Case 4: Keratitis Flashcards
Classic description of staph marginal keratitis
Mulitple, bilateral, peripheral corneal stromal infiltrates (w/o overlying epi defects) secondary to chronic blepharitis
Corneal ulcer
Corneal epi defect w/ an underlying stromal infiltrate
Recurrent corneal erosions
Poor hemidesmosome attachments between corneal epi & underlying basement membrane
RCEs are most common in eyes w/ a Hx of ______or ______ ______
Trauma; corneal dystrophies
What would a pt w/ an RCE report?
Pain in the morning upon awakening, photophobia, FB sensation
50% of pts w/ RCEs have ______, only 10% of pts w/ _____ will develop RCEs
EBMD, EBMD
Corneal abrasion
Occur secondary to trauma that results in corneal epi defect WITHOUT an underlying infiltrate
Infectious corneal ulcers
The size of the epi defect will match the size of the infiltrate
Sterile corneal ulcers
Epi defect will be smaller than size of the infiltrate
Staphylococcus marginal keratitis is a type ______ hypersensitivity reaction
3
What is staph marginal keratitis most commonly assoc w/?
Staph bleph, acne rosacea, & phylctenule
Which inflammatory bowel disease most commonly is assoc w/ uveitis?
Ulcerative colitis
IBD is most commonly assoc with what type of uveitis?
Acute, bilateral, anterior or posterior, non-granulomatous uveitis
MC systemic sx of IBD
chronic diarrhea w/ alternating episodes of constipation, cramping & feeling bloated after meals
What is most appropriate to treat staph marginal keratitis?
Topical ophthalmic antibiotic/steroid combo (Tobradex)
Anterior Blepharitis Tx
- eyelid scrubs BID or TID until the condition stabilizes, & then QD thereafter 2. Bacitracin or erthromycin ointment at bedtime for approx 2-4 weeks 3. Azasite (topical ophthalmic azithromycin) drops BID x 2 days then QD x 12 days 4. Topical ophthalmic antibiotic/steroid combination ointment at bedtime if sig redness or inflammation is present
Posterior blepharitis Tx
- warm compress 5-10 min QID 2. eyelid scrubs BID or TID until condition stabilizes, then QD after 3. topical opthal antibiotic/steroid combo (Tobradex) 4. Azasite BID 2 days then QD x 12 days 5. Oral doxy 100 mg BID for 4 wks, then 100 mg QD for 3-6 mo. or 40-50 mg QD for 6-12 mo. 6. Fish oil + omega 3 fatty acids
Seborrheic blepharitis
Less eyelid inflammation, more oily, greasy scales, & flaking compared to staph bleph
What are 3 objectives for RCEs?
- Prevent infection & heal the corneal defect 2. reduce pain 3. prevent occurences
3 ways to prevent infection & heal corneal defect in RCE
- broad-spectrum topical opthal antibiotic BID to QID 2. preservative-free AT up to Q1H 3. debridement
3 ways to reduce pain of RCE
- cycloplegic 1 gt in office 2. topical opthal NSAID BID x 2-3 days or until corneal epi heals 3. bandage CL
2 ways to prevent occurrence of RCE
- oral doxy 50 mg BID & topical opthal steroid TID x 3-4 wks 2. muro 128 ointment qhs x 3mo.
Anterior stromal micropuncture
making numerous micropunctures into & thru the corneal epi BM/Bowman’s layer complex -> SL w/ blunt stromal micropuncture needle
What is the MC type of infectious keratitis?
Bacterial keratitis
Canadian National Hockey League- bacteria that can invade an intact corneal epi
Corynebacterium diphtheria, Nisseria gonorrhea & meningitidis, Haemophilus, Listeria
Tx of small corneal ulcers
Topical ophthal antibiotic Q1-2H after initial loading dose followed by slow taper
Tx of large sight-threatening ulcers
Fortified topical opthal antibiotics (cephazolin 50 mg/mL & tobramycin 14 mg/mL every 15-30 min after a loading dose of 1 drop every min for 5 min
Fungal keratitis presentation
Gray-white corneal infiltrate w/ feathery edges & satellite infiltrates
Fungal keratitis Tx
Topical opthal antifungals Q1H while awake (Amphotericin B & Natacin). Systemic antifungals advised in severe cases (Ketaconazole, Itraconazole)
Acanthamoeba keratitis presentation
Severe pain that is out of proportion to corneal signs in early stages of keratitis. Corneal signs include mild SPK & pseudodendritic defects.
What culture does acanthamoeba keratitis grow on?
Culture requires a non-nutrient agar w/ Eschericha coli; acanthamoeba can also grow on blood or chocolate agar but not as well
Acanthamoeba keratitis Tx
- Topical opthal anti-parasitic agents: Propamidine isethionate Q1H (Brolene and/ or polyheamethyl biguanide PHNB) Q1H, followed by slow taper (often over the course of months. 2. oral anti-fungal agents: ketaconazole 200 mg or itraconazole 100 mg BID 3. cycloplegic agent TID 4. topical opthal antibacterial agent: Neosporin Q1H 5. topical opthal anti-inflammatory agents: topical opthal steroids (controversial)
When is the FU for corneal ulcer?
1 day
