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Therapeutics > Ocular Allergy > Flashcards

Ocular Allergy Flashcards

1
Q

What is Fuch’s Endothelial Dystrophy?

A

Slow progressive dysfunction of cornea endothelium →corneal oedema and reduced vision.

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2
Q

Demographics for Fuch’s Endothelial Dystrophy

A

Onset 4th decade or later, female 2.5:1

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3
Q

Signs of Fuch’s Endothelail Dystrophy

A

bilateral (asymmetric), guttata, thickened Descemet’s membrane, pigment on the endothelium, cystic epithelial oedema (bullous keratopathy), stroma thickening/oedema

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4
Q

Symptoms of Fuch’s Endothelial Dystrophy

A

asymptomatic in early stage or >50 years, glare, blurry vision on waking, diurnal changes in refraction, sharp pain, photophobia

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5
Q

DDx for Fuch Endothelial Dystrophy

A

pseudophakic/aphakia bullous keratopathy, posterior polymorphous dystrophy, corneal guttata, corneal hydrops, corneal oedema

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6
Q

Management for Fuch Endothelial Dystrophy

A
  1. Imaging (CCT measurement) + Specular microscopy
  2. Therapeutic CL
  3. Ocular lubricant – ocular sodium chloride 5% (for persistent oedema)
  4. Surgery
    a. Posterior lamellar transplantation (preferred for irreversible corneal endothelial decompensation)
    b. Penetrating keratoplasty
    c. Any combined with cataract surgery
  5. Mild guttata – follow up in 6 -12 months
    A) Mod or worse (i.e. stromal oedema) close follow up, with bandage CL,
    B) Refer to ophthalmologist
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7
Q

What is RCES

A

Recurrent Corneal Erosion Syndrome: instability of attachment of corneal epithelium to the stroma

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8
Q

Classification of RCES

A

a. Dystopic RCES
b. Post – traumatic RCES (post-surgery/trauma)
c. Idiopathic

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9
Q

Demographics RCES

A

30 – 80 years, prevalence 3rd and 4th decade, DED, diabetes, blepharitis, or ocular rosacea

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10
Q

Symptoms of RCES

A

unilateral, sharp pain, blurred vision, lacrimation, photophobia

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11
Q

DDx of RCES

A

band keratopathy, corneal ulcers, corneal FB, corneal dystrophies, chemical burns, DED, floppy eyelid syndrome, Salzmann’s nodular degeneration

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12
Q

Management of RCES

A
  1. Ocular lubricants + ointment nocte for 6 months since last episode
  2. Topical antibiotic + cyclosporin to decrease pupil spasm.
    a. MGD or Rosacea related: oral tetracycline (12 weeks doxycycline 50mg BID) + steroids for 3 months and taper.
  3. Surgical Intervention
    a. Laser PTK – 80% success rate
    b. Alcohol delamination and epithelial debridement - >30-50% success rate
    c. Anterior Stromal micro puncture with bent needle - 30-50% success rate
    d. Debridement and superficial keratectomy under topical anaesthetic 30-50% success rate
  4. Follow up monthly for 3 months then regular review, return sooner if reoccurrence.
  5. Review 2 – 4 weeks post procedure if they have surgery.
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13
Q

What is Band keratopathy (BK) ?

A

Band Keratopathy: corneal degeneration that present with calcium deposits in the sub epithelium, bowman’s layer, and anterior stroma. Forms a horizontal band from the peripheral cornea. May be chronic (ocular disease), idiopathic, or due to corneal oedema.

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14
Q

Signs of BK

A

Decrease visual acuity, horizontal band corneal opacity

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15
Q

Symptoms of BK

A

decrease vision, FB sensation, ocular irritation, redness, photophobia.

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16
Q

BK systemic work up

A
  1. Urinalysis (deposits and pH levels)
  2. Serum
    a. calcium →high levels lead to increased precipate.
    b. phosphorus → low calcium = precipices of calcium, possible renal failure
    c. ACR → exclude sarcoidosis.
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17
Q

DDx for BK

A

Interstitial keratitis, calcareous degeneration of the cornea (primary/secondary), limbal stem cell defiency, spheroidal degeneration, ciprofloxacin crystalline deposits, advanced basement membranes dystrophy

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18
Q

Management for BK

A
  1. Asymptomatic: monitor carefully
  2. Mild: lubricating eyedrops/ointments/gels
  3. Mod to severe: bandage CL with prophylactic antibiotic
    a. Consider RGP or scleral lens to correct irregular astigmatism if visual axis clear.
  4. Referral for manual dissection and removal or EDTA chemical chelation (risk of irregular refractive outcome)
  5. Consider laser PTK for better refractive outcome.
  6. Review 3 -12 months depending on recovery.
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19
Q

Define sjogren syndrome

A

systemic autoimmune disorder: lymphocytic infiltration leading to tissue dysfunction or destruction and reduction in tear secretion.

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20
Q

Sjogren Symptoms

A

Gritty/burning sensation. Dry eye, stringy discharge, blurred vision, redness and crust of lids + Dry mouth

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21
Q

Sjogren Demographics

A

women, post menopause

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22
Q

Requirement for diagnosis of sjogrens

A

serological test: associated with autoimmune disorder.
Salivary gland biopsy: gold standard
Referral to immunologist for systemic work up

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23
Q

Clinical signs of Sjogrens

A

: Posterior blepharitis, conjunctival redness/keratinisation, debris in tear film, low tear meniscus, corneal punctate epithelial, mucus strands and plague, other corneal complications

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24
Q

Management of Sjogrens

A

Management:
1. Patient education on prognosis
2. Lid hygiene + warm compress.
3. Lubricating eyedrops
4. Consider steroids/secretagogues or Bandage CL
a. Cyclosporin A 0.05% TID ongoing
b. Low dose steroids

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25
Q

Acne Rosacea definition

A

idiopathic, chronic dermatosis (associated with sun – exposed skin of face and upper neck). Result of lipases secreted by S. epidermis →inflammatory fatty acids.

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26
Q

Tx of Acne Rosecea

A
  1. As Blepharitis
  2. Oral Omega 3 fatty acid BID
  3. Consider cyclosporin emulsion BID or Doxycycline 100mg daily.
  4. May need treatment for systemic rosacea.
  5. For erythema
    a. Topical brimonidine
    b. Topical oxymetazoline
    c. Laser IPL
  6. For papules/pustules
    a. Topical azelaic acid
    b. Oral doxycycline
    c. Isotretinoin
27
Q

Define Blepharitis

A

caused by bacteria or skin conditions (e.g. acne rosacea). Associated with recurrent hordeolum, conjunctivitis, and marginal corneal infiltrates. Can e anterior or posterior.

28
Q

Anterior blepharitis

A

effects base of eyelashes, follicles, and eyelid skin. May be cause by demodex infection. Chronic associated with S. epidemidis or P. acnes.

29
Q

Signs of Anterior Blepharitis

A

: lid swelling, erythema of lid margins, fibrinous scaly collarettes at the base of lashes, possible skin ulcerations. Staphylococcal: mild sticking together of lids, thickened lid margins, missing/misdirected eyelashes. Seborrheic: greasy flakes or scales around base of eyelashes, mild redness of eye.

30
Q

Symptoms of Anterior blepharitis

A

Gritty/burning sensation. Excessive tearing, dry eyes, itching, red and swollen eyes. Severe case: blurred vision, eyelids stuck together on waking, pain photophobia

31
Q

Management of anterior blepharitis

A
  1. Lid hygiene (Lid wash or mild dilution of baby shampoo)
  2. Demodex infestation: Weekly lid scrub with 50% tea tree oil + daily lid scrub with tea tree shampoo
  3. Topical antibiotic drops or ointment (e.g. chloramphenicol) – not for long term use
32
Q

Posterior Blepharitis Define

A

caused by MGD and changes in meibomian secretions. Increase Meibum melting point, harder to express, increase surface irritation and growth of S. aureus.

33
Q

Posterior Blepharitis Symptoms

A

Gritty/burning sensation. Excessive tearing, dry eyes, itching, red and swollen eyes. Severe case: blurred vision, eyelids stuck together on waking, pain photophobia.

34
Q

Posterior Blepharitis Signs

A

Associated with Acne Rosacea, MG blockage, palpebral conjunctival redness, decreased lipid secretion with foamy tears, dilated and telangiectatic lid margin blood vessels. Seborrheic: greasy flakes or scales around base of eyelashes, mild redness of eye.

35
Q

Posterior Blepharitis Management

A
  1. Ocular lubricant - replace lipid layer.
  2. Warm compression (40 degrees for 5 mins for 12 weeks)
  3. Forceful expression (+/- heat)
  4. IPL treatment
  5. Consider ofloxacin ointment.
  6. Topical azithromycin for anti-inflammatory action
  7. Oral Antibiotics (tetracyclines or macrolides)
  8. Short course of steroids may be helpful or antibiotic and steroid combination.
  9. Review depending on severity.
    a. Check on compliance, treatment efficacy.
  10. Referral to ophthalmologist: significant corneal involvement for collaborative care.
36
Q

What is DED

A

cycle of ocular surface inflammation. Tear hyperosmolarity sets up a cascade of surface epithelial cells that release inflammatory mediators and proteases.

37
Q

What is AKC

A

Atopic Keratoconjunctivitis (AKC): chronic inflammation as a result of ocular atopy. Perennial allergy but exacerbated by air borne allergens.

38
Q

AKC Symptoms

A

photophobia, burning, severe itching, blurred vision, mucopurulent discharge, sticky eyes on waking, red eyelids with scaling and crusting on skin

39
Q

AKC demographics

A

onset late teens to early twenties, may persist till 4th or 5th decade, family history

40
Q

AKC associated conditions

A

asthma, eczema, rhinitis, other allergy disorders

41
Q

AKC symptoms

A

photophobia, burning, severe itching, blurred vision, mucopurulent discharge, sticky eyes on waking, red eyelids with scaling and crusting on skin

42
Q

AKC signs

A

stringy mucus discharge, conjunctiva hyperaemia, papillae, trantas dots, punctate epitheliopathy, subepithelial corneal opacities

43
Q

AKC DDx

A

VKC, SAC, PAC, GPC, Phlyctenule KC, toxic conjunctivitis

44
Q

AKC Tx

A
  1. Avoid specific allergens.
  2. Good lid hygiene + Blepharitis treatment
  3. Combination mast cell stabilization and antihistamine
  4. Severe case
    a. Consider topical cyclosporin A 2%
    b. Consider immunosuppressive drugs (e.g. steroids, tacrolimus)
  5. Refer to ophthalmologist if there are corneal complications (within 1 week)
  6. Co – manage care with Allergist/Dermatologist, ophthalmologist, and immunologist.
  7. Review closely and manage complications:
    a. Conjunctival scarring
    b. Cataracts (10 years after)
    c. Corneal pannus
    d. Associated HSV or staph infection
45
Q

What is VKC

A

Vernal Keratoconjunctivitis (VKC): severe chronic ocular inflammation process of upper tarsal conjunctiva (rare)

46
Q

VKC demographics

A

Demographics: before puberty, males, eye rubbing, family history, Asian, Africans, keratoconus.

47
Q

VKC symptoms

A

: ocular itching, redness, swelling, mucoidal discharge, photophobia

48
Q

VKC signs

A

Conjunctiva: bulbar: hyperaemia and chemosis. Papillae on palpebral conjunctiva
Limbus: papillae on superior limbus, trantas dots
Cornea: punctate epitheliopathy, small corneal opacities (ulcers), shield ulcer, chemical and mechanical damage to epithelium

49
Q

VKC management

A
  1. Patient education
    a. May resolved after puberty.
    b. Avoid eye rubbing.
    c. Try to avoid warm and dry environment.
  2. Cold compress
  3. PF artificial tears
  4. Good hand, face, and hair hygiene
  5. Mast cell stabilizer and antihistamine for micro papillae (for maintenance)
  6. Topical steroids for corneal vascularisation and mucus (or when disease is exacerbated)
  7. Topical NSAIDs for shield ulcer, persistent inflammation, and macro erosion
  8. Monitor for complications:
    a. Steroid side effects: glaucoma, cataracts
    b. Irregular astigmatism due to corneal changes
    c. Keratoconus / dry eye
50
Q

CL GPC

A

Contact lens associated Papillary Conjunctivitis (CLPC) inflammatory disease with papillary hypertrophy of the superior tarsal conjunctiva. Common in px with asthma, rhinitis, or hay fever

51
Q

Symptoms of CL GPC

A

itchy, mucus discharge, redness, discomfort, intolerance of CL

52
Q

CL GPC Signs

A

giant papillae on upper tarsal, white or clear exudate on waking, trantas dots, limbal infiltration, coating of CL

53
Q

CL GPC Management

A
  1. Cease CL use (2-4 weeks) – reduce wear time, change to dailies, change to PF CL solution.
  2. Mild case: consider combination antihistamine/mast cell stabiliser e.g. Olopatadine 0.1% BID
  3. Papillae >Grade 3 or severe inflammation – consider topical steroids e.g. FML QID for 2 weeks.
  4. Follow up in the coming weeks depending on severity.
54
Q

DDx for CL GPC

A

VKC, AKC, SAC, SLK

55
Q

Contact allergy define

A

either irritant – induced (1-2 hours after exposure) or type 4 hypersensitivity (cell – mediated). Caused by chemicals and toxin (i.e. make up, ocular medications)

56
Q

Contact allergy Symptoms

A

itching, scaling of skin, redness of skin, oedema

57
Q

Contact Ocular Allergy signs

A

follicles, conjunctival hyperaemia, eczema, erythema, oedema, papules, vesicles, weeping

58
Q

DDx Contact Allergy

A

SAC or PAC, toxic conjunctivitis, conjunctivitis – usually excluded through history

59
Q

Management for Contact Allergy

A
  1. Refer to dermatologist for patch test.
  2. Remove allergen (discard make up)
  3. Cool compress
  4. Consider topical steroids in non – resolving acute cases.
  5. Follow up in 1 week to monitor for reoccurrence.
  6. Refer to GP for systemic steroids in severe cases.
60
Q

SAC Symptoms

A

Symptoms: bilateral Itchy eyes, usually in spring / summer when pollen is up

61
Q

SAC signs

A

dry eye disease, bacterial/viral conjunctivitis, blepharitis/ blepharoconjunctivitis

62
Q

SAC classification

A

Intermittent: <4 days a week or <4 consecutive weeks
Persistent: > 4 days a week or > 4 consecutive weeks
Severity:
Mild: no effects on VA, no change to quality of life
Moderate: some effects on VA, decreased quality of life
Severe: severe effects on VA, decreased quality of life

63
Q

SAC Management

A
  1. Reduce exposure to allergen (change location)
  2. Cold compress + Artificial tears
  3. Topical antihistamines (e.g. 0.05% Levocabastine or azelastine OTC) reduce itching and vasodilation. (Side effects: sedation, irritation, dry eye)
  4. Topical mast cell stabilizer (e.g. sodium cromoglycate 2% QID) – start before allergy seasons, therapeutic effect takes weeks.
  5. Topical decongestants for vasoconstriction (reduce redness: caution with rebound hyperaemia) (e.g. phenylephrine)
  6. Combination mast cell stabilizer and antihistamine (e.g. ketotifen fumarate 0.025% BID (OTC) – minims)
  7. Refer to GP for oral antihistamines (especially in rhino conjunctivitis) – Caution exacerbates dry eye symptoms.
  8. Consider topical steroid if there is severe inflammation.
  9. Consider topical NSAID if there is corneal involvement (Ketorolac tromethamine 0.5% - approved for SAC)
  10. Collaborative care with GP/immunologist
64
Q

SAC follow up

A
  1. Mild: 5 – 7 daily
  2. Moderate: 3 – 5 daily
  3. Severe: 1 -3 daily
     

Therapeutics (10 decks)

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