CL related pathology Flashcards
what are the CL adverse events?
. ( 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
what is asymptomatic infiltrative keratitis ?
. sterile corneal infiltrates - white dots in the cornea
. inflammatory cells from limbal vessels
. in response to hypoxia , bacteria , lens deposits , allergic reaction , poor hygiene
what are the clinical signs of infiltrative keratitis ?
. eye moderately red and slightly watery
what does patient complain of in infiltrative keratitis ?
. mild foreign body sensation
. mild photophobia
what is the management of infiltrative keratitis ?
. 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
what is superior epithelial arcuate lesion caused by?
. caused by mechanical pressure due to design or material
. this happens against the superior part of the cornea below the superior eyelid
what does patient complain of when they have superior epithelial arcuate lesion?
. usually unilateral , asymmetric or mildly symptomatic
. irritation
. foreign body sensation
what is the clinical presentation of superior epithelial arcuate lesion?
. arcuate staining in the cornea that can run form 10 o’clock to 2 o’clock within 1mm from limbus
what is the current hypothesis of SEAL?
. SEAL are produced by mechanical chafing at the peripheral cornea
what is SEAL management?
. 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
what is contact lens associated papillary conjunctivitis ?
. conjunctival inflammation
. refers to appearance of localised swellings or papillae on tarsal conjunctiva
where are papillae mostly found?
. papillae mostly observed in upper eyelid and observed by everting the lid
what is the cause of contact lens associated papillary conjunctivitis ?
. immunological response due to hypersensitivity to lens deposits or solution or mechanical response due to lens design or modulus
where are papillae found in RGP wearers ?
. they tend to be flatter
. located towards lash margin
where are papillae in SCL wearers?
. located in upper tarasal plate
. they take more rounded form
how do papillae appear ?
. they appear as round light reflexes giving irregular specular reflection
how does tarsal conjunctiva appear in early stages of associated papillary conjunctivitis ?
. in less than grade 2
. the tarsal conjunctiva may be indistinguishable from the normal tarsal conjunctiva apart from increased redness
how do papillae appear in advanced cases?
. when there is greater than grade 2 , papillae can exceed 1mm in dimeter and take bright red or orange hue
what are other signs in contact lens associated papillary conjunctivitis greater than grade 3 ?
. conjunctival odema
. excessive mucus
. mild ptosis
. cornea may display superior infiltrates
what is the aetiology of contact lens associated papillary conjunctivitis ?
. lens induced mechanical irritation
how to manage CLPC?
. manage if grade >2
. lens wear can continue if symptoms permit
. improve lens hygiene ( cleaning and wearing time modality )
what are other treatment options for CLPC ?
. 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
what is contact lens acute red eye?
. inflammatory response of cornea and conjunctiva subsequent to period of eye closure with CL wear
what does px complain of with contact lens acute red eye?
. itching
. pain
what is the cause of contact lens acute red eye?
. contact lens acute red eye occurs due to endotoxins from gram negative bacteria
( especially pseudomonas app )
how is contact lens acute red eye characterised ?
. unilateral . epiphora . ocular irritation . anterior chamber reaction . acute hyperaemia . diffuse infiltrate keratitis
what are the risk factors of contact lens acute red eye?
. upper respiratory tract infection
. high water content CLS
. tightly fitted lenses
what is the management of CLARE ( contact lens acute red eye ) ?
. self limiting
. temporary discontinuation CL wear
. careful monitoring
what is the recurrence of CLARE ?
. 50 -70 %
what are signs of CLARE similar to ?
. 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
what do corneal ulcers present with ?
. conjunctival redness
. white spot in iris
. corneal haze in mid peripheral cornea
what are predisposing factors of corneal ulcers ?
. trauma . corneal surgery . ocular surface disease . systemic diseases . immunosuppression . CL wear
what is the presentation of corneal ulcers ?
. red eye . pain . photophobia . watering . visual disturbance ( depending on cause and severity )
what are differential diagnosis of corneal ulcers?
. non-infectious corneal ulcers such as :
- marginal keratitis
- peripheral ulcerative keratitis
- sterile corneal infiltrates associated with CL wear and toxic keratitis ( solution/eye drops )
what is the difference of CL peripheral ulcers and infectious microbial keratitis ?
. 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
what to do when you find an ulcer ?
. measure and record size and shape of epithelial defect and infiltrate, location, depth , margin and colour of ulcer
. look for anterior chamber reaction
what is severe anterior chamber reaction a characteristic of ?
. superlative infective keratitis which occurs subsequent to corneal trauma and can be initiated by airborne particles
what information does NaFI staining give?
. presence of dendrites
. loose/exposed sutures
. epithelial defects
. ocular surface disease
what does a dendritic pattern mean ?
. mostly likely herpes keratitis
what does localised punctate staining mean ?
. acanthamoeba keratitis
what are differential diagnosis of contact lens-associated infiltrative events?
- contact lens-associated peripheral ulcer ( CLPU )
- contact lens associated infiltrative keratitis
these Differential diagnosis are - microbial ( bacterial or fungal ) keratitis - marginal keratitis - corneal scar - herpes simplex keratitis - adenovirus keratoconjunctiviits
what is microbial ( bacterial or fungal keratitis ) also similar to ?
. 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
how to differentiate between contact lens pathologies ?
. 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
what are different cause of bacterial ulcers ?
1 . gram positive - causes a well circumcised ulcer
- staph - round or oval lesions with dense infiltration and a distinct border
- gram negative - poorly defined infiltrates with copious mucopurulent discharge
- pseudo monas - rapid progression , dense stromal infiltrate and corneal perforation
what are the common viral ulcer pathogens ?
- herpes simplex - dendritic epithelial staining including terminal bulbs - look for associated skin lesions
- herpes zoster - smaller and finer dendritic lesions , tapered ends without terminal bulbs
- adeno viral - ‘ adeno-spots’ subepithelial deposits with punctate staining associated with recent upper respiratory tract infection with conjunctivitis
what is the diagnosis of acanthamoeba ?
. irritation corneal nerves
what are the clinical signs of acanthamoeba ?
. subtle irregular corneal surface and punctate staining ( or dendritic )
. gradual enlargement and coalescence of infiltrates . inflammation or corneal nerves . raised ulcers
what is the cause of acanthamoeba?
. history of CL wear with poor hygiene or water contact
what is the difference between acanthamoeba and herpes zoster ?
. ulcers are raised in acanthamoeba and do not stain with fluorescence
what is fungal keratitis ?
. 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
what is the management of bacterial keratitis with small infiltrates or peripheral location?
. broad spectrum topical antibiotics
what is the management of central , large , deep stromal infiltrates ?
. corneal scrape and topical antibiotic therapy
when do we admit px to hospital ?
. if px is not compliant not with treatment in the initial days
when do we use antibiotics ?
. antibiotics are preferred for infective ulcers
. ointments for overnight
. systemic antibiotics in severe cases
when do we use cyclopegics?
. pain relief
. helps with decreasing bacterial load
. debriding helps with penetration
when do we use steroids?
. to reduce inflammation and increase comfort once clinical signs have improved
what is the management of microbial keratitis ?
. 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
what is management of viral specific ulcers such as herpes simplex keratitis ?
. 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
what is the management of herpes zoster zoster ophthalmicus ?
. 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
what is the management of adeno virus ?
. artificial tears
. lubricating ointments
. topical antihistamines
. refer same day in case of severe conjunctivitis or significant keratitis ( severe pain/ visual loss)
what is the management of acanthamoeba keratitis ?
. same day ophthalmology referral
. no intervention for optometrist
. call ahead
. advice to take CLs and case for possible culture
what is the management of fungal keratitis ?
. same management of acanthamoeba keratitis
. same day referral
. call ahead
. advice to take CLs and case for possible culture
