eye Works, for more details). AMD occurs in two types: dry AMD and wet AMD.
• Laser Eye Surgery
  The patient noticed a central grey spot in her right eye vision for about 3 weeks duration which slowly progressed. She also described having associated intermittent flashes of light in this eye. She denied any significant past ocular history except for LASIK surgery over 5 years ago to correct her mild myopic refractive error. Her past medical history and family history were unremarkable. She denied smoking or alcohol use. Her review of systems was otherwise negative, with no recent upper respiratory symptoms, skin lesions, or rashes. There were also no young children in her household. She received a COVID-19 vaccine over 5 months prior to her initial presentation.
• Cataracts
  The patient’s best corrected Snellen visual acuity measured 20/50 OD and 20/200 OS. Intraocular pressures were normal. Anterior segment exam showed mild cataracts. The fundoscopic exam of both eyes showed flames hemes, cotton wool spots, and dot blot hemes scattered throughout the posterior pole and periphery (Figures 1A and 1B). Optical coherence tomography (OCT) of the macula revealed subretinal fluid and macular edema in both eyes (Figures 2A and 2B).
• Cataract Surgery
  Holló G, Aung T, Cantor LB, Aihara M. Cystoid macular edema related to cataract surgery and topical prostaglandin analogs: Mechanism, diagnosis, and management. Surv Ophthalmol. 2020 Sep-Oct;65(5):496-512. doi: 10.1016/j.survophthal.2020.02.004. Epub 2020 Feb 22. PMID: 32092363.
• Eye Exam
  Floaters are very common, and most people will see some. However, a sudden change, or sudden increase in floaters can be an indication of a potentially serious problem in the eye. If this occurs, a thorough, dilated eye examination is very important.

Gynecologists

• Female Infertility

Internists

• Colon Cancer
  She has had regular colonoscopies for cancer screening as recommended for her age. Colonoscopies have been negative for colon cancer and colonic polyps.
• Prostate Cancer
  The patient had a diagnosis of metastatic castration-resistant prostate cancer (mCRPC) with known metastases to the lymphatics and bone. He was taking abiraterone and oral prednisone for the last 3 years. PET CT performed 2 months prior to his ocular evaluation showed stable disease.
• Lung Cancer
  Reddy M, Chen JJ, Kalevar A, Terribilini R, Agarwal A. Immune retinopathy associated with Nivolumab for metastatic non-small cell lung cancer. Retinal Cases and Brief Reports. 2017 Nov 22 Epub.

Neurologists

• Neurology
  Roland P. Mackay Award in the History of Neurology presented by the American Academy of Neurology for an essay entitled, "A Historical Survey of the Neural Basis of Homeostasis" (1988).
• Multiple Sclerosis
  4 Infectious causes can be bacterial (tuberculosis, Whipple’s disease, Bartonella), viral (CMV, HSV, VZV, EBV, HTLV-1, Dengue fever), or parasitic (Rickettsia, Toxplasma gondii). Non-infectious causes include intravitreal medications such as vancomycin or brolucizumab (secondary to a type IV hypersensitivity reaction), and systemic diseases such as Behcet’s, sarcoidosis, ANCA associated vasculitis, SLE, systemic sclerosis, Susac syndrome, multiple sclerosis, primary vitreoretinal lymphoma, amyloidosis and inflammatory bowel disease. Rarely BRVO can be caused by genetic mutations (Autosomal dominant neovascular inflammatory vitreoretinopathy (ADNIV)) or can be idiopathic (idiopathic retinal vasculitis, aneurysms, and neuroretinitis (IRVAN)). Ulcerative colitis has specifically been linked to central retinal vein occlusion, BRVO and cilioretinal artery occlusion in a handful of case reports.

Psychiatrists

• Depression

Endocrinologist

• Diabetes Care
• Endocrinology
• Hypothyroidism
  Past medical history was significant for pan-hypopituitarism, hypothyroidism, hypogonadism, undescended testis, obesity and short stature. He had a wide-based gate with otherwise normal cerebellar testing. MRI of his brain was notable for mild vermis hypoplasia, but without a “molar tooth sign” on axial images. He had near normal mentation.
• Diabetic Retinopathy
  Please see How the Eye Works for an introduction. Within the retina is a system of blood vessels – arteries, veins, and capillaries. This system of blood vessels nourishes the retina with oxygen. One large artery, the central retinal artery, carries blood to the retina. As the artery enters the eye, many branches spread out throughout the retina. The blood then goes through a fine network of very small vessels called capillaries. After the blood moves through this network of capillaries, it enters branches of veins, called, branch retinal veins. These then join together to form the large vein called the central retinal vein that drains the blood from the eye. Diabetes causes damage to retinal vessels. This is called diabetic retinopathy. Diabetic macular edema occurs when the small capillaries in the retina have become leaky due to diabetic retinopathy. As serum (the clear sticky party of blood) leaks from these damaged capillaries, it collects in the retina and causes swelling. This blurs and distorts vision.

Radiologist

• Ultrasound
  Figure 2: Ultrasound scan of the anterior segment. Note the hyphema and the haptic contact with the posterior iris surface.
• MRI
  We relayed our concern for possible cancer recurrence with new choroidal metastasis to the patient’s oncologist, who undertook pan-body imaging and held nivolumab until the work up for metastases could be completed. Prompt MRI of the brain and orbit, and CT of the chest, abdomen, and pelvis, detected no evidence of metastases. No further interventions were initiated.
• Radiology
  Department of Radiology and Radiological Sciences, and The Johns Hopkins Swallowing Center. The Johns Hopkins University. School of Medicine. Baltimore, Maryland 21205. Martin W. Donner, M.D. and Bronwyn Jones, M.D., Directors: 7/90-6/91
• X-Rays
• Computed Tomography
  Fluorescein angiography is a very commonly performed test utilizing a special dye that is injected in a vein. This dye travels to the eye and using a special camera, it is possible to evaluate the retinal and choroidal circulation. This dye is unrelated to the common intravenous contrast dyes that are utilized for radiologic studies such as CT scan. Allergies to fluorescein dye are uncommon and the test is very well tolerated. The dye leaves the body through the urine giving it a yellowish-green appearance immediately following the test. This study can be done with a standard camera or a wide-field camera.
• Chemotherapy
  The patient was admitted to the hospital for expedited treatment, consisting of three plasmapheresis sessions and IV rituximab. This was followed by three cycles of outpatient chemotherapy (rituximab and bendamustine).
• Radiation Therapy

Surgeons

• Neurosurgery
  Aliaga L, Yassari R, Straus D, Hekman K, Luther A, Chen JJ, Sampat A, Frim DM. A novel scoring system for assessing Chiari Malformation Type I treatment outcomes. Neurosurgery. 2012 Mar; 70(3): 656-64.
• Reconstructive Surgery
  Chen JJ, Aakalu VK, Setabutr P. (2015) Analysis of lacrimal gland lesions. American Society of Ophthalmic Plastic and Reconstructive Surgery (ASOPRS) 2015 Annual Fall Scientific Symposium: Las Vegas, NV.

Dermatologists

• Skin Cancer
  Malignant “choroidal” melanoma arise from a layer under the retina called the choroid. Please see ‘How the Eye Works’ for more detailed description of the eye. In North America, about 6-7 out of each million people will be diagnosed with a choroidal melanoma each year. It is the most common malignancy that occurs in the eye. Malignant choroidal melanomas can spread to other parts of the body.
• Dermatology
  Fujimura T, Kambayashi Y, Tanita K, et al. HLA‐DRB 1* 04: 05 in two cases of Vogt–Koyanagi–Harada disease‐like uveitis developing from an advanced melanoma patient treated by sequential administration of nivolumab and dabrafenib/trametinib therapy. The Journal of Dermatology. 2018 Jun;45(6):735-7.
• Cyst
• Ulcer
  Zegans ME, Srinivasan M, Santhi CB, McHugh T, Whitcher JP, Margolis TP, Lietman T, Jennette JC, Cunningham ET Jr. Mooren ulcer in South India: Serology and clinical risk factors. Am J Ophthalmol 1999; 128:205-210.
• Lesions
  Brief Case Description A 24-year-old Asian Indian man who is asymptomatic was referred for unusual bilateral retinal lesions.
• Rashes
• Burns

Allergists

• Allergies