marginal keratitis Flashcards
management of marginal keratitis
treat underlying bleph
ocular lubricants for self relief
self limiting condition ( but pharm tx given for symptoms)
- combination of topical antibiotic (chloramphenicol 0.5%) and topical steroid *mild) loteprednol 0.5% for 2 weeks
(but immunosuppressive effect of steroid enhances risk of infection)
- Entry level would give chloramphenicol , (can consult with IP colleague, normally dealt with in practice) see them back in 2 days and not getting better then steroids are needed
- entry level would refer urgently if > 1 week and done management of bleph
- if less compliant px then can give chloramphenicol and review in 2 days to see for steroids - IP or HES
Marginal keratitis cause?
what does it look like
common in bleph
toxins cause inflammation
Limbal infiltrate with clear gap between limbus and lesion
Be wary of diagnosis in CL wearers
differential diagnosis for marginal keratitis
- Bacterial keratitis – usually gets bigger and more centrally though
- HSK – hx of cold sores, often had it before, (marginal keratitis usually have hx with bleph and check lashes and lids), if no bleph and no hx of cold sores, NaFl would stain – not obvious difference between them, if not sure which one need to refer it in !!
- Round ulcers in the periphery is caused by contact lenses (would mange these px’s differently)
- Consider other causes of peripheral ulceration
- CLPU, rosacea keratitis, peripheral keratitis secondary to rheumatoid arthritis
why does dilation need to be done for HSK
to rule out virial retinitis
when do we manage HSK and when dont we
when acute, recurrent and no stromal involvement then IP or patient group directive
in children, when atypical, stromal, anterior chamber involvement, CL px, bilateral then urgent referral! get app in 48 hours
why do we not prescribe steroids for viral issues
as slows healing since it suppresses immune system, could get a lot worse for HSK
how to differntiate from symptoms for HSK
Herpes Simplex Keratitis HSK- Red eye, FB feeling rather than pain, more uncomfortable, watery, photophobia, vision affected if on visual axis, more photophobic the px would be in it is on the visual axis.
what is used for to treat HSK (IP)
ganciclovir 0.15% eye ointment
5 x day until healing complete
3 x day for 7 days
Treatment course to not exceed 21 days
Referral (urgent) if epithelium not healed within 7 days
CMGs recommend low threshold for referral
types of HSK
- 4 distinct types of keratitis
- Epithelial (vast majority, 50-80%, dendritic ulcer)
- Stromal
- Disciform
- Meta herpetic ulcers
- 50 - 80% of presentations are epithelial keratitis
presentation of zoster ophthalmicus
Presentations
* Mucopurulent conunctivits
* Scleritis
* Keratitis
* Anterior Uveitis
Skin features unilateral painful, red, vesicular rash on the forehead and upper eyelid, progressing to crusting after 2-3 weeks; resolution often involves scarring
periorbital oedema (may close the eyelids and spread to opposite side)
lymphadenopathy (swollen regional lymph nodes)
lesion at the side of the tip of the nose (Hutchinson’s sign) indicates three times the usual risk of ocular complications, but these may also occur in one in three patients without the sign
ocular signs of zoster ophthalmicus
Ocular lesions (variable in scope and severity, may be chronic or recurrent):
* mucopurulent conjunctivitis, associated with vesicles on the lid margin; usually resolves within 1 week
* scleritis: less common; usually develops after 1 week
* episcleritis: occurs in around one third of cases
* keratitis- varies depending on when px is seen
o punctate epithelial – early sign, within 2 days (50% of cases)
o pseudodendrites – fine, multiple stellate lesions (around 4-6 days)
o nummular – fine granular deposits under Bowman’s layer (when untreated)
o disciform – 3 weeks after the rash (occurs in 5% of cases)
o reduced corneal sensation (neurotrophic keratitis)
o endothelial changes and keratic preciptates
secondary problems: anterior uveitis, secondary glaucoma
rarely, posterior segment involvement: retinitis, acute retinal necrosis, choroiditis, optic neuritis, optic atrophy
rarely, neurological complications: cranial nerve palsies, encephalitis
post-herpetic neuralgia is defined as pain and/or itch lasting beyond 90 days after the onset of zoster. This affects around 25% of patients and is: chronic and severe in about 7%
Management of zoster ophthalmicus
- Co manage with GP if keratitis is only epithelial (would give systemic acyclovir)
- Urgent referral to GP and
- Review after one week to check for the development of uveitis, and to check epithelial defect is starting to heal, sooner review if needed
- Urgent referral to ophthalmologist if signs of uveitis, scleritis, keratitis, retinitis
Predisposing Factors Preseptal cellulitis:
- upper respiratory tract infection
- dacryocystitis
- hordeolum
- impetigo (skin infection)
- trauma, sharp or blunt, around eye
- recent surgery around eye
Predisposing Factors orbital cellulitis
- acute sinusitis (especially ethmoid sinusitis)
- trauma including orbital fracture
- dacryocystitis
- preseptal cellulitis
- dental abscess
preseptal symptoms
Preseptal cellulitis:
* acute onset of swelling, redness and tenderness of lids
* fever
* malaise
* irritability in children
orbital symptoms
- sudden onset of unilateral swelling of conjunctiva and lids that may be painful
- pain on ocular movement
- blurred vision and reduced visual acuity
- diplopia
fever
severe malaise
preseptal signs
Preseptal cellulitis:
* erythema of skin (can extend beyond orbital rim)
* lid oedema, warmth, tenderness
* ptosis
* pyrexia (fever greater than 38°C, normal temperature ranges from 36-37.5°C)
no proptosis
colour vision normal
ocular motility normal
no RAPD
VA normal
orbital signs
- proptosis
- restriction of extraocular motility
- pain with eye movement
- visual acuity may be reduced
- pupil reactions may be abnormal (RAPD)
- pyrexia
RAPD
colour vision
preseptal differential diagnosis
orbital cellulitis
hordeolum (external or internal)
dacryocystitis (acute)
acute blepharitis
viral conjunctivitis with eyelid swelling
acute allergic conjunctivitis with eyelid swelling
angioneurotic oedema (if bilateral): could indicate severe systemic allergic reaction, e.g. in peanut allerg
orbital management
emergency same day referral
preseptal management
in adults with preseptal cellulitis, begin systemic treatment with oral antibiotics with broad spectrum of activity (e.g. Flucloxacillin or Co-Amoxiclav). Use alternative antibiotic e.g. Clindamycin in the case of penicillin allergy. Requires close monitoring, if no improvement within 24-48 hours or symptoms worsen then refer as emergency (same day)
in kids emergency same day referral
what are the 4 types of HSK
epithelial
stromal
disciform keratitis
trophic keratits
what is epithelial keratitis
initially punctate lesions, becoming dendriform pattern
dendritic ulcer, single or multiple opaque cells, terminal bulbs may be visible
(associated with reduced corneal sensitivity
continued enlargement may result in an ‘amoebic’ or ‘geographic’ ulcer (especially following inappropriate use of topical steroids))
what is stromal HSK
Stromal infiltrates, vascularisation, oedema and opacification, leading to scarring and vision impairment.
can be either necrotising or non-necrotising.
In non-necrotising stromal HSK, the oedema is localised, and mostly self-limiting.
In necrotising keratitis, the stromal inflammation is widespread and the infection progresses to ulceration, necrosis and possible perforation
what is disciform keratitis
Central or eccentric zone of epithelial oedema overlying an area of stromal thickening, folds in Descemet’s membrane, raised IOP, uveitis and keratic precipitates
what is trophic keratitis
Metaherpetic keratitis is the most severe form of HSV corneal infection. Recurrent attacks of HSV, bullous keratopathy, stromal involvement, endotheliitis, neovascularisation and anterior uveitis characterise the metaherpetic phase of the disease
