Ed Beatty, O.D. Paul Karpecki, O.D. Nate Lighthizer, O.D. Nearly 1 million Americans develop shingles each year Ocular involvement accounts for up to 25% of presenting cases Over 50% incur long term ocular damage ***Varicella-Zoster Virus*** Herpes DNA virus that causes 2 distinct syndromes 1. Primary infection – Chicken pox (Varicella) Usually in children Highly contagious*** Very itchy maculopapular rash with vesicles that crust over after ≈ 5 days 96% of people develop by 20 years of age Vaccine now available Herpes DNA virus that causes 2 distinct syndromes 2. Reactivation – Shingles (Herpes Zoster) More often in the elderly and immunosuppressed (AIDS) Systemic work-up if Zoster in someone < 40 Can get shingles anywhere on the body Herpes Zoster Ophthalmicus (HZO) Shingles involving the dermatome supplied by the ophthalmic division of the CNV (trigeminal) 15% of zoster cases Symptoms: Generalized malaise, tiredness, fever Headache, tenderness, paresthesias (tingling), and pain on one side of the scalp*** Will often precede rash Rash on one side of the forehead Red eye Eye pain & light sensitivity Signs: Maculopapular rash -> vesicles -> pustules -> crusting on the forehead Respects the midline*** Hutchinson sign rash on the tip or side of the nose*** Classically does not involve the lower lid Numerous other ocular signs Other Eye Disease (Acute): Acute epithelial keratitis (pseudodendrites) Conjunctivitis Stromal (interstitial) interstitial keratitis Endotheliitis (disciform keratitis) Neurotrophic keratitis Other Eye Disease (Acute): Episcleritis Scleritis Anterior uveitis IOP elevation Retinitis Choroiditis Neurological complications (nerve palsies) Vascular occlusion
Treat the complications just like as if they were primary conditions Treatment: Treat the complications just like as if they were primary conditions Oral antivirals – must be started within 72 hours of symptoms** Acyclovir 800mg 5x/day x 7-10 days Valtrex 1000mg 3x/day X 7-10 days Famciclovir 500mg 3x/day X 7-10 days Topical ointment to skin lesions to help prevent scarring Bacitracin, erythromycin
How do you Dx Keratoconus? Tools of Diagnosis
Corneal Topography VA – Limited BCVA with SRx Refraction Changes Improvement with RGP K’s Pachymetry Biomicroscopy Wavefront aberrometry Keratoconus vs CL Warpage KC vs CL Warpage
Keratoconus often round CL Warpage Not round, ’ Smiley face’
KCS Not at 6 O’clock CL Warpage at 6 O’clock
KCS Asymmetric CL Warpage Symmetric
KCS Symmetric Pachymetry CL Warpage Symmetric Pachymetry
KCS Ks are > 45.00D steeper CL Warpage often <45.00D flatter
DISCONTINUE CL WEAR AND MONITOR Anterior surface changes present will improve! Signs of Keratoconus
Look for changes in the posterior float surface greater than the changes in the anterior surface Asymmetric refraction changes with astigmatism Asymmetric pachymetry Asymmetric topographies Slitlamp corneal findings Compare the eyes. If the corneal warpage is contact lens induced, the distortion in both eyes will be symmetrical. If it's keratoconus, they won't look like mirror images—one will be worse than the other. Biomicroscopy
Apical Vogt’s striae/ scarring Ectasia Fleisher Ring Munson’s Sign Enlarged corneal nerves KCS vs PMD
KCS PMD
Inferior corneal thinning Nasal / Temporal Thinning Fleischer ring & Vogt’s striae present Not present Round, inferior thinning “Crab-claw” or saggy bowtie Keratoconus Treatment Options
Spectacles Soft CLs RGP, Hybrid, Scleral Lenses Intacs CXL PK Recommended Treatment
Recommend Surgical evaluation for Intacs OD and Collagen Crosslinking (CXL) OU Intacs for Keratoconus How Intacs Work Intacs for Keratoconus
Indications
For moderate to advanced keratoconus
Convert CL failure to CL success
Delay the need for corneal transplant
Conservative interim surgical step
Contraindicated in patients with excess thinning
Contraindicated in patients with apical scarring
Does not work well in PMD Intacs for Keratoconus Benefits Safe, removable, replaceable Reduces myopia and astigmatism associated with keratoconus Restores cornea to a more natural dome shape Creates a plateau or platform for CL to rest upon Minimally invasive Recovery period very short compared to corneal transplant Makes CLs fit better and more comfortably May delay need for corneal transplant Intacs: Before and After What do ladders and Keratoconus have in common?
In keratoconus, the cornea has weakened structural support; fewer cross-links or support beams. This weakened structure allows the cornea to bulge outwards. The cross- linking procedure adds ladder rungs or cross-links to the cornea, making it more stable. Benefits of Collagen Cross Linking with Riboflavin (C3R or CXL)
2/3 of patients treated with collagen cross linking and riboflavin drops will have improved vision
In some cases mild regression of the steepness of their cornea may occur
Shown to slow the progression of disease in 98% of patients
CXL may even cause regression of disease.
Results appear permanent. Collagen Cross Linking / Riboflavin Epi On vs Epi Off
Epi On
Epi Off
Is CXL an OD procedure? Combining Intacs & CXL
Studies suggest additive effect! One study: The Intacs with CXL group had significantly less astigmatism than the Intacs-only group. A different study examined patients with bilateral keratoconus had Intacs implantation with subsequent corneal cross-linking treatment.3 The Intacs with CXL group had significant improvements in uncorrected (1.9 Snellen lines) and best- corrected (1.7 Snellen lines) visual acuity. Spherical visual acuity was improved, cylinder was reduced and mean keratometry values were reduced after Intacs and CXL treatment. Thus, it seems that Intacs with CXL is an effective procedure in keratoconic eyes that improves the effect of Intacs; it is as a stabilizing and flattening effect as well as enhancement to stabilize and slow progression
1. Chan CC, Sharma M, Wachler BS. Effect of inferior-segment Intacs with and without C3R on keratoconus. J Cataract Refract Surg. 2007 Jan;33(1):75-80. 1 year Post Op Intacs OD CXL OU
VA 20/25 OD 20/20 OS with soft toric CL OU
No progression of ectasia OU Post Op 1 year after Intacs and CXL CXL Post Op Mgmt
Manage similar to PRK Monitor and manage Epi defect VA, IOP Topo, Manifest Ref, 1 Day 1 Week 1 Month 3 Month 1 year Signs: Red eye (conj hyperemia) Watery discharge Follicles in the inferior fornix & conj (+) PA node***
Red/swollen eyelids Petechial sub-conj hemes SPK SEI’s (sub-epithelial infiltrates) Pseudomembranes/membranes often seen in EKC Timecourse Signs: Red eye (conj hyperemia) Watery discharge Follicles in the inferior fornix & conj (+) PA node***
Red/swollen eyelids Petechial sub-conj hemes SPK SEI’s (sub-epithelial infiltrates) Pseudomembranes/membranes often seen in EKC Diagnosis Based on clinical symptoms Treatment: Cool compresses Artificial tears “get the red out drops” Vasoconstrictors such as Visine Hygiene*** Quarantine/Isolation
Betadine 5% solution??? Zirgan??? Lotemax/Pred Forte QID??? – not until late Fuchs’ Diagnosis
VA Blurred Vision , worse in the morning compared to pm. Slit lamp Corneal Findings Guttata Stromal Edema Pachymetry Specular Microscopy- Low ECD, Guttae, Ploymegatheism, Pleiomorphism Specular Microscopy Medical Treatment
Muro 128 gtts/ ung Hyoptonic Tears Lower IOP Contact lens for Bullous K
Surgical Options Phaco c IOL DSAEK/ DMEK PK WHEN IS IT TIME FOR SURGERY? When is it time for DSAEK/ DMEK PK?
VA is affecting lifestyle Unimproved with conventional medical Tx Pachymetry >600 um Pain, Discomfort due to ruptured Bullae, Bullous K Post Cataract Sx or Combo procedure Advantages of DSAEK / DMEK over PK
No Open-Sky Replace only the diseased portion of cornea No sutures Stronger wound Less Refractive error Less Astigmatism, Astigmatically Neutral Less allogeneic tissue Disadvantages DSEK / DSAEK
Graft Dislocation Endothelial rejection ECD loss Steeper Learning Curve Risk of Pupillary Block Steroid Induced Glaucoma Limited Indications DSAEK Ultra Thin DSAEK <100um DMEK / DMAEK
DMEK- Descemet’s Membrane Endothelial Keratoplasty DMAEK - Descemet’s Membrane Automated Endothelial Keratoplasty Only Descemet’s Membrane and endothelium removed Used to avoid any stromal tissue to improve visual outcomes and interface haze Technical Challenges: -Scrolls when stripped -20um endothelium is fragile, high EC loss High dislocation rate DMEK vs DSEK DSEAK DMEK Complications
Allograft failure Graft dehiscence non- adherance Slipped graft 1 Day 1 week 20/25 3 Months 20/20-2 Posterior Blepharitis
• Meibomian gland dysfunction (MGD)** • Extremely common ocular disorder o Alteration of MG secretions • Almost always bilateral • More prevalent the older the population gets • Chronic, lifelong problem** • Pathogenesis: o Bacterial lipases result in the formation of free fatty acids -> increases the melting point of the meibum Meibomian Gland Dysfunction (MGD) • Etiology: o Diet related o Hormonal related o CL wear o Steve Jobs • iPhone, smartphones • iPad, tablets • Computers • Video games MGD
• Symptoms: o Depends on the severity o Usually bilateral, can be asymmetric • Ocular discomfort & irritation • Burning, grittiness • Crusting and redness of lid margins • Blurred vision from tear film disruptions o Symptoms are often worse in the morning** • Morning eyelid mattering/sticking o History of tender lids, hordeolum, chalazia**
• Signs and symptoms frequently do not correlate well MGD
• Signs: o Frothy or foamy tear film o Thickened lid margins o Express the meibomian glands: • Mastroda paddle o Hold for 10-15 seconds • Wet Q-tip
• Ideal scenario – oily • Slightly abnormal – turbid • Extremely abnormal – paste like • Worst case scenario – nothing comes out
o Red eyes o Reduced TBUT o Scarring of the eyelid o Telangiectasia o Capped glands MGD
• Frothy tears MGD
• Signs: o Frothy or foamy tear film o Thickened lid margins o Express the meibomian glands: • Mastroda paddle o Hold for 10-15 seconds • Wet Q-tip
• Ideal scenario – oily • Slightly abnormal – turbid • Extremely abnormal – paste like • Worst case scenario – nothing comes out
o Red eyes o Reduced TBUT o Scarring of the eyelid o Telangiectasia o Capped glands Mastroda Paddle MGD
• Signs: o Frothy or foamy tear film o Thickened lid margins o Express the meibomian glands: • Mastroda paddle o Hold for 10-15 seconds • Wet Q-tip
• Ideal scenario – oily • Slightly abnormal – turbid • Extremely abnormal – paste like • Worst case scenario – nothing comes out
o Red eyes o Reduced TBUT o Scarring of the eyelid o Telangiectasia o Capped glands MGD
• Treatment: o Mild-moderate cases: • Warm compresses o 40 degrees Celsius o 5 minutes of heat minimum • 10-15 is better • Lid hygiene • AT’s o Lipid based tears • Systane Balance, Refresh Optive Advanced, Ocusoft Retaine
o Moderate-severe disease (tear osmolarity > 330) • TheraTears, Oasys tears
o Lotemax ung at night • Wonderful for patients with morning complaints • Wouldn’t use during the day Bruder Hydrating Masks MGD
• Treatment: o Mild-moderate cases: • Warm compresses o 40 degrees Celsius o 5 minutes of heat minimum • 10-15 is better • Lid hygiene • AT’s o Lipid based tears • Systane Balance, Refresh Optive Advanced, Ocusoft Retaine
o Moderate-severe disease (tear osmolarity > 330) • TheraTears, Oasys tears
o Lotemax ung at night • Wonderful for patients with morning complaints • Wouldn’t use during the day MGD - treatment
• Tetracyclines o Doxy • 50 mg BID X 1-3 months • 50 mg QD X 1-2 months o Minocycline • 50mg BID o Periostat • Approved for gingivitis • 20 mg Doxy
o Can’t give to: • Children < 12 • Women pregnant or wanting to become pregnant • Breastfeeding • Pregnancy category D o Side effects: • Teeth discoloration • Bone problems • GI upset*** #1 reason why people can’t take tetracyclines • Photosensitivity - sunburn • Dairy products and ant-Acids neutralize it • Mild dizziness/vertigo – minocycline mostly, very rare with doxy MGD - treatment
• Long term: o Fish oil • EPA/DHA – omega 3 • GLA (Gamma linolenic acid) – omega 6 MGD • My Regimen for Chronic MGD: 1. Express Meibomian glands 2. Warm Compresses QD-BID 3. Patient/severity specific AT’s • Mild-moderate (<330 mOsm) o Retaine MGD, Systane Balance, Refresh Optive Advanced • Severe (>330 mOsm) o Thera Tears, Oasys Tears 4. Steroid ung qhs • Lotemax, FML, etc 5. Doxycycline 50mg QD-BID 6. Fish Oil • EPA/DHA/GLA CLAIK Contact Lens-Associated Infiltrative Keratitis
AKA..
Contact lens-associated Peripheral Ulcer - CLPU Contact lens-associated Red Eye -CLARE Contact lens-associated Sterile Ulcer Staph Marginal Ulcer/ Infiltrate Etiology
Staphylococcus exotoxin produces an immune reaction Sterile infiltrate ulcer as opposed to live bacteria in MK Chronic Staphylococcal blepharitis (mild to severe) Contract lens patients, especially extended wear more prone Treatment
Topical Antibiotic Steroid treatmnt Maxitrol (Neo/Poly/Dex) gtts q2hrs Maxitrol Ung qhs OD. Cyclopentolate 1% OD Eyelid Hygiene Ocusoft lidscrubs DC CL wear, Dispose of old CL case Advise against extended wear Call later than evening to check on pt FU 1 day to monitor improvement
Many Possible Treatments Options: Tobradex ST, Zylet, Polytrim, Azasite, Pred Forte Erythromycin, Bacitracin, Lotemax, Tobradex ung qhs Consider oral Doxycycline for recurrent episodes Is CLAIK Associated with Certain Solutions and Lenses? What do Biofilm and Lens Cases have to do with CLAIK? How do I know if its MK vs. Sterile Infiltrate? Infiltrates
When to Culture?
Central Thinning VA affected History of sleeping in CLs History of pool or hot tub use with CLs History of being in hospital / other health care setting Ordering a Culture
Culture Prior to Instilling ANY DROPS Corneal scraping or swab Try to Culture Contact Lens Case Order aerobic organism & antibiotic sensitivity Takes 2-5 days to grow out MK Treatment
Small Mid-peripheral Ulcers 4th Gen (Moxeza or Besivance) q2hrs Polytrim q 2hrs Maxitrol Ung qhs
Central Ulcers / Pseudomonas, MRSA, MRSE 4th Gen Fluroquinolones (Besivance et al) q 2 hrs alternate with Fortified Vancomycin 25mg/ml q 2hrs Maxitrol Ung qhs Continue meds until infiltrate is completely resolved then taper. Sterile Infiltrates vs. Infectious Infiltrates
Sterile Infiltrate Infectious Infiltrate (MK)
Smaller lesion (<1mm) Larger lesion (>1mm) Peripheral More Central Minimal epi damage Significant Epi defect No Mucous discharge Mucopurulent discharge Less pain and Pain and photophobia photophobia AC Rxn No lid involvement Lid edema