Lids/conjunctiva/cornea Flashcards
what are phlyctenules (or phlyctens)?
focal, translucent lymphocytic nodules generally located at limbus and usually accompanied by inflammation
what is the hallmark sign of a phlyctenule?
elevated, finger-like projection across the limbal juncture onto peripheral cornea with overlying pannus (superficial vessels)
what is the pathophysiology for phlyctenular keratoconjunctivitis?
staphylococcus - secondary to lid disease = industrialized countries
tuberculosis or GI parasites = developing countries
what type of hypersensitivity are phylctenules?
type 4 = delayed cell-mediated hypersensitivity reaction to staphylococcal antigens or other exogenous sources
what are the 3 pieces of treatment for phylctenular keratoconjunctivitis?
topical steroid pulse (prednisolone acetate 1% or phosphate, loteprednol/lotemax 0.5%) = q2h - 3 to 4 days and taper quickly for 3 days
topical antibiotic (Besivance, vigamox, zymar) = q2-4h or q4-8h
OTC vasoconstrictor
*can also use an antibiotic/steroid combo
what do you prescribe for resistant staph-caused cases of phylectenular keratoconjunctivitis?
tetracycline 250mg PO QID until asymptomatic for 2-3 weeks
what types of lab testing would you order for phylenctenular keratoconjunctivitis?
TB testing (immigrant = SE Asia or central america, substance abusers)
GI parasites = serologic testing/Amebicide therapy
what is the treatment for mild phlyctenules?
they often self-limit and only need OTC vasoconstrictor drops QID
how would you know if phlyctenules were caused by staph or TB/GI parasites?
phlyctenules caused by staph respond poorly to steroids alone without treating the source of staph (lid disease)
what are some examples of combo antibiotic/steroid drops for phylectenular keratoconjunctivitis?
maxitrol (dexamtheasone 0.1%/neomycin/polymyxin B)
Pred-G (gentamicin/pred acetate 1%)
Tobradex or Tobradex ST (tobramycin/dexamethasone 0.10% or 0.05%)
what are some signs associated with sterile marginal corneal infiltrates (corneal ulcer)?
midperipheral island(s) of infiltrate, clear zone between infiltrate and limbus, often 4:00 - 8:00 and can present as a sterile marginal ulcer
what causes sterile marginal corneal infiltrates?
corneal hypersensitivity to sterile lid exotoxins (staphylococcal exotoxins)
what is the treatment for sterile marginal infiltrates if the cornea is intact (no staining) and generally healthy?
vigorous treatment of lid disease = hygiene and antibiotics (AzaSite)
low concentration of steroid drop to quiet inflammation = prednisolone acetate 0.12%, FML 0.1%, loteprednol (all TID to QID 5-7 days)
what is the treatment for sterile marginal infiltrates if the cornea is intact (no staining) but has diffuse SPK?
conservative approach with prophylaxis antibiotic 7-10 days (fluoroquinolone or aminoglycoside with polysporin ung or AzaSite)
lid hygiene
low concentration steroid TID to QID
possible culture if condition doesn’t improve
artificial tears
what is the treatment for sterile marginal infiltrates if the cornea is compromised (with staining) with diffuse SPK?
antibiotic gtt/ung to protect cornea
culture and sensitivity may be important for CL wearers
lid therapy for blepharitis and artificial tears
low concentration steroid drops for inflammation QID
what is the treatment for sterile marginal infiltrates that are probably sterile with a corneal ulcer?
lid therapy for blepharitis and artificial tears for cornea
combination steroid-antibiotic QID (maxitrol, trobradex, Pred-G)
**sterile ulcer represents greater inflammation and requires a stronger steroid
what is a sterile marginal infiltrate that has an indolent ulcer?
a shallow, superficial ulcer unaccompanied by vascularization and infiltration, causing little reaction, few symptoms, and little tendency to spread or heal
what are the symptoms associated with infectious bacterial keratitis (corneal ulcer)?
R = red eye (intensely) S = sensitive to light V = vision change (reduced, disrupted) P = pain (acute, unilateral with tearing)
what are some signs associated with infectious bacterial keratitis?
focal stromal infiltration surrounding excavation (ulcer), AC cells and flare, conjunctival injection, purulent discharge, mucoid plugs, eyelid edema, and folds in Descemet’s membrane
what causes infectious bacterial keratitis?
staphylococcus aureus or in CL/cosmetics = pseudomonas aeruginosa
what is the chain of events that leads to bacterial keratitis?
- pathogenic bacteria colonize cornea and become antigenic - release enzymes/toxins (antigen-antibody immune reaction and inflammatory reaction) 2. PMNs phagocytize/digest bacteria - create infiltrate 3. collagen stroma undergoes degradation/necrosis/thinning = scaring of cornea, perforation or endophthalmitis
the majority of bacterial primary care ulcers are small, peripheral and minimal AC reaction/discharge - what are they successfully treated with in outpatient?
3rd and 4th generation fluoroquinolones off/on label
what are some 4th generation fluoroquinolones used for used for bacterial keratitis off-label?
moxifloxicin (Vigamox) and gatifloxacin (Zymar)
what is a chlorofluoroquinolone used for bacterial keratitis off-label?
besifloxacin (besivance) with Durasite vehicle (increases ocular residence time) ** has non systemic counterpart - less chance of developing resistance
what are 3 fluoroquinolones used on-label for bacterial keratitis?
AzaSite (with Durasite)
Ciloxan (ciprofloxacin) for patients 12 or older
Ocuflox (ofloxacin) for patients 1 or older
how do you treat secondary iritis in patients that have bacterial keratitis?
cyclopentolate, homatropine, or atropine (dose is higher than with abrasions) - no steroids
when can you prescribe/use steroids in infectious bacterial keratitis?
after ulcer is sterile and before cornea epithelializes to speed healing and decrease inflammation and scarring
what are 4 situations when you should never use steroids alone?
epithelial (non-stromal) HSK, active bacterial or fungal infections, large corneal epithelial defects and if unsure of diagnosis
what is an exception to the rule for never using steroids alone for bacterial infections?
you can use a steroid alone IF there is clinically significant secondary inflammation (as damaging to cornea as infective organism)
what does the timing need to be in order for steroids to be beneficial in infectious bacterial keratitis?
the ulcer needs to be made sterile by the antibiotic - then it must be used while the ulcer bed is still open
what signs do you look for in bacterial keratitis before you taper off drops?
infiltrate shrinks (less stain), epithelium fills in (no plug or stain), patient feels better, and any AC reaction is reduced/eliminated
when do you take a culture with infectious bacterial keratitis?
before antibiotic drops are applied - most yield negative results from scrapping **do not wait to begin treatment = use broad spectrum therapy
what is fortified antibiotic treatment for infectious bacterial keratitis?
cephalosporin (Gm +) alternated with aminoglycosides (Gm - ) compounded by a pharmacist *Fortified Ancef + fortified Tobramycin
when should you see a patient for follow-up with infectious bacterial keratitis?
in the first 24 hours (admit patient to hospital if you are uncertain of their compliance to treatment)
what causes primary herpes simplex?
acquired from environment
how do patients with primary herpes simplex often present?
unilateral vesicular blepharoconjunctivitis, pruritic (itching) of the lids/skin, follicular conjunctivitis, membrane formation and +PAN
what is the treatment for primary herpes simplex skin lesions?
warm saline soaks, drying agents (Burow’s solution or 70% alcohol), topical antibiotic gtt/ung no steroid needed = HSK skin lesions do not scar
what is the treatment for primary herpes simplex lid lesions?
Vira-A not effective topical acyclovir (Zovirax cream)
what is the treatment for primary herpes simplex blepharitis?
if conjunctivitis only (no keratitis) = no antivirals
broad spectrum antibiotic (polytrim, vigamox, zymar, besivance)
lubricants/cool compresses
OTC vasoconstrictors QID
NO STEROIDS
can herpes simplex conjunctivitis turn into herpes simplex keratitis?
yes - up to 50% do - watch for focal SPK/dendritiform lesions/ dedrite development
how does HSK initially present that has proliferating dendrites?
diffuse or focal SPK - coalescing within several days into a dendritiform lesion consisting of swollen, opaque epithelial cells
how does HSK initially present that has ulcerative dendrites?
HSK can develop as discrete SPK and develop into dendritic (dichotomously branching) lesion with terminal bulbs often near center of cornea
how can you tell the difference between dendrites and ulcerative dendrites in HSK?
classic dendrites are characterized by raised, swollen epithelial cells that are grouped in a dendritic (“tree-like”) shape with terminal end bulbs
dendritic ulcers have positive staining located along the length of the dendrite. At the borders, however, you will see raised, swollen epithelial cells that negatively stain
what other condition can HSK look like?
staph marginal infiltrates
what does the treatment for HSK consist of?
depends on sites of involvement = oral acyclovir and other PO antivirals, topical ophthalmic trifluridine (viroptic) or ganciclovir (zirgan), or it can self-limit
what should you give a patient who is having their first episode of HSV dendritic epithelial keratitis?
oral acyclovir - reduce the probability of recurrent ocular herpes simplex disease
when will a patient develop “ghost dendrites”?
when there is mild edema and SEI’s beneath the epithelial dendrites - marker for past epithelial keratitis
besides ghost dendrites, what is another sign that a patient has had past HSV epithelial keratitis?
sectoral or diffuse reduction in sensation (hyposthesia) of the cornea
what are 3 things you should think of when thinking of HSK?
focal SPK, dentritiform lesions, and dendrites
what is the treatment for HSK mild keratitis - SPK only?
(no dendrites) use Viroptic QID, Zirgan TID as prophylactic OTC vasoconstrictors, lubricants, cool compress NO STEROIDS
what is the treatment for HSK dendritiform/dendritic keratitis?
zirgan (ganciclovir gel) = 1gtt 5x day until decreased RB staining and re-epithelization occurs then go to 3x day for 7 days or viroptic (trifluridine) = q2-4h at least 6x day
when do geographic ulcers occur?
can occasionally develop by centrifugal spread of HSV infection from a central dendrite towards peripheral cornea - RB stain edge and NaCl pool in middle
what are the 3 findings with HSV interstitial keratitis?
stromal infiltration, thinning and neovascularization associated with recurring HSK (*usually associated with systemic syphilis)
when does a trophic (metaherpetic/indolent) ulcer occur?
after recurrent herpetic disease - damages epithelial basement membrane and anterior stroma and a post infectious (sterile) ulcer occurs
what does a trophic ulcer look like?
round/oval, smooth/thickened edges that often overlie an area of stromal inflammation or inactive stromal scarring (neurotrophic in nature)
what is the treatment for a trophic/metaherpetic ulcer?
needs to protect cornea from stromal melting and perforation = lubricants, therapeutic SCLs, broad spectrum antibiotics and occasionally tarsorrhaphy (shortening/closing palpebral fissure)
what are the antiviral treatment options for recurrent HSK epithelial disease?
gangiclovir (zirgan gel), trifluridine (viroptic sol), vidarabine (Vira-A ung *can be used with trifluridine), and idoxuridine (Herplex sol - most toxic)
besides antivirals what other treatments do you give for recurrent HSK?
debridement of ulcer, broad spectrum antibiotic QID, cycloplegics for iritis, topical acyclovir ointment, and oral acyclovir 400mg BID x 12 months (reduces recurrence)
what are the treatments for HSK stromal scarring and edema?
pre-sterilize cornea prior to steroids - then add steroids with antiviral, cycloplegic as needed, oral acyclovir 400mg 5x day during acute phase
what causes HSK stromal scarring and edema?
immune process = type 4 hypersensitivity reaction
what causes HSK interstitial keratitis?
antigen-antibody reaction to viral residue = type 3 hypersensitivity reaction
what are the treatments for HSK interstitial keratitis?
cycloplegics, steroids if iritis is progressing or visual axis is threatened, artificial tears
what causes HSK trophic ulcers?
damaged basement membrane and poor healing
where does chickenpox (varicella virus) first appear and where is the rash typically located?
vesicular lesions (quickly erupting to ulcers) may first appear in oropharynx
rash is centripetal and most prominent on face, scalp, trunk (less on extremities) **non dermatomal distribution
how long do new lesions erupt in chickenpox?
1-5 days so all stages of the eruption are simultaneous
what is the pathophysiology for chickenpox?
varicella virus - human herpesvirus 3
how contagious is chicken pox and how is it spread?
highly contagious - spread by inhalation of infective droplets or contact with lesions = clinical after 10-20 days (average 14-15)
what is the treatment for the skin rash in chickenpox?
oral acyclovir (Zocirax) = start within 24 hours
supportive therapy = drying/cooling lotions (calamine, benadryl, burow’s, caladryl)
topical antibiotic ointment
oral antihistamines (not all FDA approved for children)
how do you treat less common conjunctival and corneal presentations of chickenpox?
lubricants, topical OTC vasoconstrictors, acetaminophen (not children’s aspirin = Reyes syndrome), broad spectrum antibiotic (polytrim), mild cycloplegics for iritis **topical antivirals are ineffective
what is the pathophysiology for herpes zoster virus?
herpesvirus 3 = same one that causes chicken pox (varicella virus)
what limits where HZV (shingles) presents on the body?
limited to the skin distribution (dermatomes) of the nerve root(s) were it was latent
how long after initial symptoms of scalp and forehead neuralgia does HZV cause ocular problems?
4-5 days = acute dermatologic and blepharitic vesicles, ulcerations, and exudative lesions
how long after initial symptoms of scalp and forehead neuralgia should you initiate treatment?
first 3-5 days after = maximize the potential for immediate and long-term benefits
what are the treatments for HZV?
oral antivirals (acyclovir 800mg, valacyclovir 1,000mg, famciclovir 500gm *all double HSK dose), drying lotion, topical antibiotic ointment (polysporin), topical steroid ointments (blephamide) and oral antihistamines
how does HZO (herpes zoster ophthalmicus) present?
non-ulcerative “pseudodendrites” that differ from HSV keratitis = heaped up epithelium with unusual branching patterns and no terminal end bulbs (stain with RB)
how long can the ocular complications of HZO persist?
weeks, months or years
what is HZO mucous plaque keratopathy?
elevated formulations resembling the HZO pseudodendrites - sterile ocular surface disease and are associated with deeper corneal inflammation
how do you treat HZO mucous plaque keratopathy?
usually self-limiting = lubrication, topical steroids or acetylcysteine drops
what are some ocular manifestations that can occur with HZO?
anterior uveitis, blurred watery VA, photophobia, chronic stromal keratitis, nonhealing epithelial trophic defects and sterile stromal ulceration and perforation
what are some treatments for HZO?
broad spectrum antibiotic = aminoglycoside, chlorofluroquinolone (besifloxacin, moxifloxicin, gatifloxacin)
topical steroids (keratitis) = prednisolone or dexamethasone, tobradex
cyclopentolate or homatropine
topical antivirals for prophylaxis HSV = zirgan, viroptic
what are some systemic treatments for HZO pain?
antidepressants = amitriptyline (elavil)
opioid or nonopioid analgesic
oral steroid Zostrix ointment (not in eye)
Example = 40 y/o steroid responder - “tearing, irritated, painful, photophobic, something growing OD”, crusty/red, thickened eyelid margins and small elevated finger-like projection of fibrous tissue across limbal juncture onto midperipheral cornea What is the condition and what is the plan/treatment?
phlyctenular keratoconjunctivitis
Lotemax pulse and AzaSite/lid hygiene **need a soft steroid (not prednisolone acetate or dexamethasone for steroid responder
Example = “eyes burn and itch, uncomfortable”, collarettes, missing lashes, small 1mm peripheral circumscribed corneal defect 4:00, no surrounding infiltration and no staining OS What is the assessment and plan?
sterile marginal corneal infiltrate
AzaSite, 0.1% fluorometholone alcohol (FML) and lid hygiene
what is this picture an example of?
phylectenular conjunctivitis
what is this picture an example of?
sterile marginal corneal infiltrate
Example = patient is using fortified antibiotics q2h, no change in 2.2mm superior paracentral lesion OS, mucoid plug blinked on SLEx revealing 80% penetration of corneal stroma, no hypopion, scraping/culture was negative
what is the assessment and plan?
corneal ulcer OS
1gtt 1.0% prednisolone acetate in office, f/u 4PM today for additional 1gtt 1.0% prednisolone acetate in office
what is this picture an example of?
infetious bacterial keratitis (corneal ulcer)
what is this picture an example of?
infetious bacterial keratitis (corneal ulcer)
Example = RE itches, vesicles on lids/skin/eyelid margin and 1-2+ conjunctival injection OD only
What is the assessment and plan?
primary herpes simplex with secondary HSV blepharoconjunctivitis OD
Burow’s solution, Polytrim gtt, Polysporin ung
f/u q3-4 days to check for HSK (50% chance)
Example = “eye is scratchy, red, blurred and light bothers me”, dendritiform branching lesion, pools centrally with NaFl, stains with RB along edges OD
what is the assessment and plan?
A = Herpes Simplex Keratitis OD
P = Zirgan gel, Viroptic gtt, PO antivirals are possible
(improvement indicated by decrease in RB stain - then taper medications)
Example = “LE runs, hurts, red, light bothers, blur, has happened before”, 1-2+ conjunctival injection with thin, linear, branching epithelial lesions which pool centrally with NaFl and stain edges with RB anterior to disc-shaped stromal scarring and edema OS only
what is the assessment and plan?
A = recurrent herpes simplex keratitis OS
P = topical ganciclovir gel (zirgan), trifluridine gtt, PO antivirals and possibly prednisolone acetate (once ulcer is sterile)
*400mg oral acyclovir BID x 12 months
Example = 6y/o with fever, no energy, skin rash, red eyes, non-dermatomal vesicular skin lesions, 1-2+ interpalpebral and tr+ circumlimbal injection, trace cells/falre
what is the assessment and plan?
A = conjunctivitis secondary to HZV infection with mild iritis
P = polytrim with 0.50% tropicamide, oral acyclovir/antihistamine (consult with PCP/acetaminophen)
Example = 74 y/o, left side of head/forehead and around LE hurts, skin breaking out, fluid-filled blisters within dermatomal left upper scalp/facial/periorbital region
what is the assessment and plan?
A = herpes zoster (shingles)
P = oral antivirals prophylactically to decrease severity and duration of pain (*double dose from HSV)
Example = 74 y/o, previous history of HSK, unusual branching patterns of heaped up corneal epithelium (no endbulbs) that stain with RB, 1+ CF, 1-2+ conjunctival injection (interpalpebral and circumlimbal)
what is the assessment and plan?
A = HZO keratitis OS, secondary iritis OS, secondary conjunctivitis OS
P = finish PO antiviral, 1% cyclopentolate, chlorofluoroquinolone/4th gen fluoroquinolone, seperate topical antiviral (zirgan) and topical steroid (loteprednol)
what is this picture an example of?
Herpes zoster ophthalmicus (HZO)
what is this a picture of?
non-stromal ulcerative HSK lesion
what is this an example of?
RB staining the edge of a stromal ulcerative HSK lesion
what is this an example of?
Trophic epithelial defect following HSV stromal keratitis (also indolent or metaherpetic ulcer)
