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0V2022 Introduction to eye diseases > CL related pathology > Flashcards

CL related pathology Flashcards

1
Q

what are the CL adverse events?

A

. ( A)IK - asymptomatic infiltrate keratitis
. SEAL - superior epithelial arcuate lesion
. CLPC - contact lens associated papillary conjunctivitis
. CLARE - contact lens acute red eye
. CLPU - contact lens peripheral ulcer
. MK - microbial keratitis

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2
Q

what is asymptomatic infiltrative keratitis ?

A

. sterile corneal infiltrates - white dots in the cornea
. inflammatory cells from limbal vessels
. in response to hypoxia , bacteria , lens deposits , allergic reaction , poor hygiene

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3
Q

what are the clinical signs of infiltrative keratitis ?

A

. eye moderately red and slightly watery

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4
Q

what does patient complain of in infiltrative keratitis ?

A

. mild foreign body sensation

. mild photophobia

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5
Q

what is the management of infiltrative keratitis ?

A

. temporary discontinuation
. most signs and symptoms resolve within 48 hours this is because bacteria doesn’t replicate
. infiltrates resolve over 2-3 weeks
. advice against Extended wear
. if reoccur , switch to daily disposable
. careful monitoring
. ocular lubricants and cold compresses for symptomatic relief

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6
Q

what is superior epithelial arcuate lesion caused by?

A

. caused by mechanical pressure due to design or material

. this happens against the superior part of the cornea below the superior eyelid

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7
Q

what does patient complain of when they have superior epithelial arcuate lesion?

A

. usually unilateral , asymmetric or mildly symptomatic
. irritation
. foreign body sensation

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8
Q

what is the clinical presentation of superior epithelial arcuate lesion?

A

. arcuate staining in the cornea that can run form 10 o’clock to 2 o’clock within 1mm from limbus

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9
Q

what is the current hypothesis of SEAL?

A

. SEAL are produced by mechanical chafing at the peripheral cornea

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10
Q

what is SEAL management?

A 
. cease CL wear for 1-7 days
. issue lubricants
. review lens fit or material 
. use thinner, more flexible lens material 
. change back surface geometry of CL
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11
Q

what is contact lens associated papillary conjunctivitis ?

A

. conjunctival inflammation

. refers to appearance of localised swellings or papillae on tarsal conjunctiva

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12
Q

where are papillae mostly found?

A

. papillae mostly observed in upper eyelid and observed by everting the lid

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13
Q

what is the cause of contact lens associated papillary conjunctivitis ?

A

. immunological response due to hypersensitivity to lens deposits or solution or mechanical response due to lens design or modulus

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14
Q

where are papillae found in RGP wearers ?

A

. they tend to be flatter

. located towards lash margin

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15
Q

where are papillae in SCL wearers?

A

. located in upper tarasal plate

. they take more rounded form

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16
Q

how do papillae appear ?

A

. they appear as round light reflexes giving irregular specular reflection

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17
Q

how does tarsal conjunctiva appear in early stages of associated papillary conjunctivitis ?

A

. in less than grade 2

. the tarsal conjunctiva may be indistinguishable from the normal tarsal conjunctiva apart from increased redness

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18
Q

how do papillae appear in advanced cases?

A

. when there is greater than grade 2 , papillae can exceed 1mm in dimeter and take bright red or orange hue

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19
Q

what are other signs in contact lens associated papillary conjunctivitis greater than grade 3 ?

A

. conjunctival odema
. excessive mucus
. mild ptosis
. cornea may display superior infiltrates

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20
Q

what is the aetiology of contact lens associated papillary conjunctivitis ?

A

. lens induced mechanical irritation

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21
Q

how to manage CLPC?

A

. manage if grade >2
. lens wear can continue if symptoms permit
. improve lens hygiene ( cleaning and wearing time modality )

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22
Q

what are other treatment options for CLPC ?

A

. altering the lens material
. replacing lenses more frequently
. altering or eliminating the care system
. treating any associated meibomian gland dysfunction
. prescribing pharamaceutical agents
. dispensing ocular lubricants for symptomatic relief
. reducing wearing time
. suspending or ceasing lens wear

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23
Q

what is contact lens acute red eye?

A

. inflammatory response of cornea and conjunctiva subsequent to period of eye closure with CL wear

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24
Q

what does px complain of with contact lens acute red eye?

A

. itching

. pain

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25
Q

what is the cause of contact lens acute red eye?

A

. contact lens acute red eye occurs due to endotoxins from gram negative bacteria
( especially pseudomonas app )

26
Q

how is contact lens acute red eye characterised ?

A 
. unilateral 
. epiphora 
. ocular irritation 
. anterior chamber reaction
. acute hyperaemia
. diffuse infiltrate keratitis
27
Q

what are the risk factors of contact lens acute red eye?

A

. upper respiratory tract infection
. high water content CLS
. tightly fitted lenses

28
Q

what is the management of CLARE ( contact lens acute red eye ) ?

A

. self limiting
. temporary discontinuation CL wear
. careful monitoring

29
Q

what is the recurrence of CLARE ?

A

. 50 -70 %

30
Q

what are signs of CLARE similar to ?

A

. similar to microbial keratitis
. it’s important to instil fluorescence and assess the corneal integrity for any epithelial disruption
. CLARE doesn’t usually have epithelial disruption

31
Q

what do corneal ulcers present with ?

A

. conjunctival redness
. white spot in iris
. corneal haze in mid peripheral cornea

32
Q

what are predisposing factors of corneal ulcers ?

A 
. trauma
. corneal surgery
. ocular surface disease 
. systemic diseases 
. immunosuppression 
. CL wear
33
Q

what is the presentation of corneal ulcers ?

A 
. red eye
. pain 
. photophobia
. watering
. visual disturbance ( depending on cause and severity )
34
Q

what are differential diagnosis of corneal ulcers?

A

. non-infectious corneal ulcers such as :

  • marginal keratitis
  • peripheral ulcerative keratitis
  • sterile corneal infiltrates associated with CL wear and toxic keratitis ( solution/eye drops )
35
Q

what is the difference of CL peripheral ulcers and infectious microbial keratitis ?

A

. infectious ulcers are caused by fungus or a virus or parasite or bacteria
. non-infectious ulcers are caused by auto-immunity and marginal keratitis and allergy and inflammation from blepharitis or chemical burn

36
Q

what to do when you find an ulcer ?

A

. measure and record size and shape of epithelial defect and infiltrate, location, depth , margin and colour of ulcer
. look for anterior chamber reaction

37
Q

what is severe anterior chamber reaction a characteristic of ?

A

. superlative infective keratitis which occurs subsequent to corneal trauma and can be initiated by airborne particles

38
Q

what information does NaFI staining give?

A

. presence of dendrites
. loose/exposed sutures
. epithelial defects
. ocular surface disease

39
Q

what does a dendritic pattern mean ?

A

. mostly likely herpes keratitis

40
Q

what does localised punctate staining mean ?

A

. acanthamoeba keratitis

41
Q

what are differential diagnosis of contact lens-associated infiltrative events?

A
  1. contact lens-associated peripheral ulcer ( CLPU )
  2. contact lens associated infiltrative keratitis
these Differential diagnosis are 
- microbial 
( bacterial or fungal ) keratitis 
- marginal keratitis 
- corneal scar
- herpes simplex keratitis 
- adenovirus keratoconjunctiviits
42
Q

what is microbial ( bacterial or fungal keratitis ) also similar to ?

A

. similar to ulcer
. it is important to monitor closely especially over the first 24 hours and if diagnosis remains in doubt , refer to ophthalmologist as an emergency

43
Q

how to differentiate between contact lens pathologies ?

A

. ask specifically about contact with chemicals, CL hygiene, previous herpetic infection , chronic dry eye and ocular surface problems
. systemic history should include : diabetic status , rheumatoid arthritis , Sjogren’s syndrome , systemic immunosuppressants

44
Q

what are different cause of bacterial ulcers ?

A

1 . gram positive - causes a well circumcised ulcer

  1. staph - round or oval lesions with dense infiltration and a distinct border
  2. gram negative - poorly defined infiltrates with copious mucopurulent discharge
  3. pseudo monas - rapid progression , dense stromal infiltrate and corneal perforation
45
Q

what are the common viral ulcer pathogens ?

A
  1. herpes simplex - dendritic epithelial staining including terminal bulbs - look for associated skin lesions
  2. herpes zoster - smaller and finer dendritic lesions , tapered ends without terminal bulbs
  3. adeno viral - ‘ adeno-spots’ subepithelial deposits with punctate staining associated with recent upper respiratory tract infection with conjunctivitis
46
Q

what is the diagnosis of acanthamoeba ?

A

. irritation corneal nerves

47
Q

what are the clinical signs of acanthamoeba ?

A

. subtle irregular corneal surface and punctate staining ( or dendritic )
. gradual enlargement and coalescence of infiltrates . inflammation or corneal nerves . raised ulcers

48
Q

what is the cause of acanthamoeba?

A

. history of CL wear with poor hygiene or water contact

49
Q

what is the difference between acanthamoeba and herpes zoster ?

A

. ulcers are raised in acanthamoeba and do not stain with fluorescence

50
Q

what is fungal keratitis ?

A

. not associated with contact lenses
. systemic immunosuppression or long-term use of topical steroids

. yeast : yellow-white dense suppurative infiltrate

. aspergillus/fusarium : yellow-white stromal infiltrate with fluffy margins and feathery extensions and hypopyon

51
Q

what is the management of bacterial keratitis with small infiltrates or peripheral location?

A

. broad spectrum topical antibiotics

52
Q

what is the management of central , large , deep stromal infiltrates ?

A

. corneal scrape and topical antibiotic therapy

53
Q

when do we admit px to hospital ?

A

. if px is not compliant not with treatment in the initial days

54
Q

when do we use antibiotics ?

A

. antibiotics are preferred for infective ulcers
. ointments for overnight
. systemic antibiotics in severe cases

55
Q

when do we use cyclopegics?

A

. pain relief
. helps with decreasing bacterial load
. debriding helps with penetration

56
Q

when do we use steroids?

A

. to reduce inflammation and increase comfort once clinical signs have improved

57
Q

what is the management of microbial keratitis ?

A

. remove and retain CLs for culture
. emergency same day referral to an ophthalmologist without any intervention . phone the department to explain what you have done

58
Q

what is management of viral specific ulcers such as herpes simplex keratitis ?

A

. this should include ruling out vasculitis , intra retinal haemorrhages and vitreous inflammation
. Ganciclovir 0.15% ophthalmic gel: 5x daily 7-10 days and refer within one week ( if not healed after 7 days )

. or same day referral for children , bilateral , CL wearers or stromal involvement

59
Q

what is the management of herpes zoster zoster ophthalmicus ?

A

. rest, fluids , diet , no contact with babies , pregnancy and elderly
. topical lubricants for ocular relief and pain relief
. refer immediate GP ( skin lesions ) or one week ( deep , uveitis , IOP raised ) or co-manage if epithelial only

60
Q

what is the management of adeno virus ?

A

. artificial tears
. lubricating ointments
. topical antihistamines
. refer same day in case of severe conjunctivitis or significant keratitis ( severe pain/ visual loss)

61
Q

what is the management of acanthamoeba keratitis ?

A

. same day ophthalmology referral
. no intervention for optometrist
. call ahead
. advice to take CLs and case for possible culture

62
Q

what is the management of fungal keratitis ?

A

. same management of acanthamoeba keratitis
. same day referral
. call ahead
. advice to take CLs and case for possible culture

0V2022 Introduction to eye diseases (22 decks)

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