Viral Conjunctivitis/Epidemic Keratoconjunctivitis (EKC) Flashcards
Viral Conjunctivitis / Epidemic Keratoconjunctivitis (EKC)
infection control symptomatic therapy antibiotic prophylaxis steroid use
anterior uveitis prevention of spread
symptoms
watery, tearing scratchy, FB sens
lids “matted shut in AM” itchy, red, swollen
signs
development of palpebral conjunctival follicles 4 watery mucus discharge
AM crusting of lashes from drying of tears, serous secretions red and edematous eyelids
conjunctival chemosis?
palpable? tender? preauricular node (PAN)?
pinpoint subconjunctival hemorrhages (SCH)? pseudomembrane? membrane?
concurrent upper respirtatory infection (URI)? subepithelial infiltrates (SEI)? several weeks after onset
pathophysiology
• infection by adenovirus → search for memory B cells
• clinical course is short, possibly subclinical, if viral memory cells are
found which proliferate and secrete antigen-specific antibody to identical or closely related viruses (antigenic structures) previously encountered = response is more rapid and efficient
• clinical course of disease represents the time needed by the patient’s immune system to encounter the virus, proliferate and secrete antigen- specific antibody; forming follicles to develop a pool of activated B lymphocyte cells that differentiate to form memory cells for encounters
What are most forms of conjunctivitis from?
VIRAL OR ALLERGIC
How does viral conjuncitivits beign?
-hyperemic and congestive conjunctival reaction and follicular conjunctivitis within days
-abrupt and involves fellow eye within days
-conjunctival follicles develop + serous discharge
+PAN
What can different seasonal adenoviruses cause?
severe conjunctival inflammation leading to fibrinous pseudomembranes/membranes/conjunctival scarring
treatment options for typical viral conjunctivitis
- “typical” viral conjunctivitis (your patient’s virus may vary!)
a. Hx of recent URI or contact with someone with red eye; generally
starts with one eye and a few days later can involve fellow eye
b. palpebral conjunctival follicles, watery mucus
discharge, eyelid sticking, tearing, may have pseudomembrane / membrane, possibly photophobia, possibly palpable (tender?) preauricular node (+PAN) and/or subepithelial infiltrates (+SEI)
c. Tx includes cool compresses and AT’s (consider non-preserved);
d. may need vasoconstrictor / antihistamine (OTC Naphcon-A5); if itching severe,
low dose steroids (e.g. fluorometholone alcohol or prednisolone phosphate
0.125%)
e. may need low dose steroids (e.g. fluorometholone alcohol or prednisolone
phosphate 0.125%) if pseudomembranes develop (slowly peel off with sterile jeweler’s forceps and maintain low dose steroid 1 wk, then slowly taper) or SEI’s are clinically observed which reduce vision; sunglasses
f. F/up if not better in 1-3 wks (your patient’s virus may vary!), but sooner if condition worsens significantly
Follicular conjunctivitis or keratoconjunctivitis could be what other diseases?
EKC or herpes simplex keratitis
follicular conjunctivitis or keratoconjunctivitis
a. rule out punctate epithelial lesions (focal SPK, dendritiform lesions?, dendrites? HSK?) and avoid steroids!
b. scrupulously maintain hygiene (EKC contagion)
c. hand washing
d. disposable gloves while examining recommended
e. use and sterilize Goldmann tonometer tip; some clinicians avoid NCT which
“blasts” virus into the air to contaminate the room and your assistant
What is EKC associated with?
punctate epithelial keratitis (focal corneal elevations) with irritation and photophobia –> progress to immune-meidated +SEI
what treatment is NOT effective for EKC
ANTIVIRAL MEDS
EKC is contagious
a. virus shed in tears and through nasopharynx
b. patient will be contagious for at least two weeks
c. patient said to be non-contagious when SEI’s appear
d. family and co-workers potentially infected during the first asymptomatic week of
infection
e. possible to be re-infected since < 5% of patients do not develop immunity via
antibody production with EKC
supportive, symptomatic therapy for EKC
a. cool compresses (patient may experiment with warm soaks alternating with cool,
though warm may worsen the hyperemia and chemosis, while enhancing the
immune response)
b. lubricants as frequently as possible (even q1h)
c. vasoconstrictors ≤QID, eg Naphcon-A
d. aspirin or other analgesics (NSAID’s)
e. sunglasses
treatment for bacterial conjunctivitis/keratitis; antibiotic prophylaxis
a. Chlorofluoroquinolone, Polytrim, fluoroquinolones etc QID or more frequently
b. Polysporin, Ciloxan, Erythromycin ointment qhs possible
c. True Primary / Secondary Bacterial Conjunctivitis may present earlier than /
simultaneously with follicles, rather than later; eg kids (less mature immune system) or Seniors (reduced immune response), especially with recent surgery Hx
Steroid treatment for viral conjunctivitis/EKC
controversial
NEVER use them if uncertain about HSK; if you (or someone else) unintentionally
grows HSK dendrites using a steroid, then D/C steroid and start Zirgan / Viroptic
(see Cornea)!
b. definitely use if pseudomembranous / membranous conjunctivitis is occurring (to prevent later risk of permanent scarring) in the absence of HSK; prefer using low concentration (0.125%) prednisolone phosphate solution (less AC penetration with intact cornea than acetate form, suspension acetate is very irritating and patient can complain of increased FB sensation) or Lotemax sol/gel
c. consider steroid if SEI’s are unusually damaging to vision (eg hazardous to patient’s occupation)
i. very difficult to wean patient off, may be on 6-8 months
ii. SEI’s can recur after steroids discontinued
iii. possible use of FML or Pred Mild QID for several days, then quick taper
through TID/BID/qD/qOD
treatment for mild secondary iritis
cycloplegics (depending on effect on vision)a. homatropine 2-5% (at least BID)
b. cyclopentolate 1% (at least BID)
c. steroids generally not needed
Follow up with patient
every 4-6 days
Is there a cure for the cold in the eye?
no
Do antibiotics help a virus?
no
“pink eye”
viral conjunctivitis will start in one eye and then infect the other eye;
may get worse before it get sbetter
how long does VK last if previously encountered and good immune system?
1-3 days
How long does VK last if new to patient with good immune system?
1-3 weeks
How long does EKC last?
1-3 months
How many days can others be infected prior to Sx while patient is subclinically contagious?
3-7 days
Whats a possible cure for cold in eye?
Cidofovir
What medication can be used to suppress pseudomembrane formation after removal?
low dose steroid (fluromethalone alcohol or prednisolone phosphate 0.125%) for 1 week then taper
Treatment for EKC?
Betadine protocol
Use for patients with moderate to advanced acute EKC Tx Goal: rapid decrease or elimination of live virus from ocular
surface → decreased time for viral particles to migrate into
anterior stromal tissues and incite an immune response (SEI)
1. Take Hx to R/O (rule out) allergy to iodine (molecular
backbone of Betadine)
2. Instill 1gtt topical anesthetic, eg 0.5% proparacaine,
because Betadine can sting
3. Instill 1-2gtt topical NSAID because Betadine can cause
mild stippling and result in marked stinging
4. Instill 4-6gtt of Betadine 5% into eye(s), gently close /
roll eyes to distribute across all ocular surfaces
5. Wait 1-2min (2min is presurgical prep time), then
lavage out the Betadine with sterile ophth irrigating solution
6. Reinstill 1-2gtt top NSAID (even 1gtt proparacaine for
discomfort), then potent steroid QID x 4d, eg Lotemax
