Case report guidelines



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CASE REPORT GUIDELINES

A case report is an opportunity to show good ophthalmologic concepts and the ability to deliver a well written and well-documented scientific paper about a case performed well by current standards. The use of advanced technology or skill in the reported cases is not required. The Credentials Committee will evaluate each of the items below. The case reports must be selected from the case log and the case log number should be noted in the header of the case report.


Technical Details

  • Each case report should be no longer than five pages

  • Times New Roman font; font size 10

  • Margins justified and 0.5” top, bottom, and sides

  • Top right of each page: CASE REPORT #, CASE LOG #, PAGE #

  • Bottom Right should have your Applicant Number. Please do not include your name on your reports.

  • All drug doses should be listed. They should be listed in mg/kg (not mg/ml) along with actual amount in mls that was given. All drugs should be listed as their generic name. The specific drug used must include its concentration-(this can be in mg/ml)

  • Use only approved abbreviations from the list provided in your packet.

  • All references should be listed in AMA reference citation format superscripted throughout the report and fully listed at the end of the report. References should be limited to one additional page.

  • Read your manuscript while playing the role of a critic. Keep it technical. Please remember that this is scientific writing, and spelling and grammar are very important. Plagiarism of any kind will be result in severe penalties.

Introduction

Present the topic of the case report.



Case Report

1. History

A. Include a signalment and presenting problem or chief complaint.

B. Describe lesions/problem.

C. Describe past ophthalmic history.

D. Describe past medical history if relevant.

E. Describe any other relevant problems.



2. Diagnosis

A. Include results of physical and ophthalmic examinations, ultrasound, ERG, etc.

B. Demonstrate attention to the patient as a whole. Perform appropriate preoperative diagnostics and laboratory tests.

3. Problem List

A. Provide an accurate assessment.

B. Mention all ophthalmic lesions observed.

C. Mention differential diagnosis and their rule-outs.



4. Treatment Plan

A. Discuss different modalities for treatment and their prognosis.

B. If other lesions are apparent, you should mention them and note if treated or not treated.

C. Address any potential genetic impact of the condition, if applicable.



5. Treatment

A. Highlight your involvement in the procedure.

B. Include your anesthetic management: using appropriate anesthetic protocol, drugs (generic name preferred), dosages, route of administration, and monitoring.

C. Demonstrate appropriate peri-operative care: vital functions monitoring and support, intravenous fluid administration, control of body temperature, etc. Adequate pain management is very important.

D. Include dosages and administration routes of any medication used or prescribed. Use generic name when possible. If trade name is used, note generic name and manufacturer. All drug doses should be in mg/kg along with the amount given in mls and route given

E. Describe the handling of any complications.



6. Postoperative Care

A. Describe instructions given to client, including medication dispensed.



Discussion

A. Discuss any point relative to your case.

B. Briefly review the literature on the disease condition and/or procedure in question, if appropriate.

C. Discuss pertinent aspects of the diagnostic work up.

D. Provide references to support your statements.

Conclusion

What conclusion, if any, could be drawn from the case?

Example Case report

CASE REPORT #1, CASE LOG # 1, PAGE # 1

Phacoemulsification is preformed every day in many veterinary ophthalmology practices across the country. Many go as smoothly as planned with absolutely no complications, others are riddled with complications. How the ophthalmology team handle these complications can make all the difference to the owners. How the nurses handle the owners can make all the difference to the doctors.

Genesse is a bichon mix that had behavior issues that they owners had to correct before we felt that she was an appropriate candidate for cataract surgery. This case report is going to discuss my involvement with the owners with dealing with the behavior issues, preparing the owners and the patient for cataract surgery, preparing the operating room for cataract surgery, assisting in cataract surgery, and postoperative care of the patient and owners after cataract surgery.

When Genesse first presented, she was a 4 yo FS Bichon mix. The owner’s acquired her at 6 months of age. 6 months prior to presentation, the owner’s son noticed an opacity in the right eye. The referring veterinarian diagnosed the opacity as a cataract 1.5 months prior to presentation. The owners felt that Genesse was visual, but “she kind of looks out of the side of her right eye”. They reported no pain, ocular discharge, or rubbing of either eye. They presented Genesse to our clinic to confirm the diagnosis, and hear a prognosis and options. The owners’ goal was to restore what vision had been lost and prevent further loss of vision.

The ophthalmic examination revealed a late immature cataract that was mainly nuclear with some cortical involvement (focal area temporally-capsular wrinkling) in the right eye. The lens in the left eye was clear. There were no other anterior segment abnormalities. The STT OD was not done due to Geneses’ behavior. The STT OS was 15 mm/min. There was no fluorescein stain uptake OU. The IOP’s were 13 mmHg OD and 14 mmHg OS. The post seg was NV OD and WNL OS.

Genesse was very anxious and resented having eye drops given during the exam. I had a very in depth conversation with the owners about her behavioral issues and how they could be detrimental to the outcome of the surgery. The owners understood and were willing to spend time working with Genesse and a behaviorist if necessary to get Genesse to a point where she would tolerate being medicated, restrained, and examined.

Genesse came back 3 months later with a hypermature cataract OD and an incipient cataract OS. The owners had been diligently working with Genesse to overcome her behavioral issues. She was more compliant at this visit. Her current medications were flurbiprofen BID OD, prednisolone acetate QID OD, ofloxacin QID OD, and carprofen 2.2 mg/kg PO BID. The cataract in the right eye had resorbed some from the previous visit. The incipient cataract in the left eye was a new finding at this visit. Genesse behaved for her exam and we could tell that they had been working with her. We discussed that it was still a possibility that she could freak out after surgery and injure her eye.

The owners were presented with 3 treatment options.



  1. Retinopexy OS only

  2. Unilateral phacoemulsification OD and bilateral retinopexy

  3. Bilateral phacoemulsification and bilateral retinopexy

After much discussion of risks (retinal detachment, glaucoma, enucleation, etc.) and benefits, the owners elected option 1. This also was helpful as we could see how Genesse would behave in the hospital and get a better idea of how she would do at the time of surgery. It was decided that we would ERG and ultrasound both eyes and preform a retinopexy of the left eye at this visit and have her come back in 6 weeks for a phacoemulsification of both eyes and retinopexy of the right eye.

I performed the ERG and the results were within normal limits. I set up the ultrasound unit and restrained Genesse while the resident performed the ocular ultrasound. There was no retinal detachment seen in either eye. I also drew



CASE REPORT #1, CASE LOG # 1, PAGE # 2

blood for a CBC and Chemistry panel. The only abnormalities on the blood work were hyperalbuminemia and mild decreased amylase.

I premedicated Genesse with Acepromazine and Butorphanol prior to the retinopexy. She was induced with Propofol. I irrigated the cornea with Balanced Salt Solution (BSS) throughout the procedure to maintain corneal hydration and enhance visualization of the fundus. The unoperated right eye was lubricated to maintain corneal hydration. I also was in charge of setting up the OR including the diode laser and overseeing that laser safety procedures were followed while the laser was in use.

Genesse had no traumatic events during her anesthesia, anesthetic recovery, and behaved well during her stay in the hospital.

Genesse came back 6 weeks later for phacoemulsification of both eyes. The owners reported that she had been doing well at home. She was receiving ofloxacin OU QID, prednisolone acetate OU QID, and carprofen 2.2 mg/kg BID PO. She did not like to wear her harness. The right eye had a hypermature cataract, inconsistent menace, mid to mydriatic pupil. The left eye had an incipient anterior cortical cataract. The STT was 14 mm/min OD and 15 mm/min OS. The corneas were Fluorescein negative OU. The IOPs were 8 mmHg OD and 12 mmHg OS. The fundus was not visible OD and normal OS. The ocular ultrasound was repeated OD and no retinal or vitreal abnormalities were seen.

I took the history, performed the STT, fluorescein stain, and IOPs. I also set up for and restrained for the ocular ultrasound.

The next day Genesse was placed under anesthesia for phacoemulsification. An IOL was placed OS, but she was left aphakic OD due to a posterior capsular tear. A retinopexy was performed OD. Genesse had a post-operative intraocular pressure spike OD (50 mmHg), so she was anesthetized again and an aqueocentisis was performed after the IOP failed to respond to latanoprost.

My responsibilities included setting up the OR, clipping and surgical prepping the patient, and monitoring the phaco machine including making sure that the phaco fluids never ran empty, emptying the cassette when it was full, and changing settings.

One day post op, Genesse was visual OU. She had 2+ flare OD and 1+ flare OS. The right pupil was miotic due to latanoprost use. STT was not preformed. Fluorescein stain was negative OD and positive OS. The IOPs were 9 mmHg OD and 15 mmHg OS. The fundus was not visible OD due to miosis and OS was normal. The decision was made not to dilate the pupils due to the post-operative pressure spikes.

Genesse was sent home with an Elizabethan collar and instructions to leave it on at all times. The owners were also instructed to only leash walk Genesse using her harness; as well as no running, jumping, playing, or other off- harness activity. Due to the corneal ulcer in Genesse’s left eye, we discussed the importance of using the topical steroid, prednisolone acetate, only in the right eye. Genesse was also sent home on an anti-anxiety medication, Trazodone, in addition to ofloxacin QID OU, timolol BID OU, latanoprost BID OD, dorzolamide TID OU, carprofen 2.2 mg/kg PO q 12 hr, and Optixcare QID OU.

5 days post operatively, Genesse was visual in both eyes and the inflammation had resolved. The superficial corneal ulcer in the left eye was healing. The corneal incisions were intact OU. The IOPs were 11 mmHg OD and 9 mmHg OS. The post seg exam was normal OU.

We recommended that Genesse’s Elizabethan collar stay on and that she continue to be leash walked only. The doctor discontinued the use of latanoprost at this time, but pred acetate OD QID, ofloxacin OU QID, dorzolamide OU TID, timolol OU BID, carprofen 2.2 mg/kg PO BID, trazodone PO BID, and Optixcare OU QID were continued.

3 days later Genesse’s owners brought her back to us to have the cornea stained and the IOPs checked. The corneal ulcer had healed and the IOPs were 11 mmHg OD and 10 mmHg OS. Mild vitreal syneresis was noted OU. Optixcare

CASE REPORT #1, CASE LOG # 1, PAGE # 3

was discontinued at this time. Other medication changes included pred acetate OU QID, dorzolamide OU BID, carprofen 2.2 mg/kg PO BID and ofloxacin OU QID until the bottles were finished, trazodone PO BID only for 2 more weeks. Timolol was continued at OU BID.

Genesse presented for her next appointment 3 weeks post-surgery. The owners reported that she was still doing fine. Her exam findings agreed. She was visual with IOPs of 14 mmHg and no flare OU. She was released from wearing her Elizabethan collar. Genesse was decreased to 2 medications pred acetate TID OU and dorzolamide BID OU with instructions to stop the dorzolamide 3 days before the next appointment.

At the 5 week post-operative visit, Genesse was doing excellent with no concerns regarding the eyes from the owners. Menace and dazzle were intact OU. She did however have a less than 1 mm superficial corneal ulcer with focal area of subepithelial lipid deposit. Her STT were NE. Her IOPs were 12 mmHg OD and 10 mmHg OS. The owners had forgotten to stop the dorzolamide, so Genesse was left on it until 3 days prior to the next visit. She was also sent home on pred acetate BID OD, tobramycin QID OS, and GenTeal severe gel as a lubricant in the OS.

We rechecked the corneal ulcer 1 week later. The owners reported that she was occasionally rubbing the left side of her face on the carpet and appeared to be squinting her left eye. The exam showed a small, central superficial corneal ulcer and a focal subepithelial lipid deposit. The STT were NE, the fluorescein stain was negative OD and positive OS, the IOPs were 12 mmHg OD and 6 mmHg OS, the post seg was WNL. The doctor prescribed prednisolone acetate OD BID, tobramycin OS QID, GenTeal OS QID, and carprofen 2.2 mg/kg PO BID. They were told to discontinue the dorzolamide at this time.

We again saw Genesse 1 week later. She was now 7 weeks post phacoemulsification. She was doing well at home. Only occasionally rubbing the right side of her face on the carpet but not squinting either eye since her previous visit. Menace and dazzle were positive OU. There was a less than 1 mm centrally located superficial lipid deposit and corneal fibrosis and trace flare in the left eye. The right eye had no flare. The STT were not measured. There was no fluorescein stain uptake in either eye. The IOPs were 11 mmHg OD and 6 mmHg OS. No abnormalities were noted OU on posterior segment examination. The corneal ulcer in the left eye had healed, but she now had mild inflammation, therefore, topical steroids were reinstituted as well as systemic nonsteroidal anti-inflammatories.

17 days later Genesse presented for a recheck of the uveitis. The owners reported no ocular discharge, squinting, or redness. On the ophthalmic exam, the menace and dazzle were both positive and there was no flare OU. The lipid deposit OS was static. The STT were not measured. The fluorescein stain was negative OU. The IOPs were 11 mmHg OD and 14 mmHg OS. There was mild syneresis noted on the posterior segment exam OU. The doctor decided the prednisolone acetate should continue to be given BID for two more weeks, and then decrease to SID. The owners were instructed to start medicating with flurbiprofen OU SID in two weeks, when they decrease the Prednisolone acetate to SID.

Genesse came back 6 weeks later for her 3 month post phacoemulsification recheck. The owners were happy with her progress. They reported that she was visual and comfortable. The ophthalmic exam findings were unchanged. There was a lipid opacity OS, pseudophakia with mild capsular fibrosis OS, aphakia with wrinkled capsule OD, STT were NE, fluorescein stain was NE, IOPs were 12 mmHg OD and 9 mmHg OS, and mild vitreal syneresis OU. The doctor recommended discontinuing the prednisolone acetate and increasing the flurbiprofen to BID OU.

3 months later Genesse presented for her 6 month recheck. Her owners reported good vision and no ocular discomfort. They had recently noticed a slight cloudiness in her left eye. Current medications were flurbiprofen 1 drop BID OU. The ophthalmic exam revealed menace and dazzle were positive OU, static lipid in the cornea OS, 3+ capsular opacification OS with a focal spot of pigment on the anterior lens capsule, 3+ capsular opacification with a wrinkled capsule OD. The STT and fluorescein stain were not performed. The IOPs were 9 mmHg OD and 11 mmHg OS. The posterior segment exam was unchanged. The doctor recommended decreasing the Flurbiprofen to SID OU.

The owners brought Genesse back 7 months later for another recheck appointment. At this visit she was 13 months post phacoemulsification. There had been no obvious sign of pain or discomfort or changes with her vision. The



CASE REPORT #1, CASE LOG # 1, PAGE # 4

ophthalmic exam was unchanged. Anterior segment: no flare, 3+ PCO OU, IOPs: 13mmHG OU, Posterior segment: normal fundus. The doctor recommended continuing flurbiprofen SID OU.

8 months later the owners brought Genesse back due to the fact that the primary veterinarian made a comment about the cataract regrowing during Genesse’s annual wellness visit. Genesse was still visual and had no signs of ocular discomfort. The ocular exam was once again unchanged. We discussed that the primary veterinarian was probably noticing the capsular opacities and that there was not cataract regrowth. The doctor recommended keeping Genesse on Flurbiprofen SID OU and following up with us annually.

Glaucoma can be a complication associated with phacoemulsification, but another condition known as postoperative ocular hypertension (POH) has also been associated with cataract removal in dogs. As the name implies this condition is associated with increased IOP following surgery that resolves within 24-48 hours and/or responds to IOP lowering medications. If the pressure remains elevated this condition has been associated with intraocular inflammation, debris in the aqueous humor outflow pathways, vitreal herniation, retention of fluids used in surgery in the anterior chamber, and tight surgical incision apposition. Glaucoma due to phacoemulsification may be due to fibrin formation leading to synechia blockage of the pupil leading to iris bombe, or closure of the ciliary cleft associated with loss of the lens. To determine if the spike in Genesse’s IOP was due to POH vs. Glaucoma she was weaned off of her anti-glaucoma medication and had her IOP’s monitored for any increase.

The most likely cause of the IOP spike for her would be vitreal herniation due to a tear in the posterior capsule of the lens. This was the reason an IOL was not placed in the right eye. The medications to treat glaucoma include prostaglandin analogs such as latanoprost or travoprost, carbonic anhydrase inhibitors such as dorzolamide or brinzolamide, or topical beta blockers such as timolol. Prostaglandin analogs work to increase aqueous outflow while carbonic anhydrase inhibitors and beta-blockers work by decreasing aqueous humor production. Mannitol can also be used in emergency situations to rapidly reduce the amount of fluid in the eye through osmotic diuresis.

Bichon Frises with inherited cataract have been reported to be at greater risk for retinal detachment post phacoemulsification. Therefore prophylactic retinopexy was performed on Genesse. A paper by Pryor et al, has since shown there is no statistical evidence to support that this decreased the rate of retinal detachment in Bichon Frises.

Bichon Frises are also predisposed to corneal dystrophy including corneal lipid deposits. Topical anti-inflammatory medications have been shown to exacerbate these lesions. Therefore, it is not surprising that Genesee developed corneal lipid deposits.

References

Schmidt GM, Vainisi SJ. Retrospective study of prophylactic random transscleral retinopexy in the Bichon Frise with cataract. Veterinary Ophthalmology 2004; 7: 307-310

Pryor SG, Bentley E. Retinal detachment post phacoemulsification in Bichon Frises: a retrospective study of 54 dogs. Veterinary Ophthalmology 2016; 19, 373-378

Klein HE, Krohne SG. Postoperative complications and visual outcomes of phacoemulsification in 103 dogs (179 eyes): 2006-2008. Veterinary Ophthalmology 2011; 14: 114-120

Crasta M, Clode AB. Effect of three treatment protocols on acute ocular hypertension after phacoemulsification and aspiration of cataracts in dogs. Veterinary Ophthalmology 2010; 13: 14-19



Hacker DV, Farver TB. Effects of tropicamide on intraocular pressure in normal dogs − preliminary studies. Journal of the American Animal Hospital Association 1988; 24: 411–415.

Gelatt, K. N. (ed) (2014) Canine Cornea: Diseases and Surgery, in Essentials of Veterinary Ophthalmology, Third Edition, John Wiley & Sons, Ltd, Oxford, UK. doi: 10.1002/9781118910337.ch11


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