Lid sensitivities Flashcards
Classic description of staph marginal keratitis
Multiple, bilateral, peripheral corneal stromal infiltrates (without overlying epi defects) secondary to chronic blepharitis. Corneal infiltrates most commonly occur at the 2, 4, 8, and 10 positions where the eyelid margins contact the limbus. Corneal thinning, surface neo, and scarring may eventually occur over time
Corneal infiltrates
Sign that the patient’s immune system is attack the staph antigens with Abs, in isolation, it is an immune mediated response and NOT sign of infection
Corneal ulcers
Corneal epi defect with an underlying stromal infiltrate
RCE
Due to poor hemidesmosome attachments between the corneal epi and the underlying basement membrane, most commonly develop in eyes with a history of trauma or with corneal dystrophies (EBMD), patients classically report pain in the AM upon wakening as well as photophobia and a FB sensation. Recall that although 50% of patietns with RCEs have EBMD, only 10% of patients with EBMD will develop RCE
Diff between corneal ulcer and abrasion
Ulcers have stromal infiltrate
Infectious vs sterile ulcer
Corneal ulcers will have epi defects and an underlying infiltrate, patients will present with mod-severe pain, a mild AC reaction, and diffuse conj injection
- infectious ulcers, the size of the epi defect will match the size of the infiltrate
- sterile ulcers, the epi defect will be smaller than the size of the infiltrate
An infiltrate WITHOUT an overlying epi defect is referred to as an infiltrate. Patients typically have less pain compared to a corneal ulcer, despite having multiple lesions. Sectoral (rather than diffuse) conj injection will be present in the area of corneal infiltrate, and the AC will be quiet
What type of HS reaction is staph marginal keratitis
Type III HS
-against antigens produced by staph aureus. Most commonly associated with staph bleph, acne rosacea, and phlyctenule.
H flu causes infiltrated in what population
Kids
Treatment for staph marginal keratitis
Topical abx/steroid (tobradex or zylet) every 4 hours
Also better lid hygiene
anterior bleph
Anterior eyelid margin inflammation with telangiectasia and flakes within the lashes
Treatment for anterior bleph
- eyelid scrubs BID or TID until condition stabilizes, and then QD thereafter
- bacitracin or erythromycin ung qhs x 2-4 weeks
- AzaSite (topical azith) gtts BID x 2 days, then QD x 12 days
- topical ophthalmic abx/steroid (tobradex) if significant redness and/or inflammation is present
Posterior blepharitis
Inflammation of the meibomian glands
Treatment of posterior bleph
- warm compresses with fingertip massage of the eyelids 5-10m QID
- eyelid scrubs BID or TID until the condition stabilsizes then QD
- AzaSite BID x 2 days then QD x 12 days
- oral doxy 100mg BID for appx 4 week, then 100mg QD (or 50mg QD) for 3-6 months, or 40-50mg QD for appx 6-12 months. Oral mino 50mg BID x 2 months is an alternative
- fish oil and omega 3 FAs
Seborrheic blepharitis
Assocaited with seborrheic dermatitis. Assocaited with less eyelid inflammation, more oily, greasy scales, and flaking compared to staph bleph
Treatment of RCCs and corneal abrasions
- Prevent infection and heal the corneal defect
- broad spectrum abx BID to QID
- PFAT up to Q1h during the day
- debridement of loose, fought, or heaped up corneal epithelium to promote proper tissue adhesion during the healing process
- Reduce pain
- cycloplegic agent 1gt in office to reduce pain
- topical NSAID BID x 2-3 days or until the corneal epithelium heals if needed to control pain
- BCL in order to decrease discomfort and trauma to the corneal epi from the eyelid contacting the epi defect with each blink
- Prevent recurrence
- oral doxy 50mg BID and a topical steroid TID x 3-4 weeks
- murro 128 ung qhs x 3 months
Additional
- pressure patching (large)
- surgical management
Anterior stromal micropuncture
Making numerous micropuncture into and through the corneal epi BM/Bowmans layer complex. This procedure is performed at the slit lamp with a blunt stromal micropuncture needle
culturing corneal ulcers
If they are large, centrally located, and/or unresponsive to treatment. Because timely treatment is critical, should NOT wait for culture results to initiate treatment.
bacterial keratitis (corneal ulcer)
Consider all CL associated ulcers to be bacterial first
Common culprits are pseudomonas aeruginosa (most common gram neg pathogen that results in a dense stromal infiltrate, significant mucopurulent discharge, hypopyon, and rapid progression), staph epid, staph aureus, H flu, and moraxella catarrhalis
Bacteria that can invade intact corneal epi
Canadian national hockey league
- corynebacterium
- N. Gonorrhea
- H flu
- Listeria
Treatment of small bacterial corneal ulcers
Topical Abx (FQ) Q1-2H after initial loading dose, followed by slow taper
Treatment for Large bacterial corneal ulcers and those that show no organisms or multiple organisms on gram stain
Fortified ABx (cephazolin 50mg/mL and tobramycin 14 mg/mL every 15-30 minutes after a loading dose of 1 drop every minute for 5 minutes
Fungal keratitis
Most common type of corneal ucler that develops after traumatic corneal injury, esp vegetable matter. Aspergillus and fusarium are the most common culprits following vegetable matter trauma. Candida most often occur in eyes with chronic corneal disease or in immunocompromised
Classically presents as gray white infiltrate with feathery edges and satellite lesions
Treatment for fungal keratitis
Topical antifungals (ampho B and Natacin) Q1H while awake, followed by a taper based on clinical appearance
Systemic antifungals may be added and are advised in severe cases
Most fungi can be culture on sabarouds
Amphotericin B
Oral antifungal that can be formulated into eye drop by a hospital grade compounding pharmacy, Natacin can be shipped overnight from Alcon
Acanthamoeba keratitis
Rare, parasitic infection that is most likely to occur in a CL wearer with poor CL hygiene
- severe pain, out of proportion to corneal signs in the early stages of keratitis. Corneal signs include mild SPK and pseudodendritic defects.
- corneal scrapings of the cysts are performed with periodic acid-Schaffer’s, giemsa stain, or calcofluor white. Culturing requires a non nutrient agar with E. coli; can also be grown on blood or chocolate agar, but not as well
Treatment for acanthamoeba keratitis
Topical ophthalmic anti-parasitic agents. Propamide isethionate q1h (Brolene or PHMB) followed by a slow taper (often over the course of months)
Oral anti fungal agents (ketoconazole 200mg or itraconazole 100mg BID)
Cycloplegic agent TID
Abx drop q1h
Topical antiinflammatory (steroids, controversial)
Even with proper treatment, many cases eventually require a PK, 30% of cases have a recurrence after initial PK
FU schedule for staph marginal keratitis
They typically respond well to therapy and will show significant improvement within a couple of days. FU in 5 days from initial visit
FU for corneal ulcers
1 day
