corneal infiltrative events Flashcards
what is an infiltrate?
white blood cells in conreal tissue due to inflammatory response to bacterial toxins
what is a corneal ulcer?
epithelial defect with underlying inflammation
are corneal ulcers infective?
can be non-infective or infective
what are the 3 different ways to classify CIEs?
ulcerative vs non-ulcerative
suppurative vs non-suppurative
central vs peripheral keratitis
how does a corneal ulcer form?
too much colonising bacteria on the CL, causes build up of endotoxins, which are trapped between CL and epithelium, then go into the epithelium, which triggers WBC response
what is a disadvantage of describing a CIE as ulcerative vs non-ulcerative?
lack of agreement over definition of ‘ulcer’
what does suppurative mean?
produces discharge (pus)
what is a disadvantage of describing a CIE as suppurative vs non-suppurative?
not all MK cases have discharge
what is a disadvantage of describing a CIE as central vs peripheral?
not always reliable indicator of whether infiltrate is sterile or not
what are asymptomatic infiltrates?
infiltrates in patients without symptoms
are asymptomatic infiltrates only in CL wearers?
no - can be in non-CL wearers too
what are asymptomatic infiltrates usually caused by?
environmental factors e.g air pollution
signs of asymptomatic infiltrates?
1 or more small discrete grey-white patches usually in periphery
intraepithelial
formed from inflammatory cells
no other signs of inflammation
symptoms of asymptomatic infiltrates?
none you donut
management of asymptomatic infiltrates?
px lens care review
review is concern over compliance or a larger number of infiltrates
what does this image show?
asymptomatic infiltrates
signs of asymptomatic infiltrative keratitis (AIK)?
small focal infiltrates up to 0.4mm
sub-epithelial
may be small punctate staining
mild limbal and/or bulbar redness
how to differentiate between AIK and AI?
sub epithelial in AIK, intraepithelial in AI
-also size on infiltrates in AI (<0.2mm) and AIK (<0.4mm)
management of AIK?
review lens care
review fitting and advise against sleeping in lenses
symptoms of AIK?
NONE YOU FRESHY
what does this image show?
AIK
who is AIK more common in?
those wearing lenses for 12-14 hours +
or sleeping in lenses
what do you say to a px with AIK?
you have signs of an inflammatory reaction, this is common if you get build up of toxins on the lenses which usually occurs when we aren;t cleaning the lenses as much as needed …. then go on to talk about your management or whatever
what is infiltrative keratitis?
inflammatory reaction of the conrea charaacterised by anterior stromal infiltration, with or without epithelial involvement, in the midperiphery to periphery of the cornea
what does this image show?
infiltrative keratitis
signs of infiltrative keratitis
single (or multiple) small round infiltrates in epithelium or anterior stroma
may be unilateral or bilateral
sectoral bulbar and/or limbal hyperaemia
epithelium generally doesn’t stain
symptoms of infiltrative keratitis
minor infiltrates = asymptomatic
discomfort
FB sensation
irritation
mild photophobia
lacrimation
symptoms reduce on lens removal
management of infiltrative keratitis
remove the cause
cease lens wear
use of lubricants for symptomatic relief and to flush out any toxins in the eye
treat marginal disease
monitor progress
what is CLARE?
cl induced acute red eye
inflammatory reaction of the cornea and conjunctiva immediately following a period of eye closure with CL wear due to endotoxins from gram negative bacteria
signs of CLARE
acute, unilateral circumferential bulbar conjunctival hyperaemia
small mid-peripheral infiltrates
SEVERE = mild anterior chamber involvement
symptoms of CLARE
wake up in middle of the night with painful red eye
lacrimation
photophobia
FB sensation
management of CLARE
self-limiting
remove lens
monitor 12-24 hours to ensure correct diagnosis
ocular lubricants
address lens compliance and lid hygiene as appropriate
daily wear - possible refit
prognosis good
cause of CLARE
usually sleeping in lenses
what is CLPU
inflammatory reaction with focal excavation of the epithelium, infiltration and necrosis of the anterior stroma
in CLPU which layer of the cornea remains intact>
bowmans layer
signs of CLPU
unilateral
single (usually) small sterile infiltrate in the peripheral cornea (<1.5mm)
clear cornea between ulcer and limbus
epithelium may stain
defined margins
mild sectoral hyperaemia
no lid oedema
SEVERE = mild AC reaction
symptoms of CLPU
50% = asymptomatic
possible FB sensation
mild photophobia
lacrimation
general lens intolerance
management of CLPU
cease lens wear until resolves (~2weeks)
self-limiting byt careful monitoring over first 24-48 hours due to MK risk
ocular lubricants
possible prophylactic antibiotics???
treat any lid margin disease
address compliance regime - consider modality
good prognosis - corneal scar likely
which modality of lens are you more likely to get a CLPU
extended wear lenses
associations of CLPU
bacterial contamination
hypoxia
tight lens
poor hygiene
why is extended wear associated with CLPU?
the longer you are wearing the lenses, the more the cornea is exposed to endotoxins on the lens = inflammatory reaction
what is MK?
microbial keratitis
INFECTION of the cornea characterised by excavation of the corneal epithelium, BOWMANS LAYER and stroma with infiltration and necrosis of tissue
which 2 bacterias are associated with microbial keratitis?
pseudomonas (gram -ve)
staphylococcus (gram +ve)
other types of keratitis?
acanthameoba
viral
fungal
does MK or CLPU have a larger infiltrate?
MK (>1.5mm)
signs of MK
large infiltrate
central or paracentral
irregular appearance
ill-defined margins
unilateral
severe hyperaemia
lid oedema
mucopurulent discharge
AC flare often present
symptoms of MK
pain, acute onset, rapid progression
very red
reduced vision
lacrimation
photophobia
mucopurulent discharge
how do you differentiate between CLPU and MK???
management of MK
cease lens wear
refer to A&E
- corneal scrapes
TAKE CL CASE TO A&E
px will require dialy follow up (possibly kept overnight) until condition resolves
topical antibiotics
dual therapy - combination of 2 antibiotics for gram +ve and -ve
no lens wear until resolved
consider dailies
signs of acanthamoeba keratitis
begins as a nonspecific keratitis with infiltrates along the conreal nerves in a radial pattern
ring infiltrate typicaly appears later in the disease process
symptoms on acanthamoeba keratits
SAME AS MK
pain, acute onset, rapid progression
very red
reduced vision
lacrimation
photophobia
mucopurulent discharge
management of acanthamoeba keratits
immediate referral to HES
mistaken for HSK
culture maybe taken
treated with broad spectrum antibiotics
what are the most common pathogens for fungal keratits
candida or fusarium
who is most likley to get fingal keratits
immune disorder
which has a slower onset:
bacterial or fungal keratitis
FUNGAL
which keratitis is associated with trauma with vegatative material?
FUNGALs
signs of fungal keratitis
unilateral
hyperaemia
lacrimation
hypopyon
lid oedema
symptoms of fungal keratitis
pain
photophobia
vision reduction
FB sensation
management of fungal keraittis
cease lens wear
emergency referral
topical anti-fungals
may require corneal graft
take lens case with you to A&E
